ANCC AGACNP-BC cheat sheet

Anion gap = Na+ − (Cl− + HCO3−); normal is about 8–12 mEq/L. An elevated gap with metabolic acidosis suggests ketones, lactate, uremia, toxins, or salicylate.

ABG stepwise: pH determines acidemia or alkalemia; PaCO2 determines the respiratory component; HCO3 determines the metabolic component. Winter's formula: expected PaCO2 = 1.5 × HCO3 + 8 ± 2.

CURB-65: confusion, urea >7 mmol/L (BUN >19 mg/dL), RR ≥30/min, SBP <90 or DBP ≤60 mm Hg, age ≥65. Score 0–1 supports outpatient care, ≥2 consider admission, ≥3 severe.

qSOFA: RR ≥22/min, altered mentation, SBP ≤100 mm Hg. Two or more criteria flag high risk for sepsis and prompt further evaluation.

Wells criteria for PE: clinical signs of DVT, PE most likely diagnosis, HR >100, immobilization or surgery, prior VTE, hemoptysis, malignancy. Low pretest probability plus negative PERC can avoid D-dimer.

HEART score: history, ECG, age, risk factors, troponin. Scores 0–3 are low risk, 4–6 moderate risk, and 7–10 high risk for major adverse cardiac events.

Type 2 diabetes diagnosis: A1c ≥6.5%, fasting glucose ≥126 mg/dL, 2-hour OGTT ≥200 mg/dL, or random glucose ≥200 mg/dL with symptoms. Prediabetes A1c is 5.7–6.4%.

Ottawa ankle rule: obtain imaging only if pain in the malleolar zone plus inability to bear weight four steps or bone tenderness at the posterior malleolus or navicular; it applies without intoxication or distracting injury.

Depression screening: PHQ-2 score ≥3 prompts PHQ-9; PHQ-9 ≥10 suggests moderate depression and warrants further assessment.

Septic shock: measure lactate, obtain cultures, give broad-spectrum antibiotics within 1 hour, give 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L, then start norepinephrine if MAP <65 mm Hg.

DKA: give isotonic fluid, start insulin infusion after K+ ≥3.3 mEq/L, add dextrose when glucose <200–250 mg/dL, and monitor K+ and anion gap. Bicarbonate only if pH <6.9.

Acute severe asthma: repeated SABA, ipratropium, systemic corticosteroids; add IV magnesium sulfate for severe refractory symptoms; consider NIV only in selected cases.

ACS: chew aspirin 162–325 mg, give P2Y12 inhibitor and anticoagulant per protocol, and obtain ECG within 10 minutes. Primary PCI is preferred if available within 120 minutes.

Heart failure with reduced EF: initiate ARNI or ACE inhibitor/ARB, beta blocker, MRA, and SGLT2 inhibitor unless contraindicated. Diuretics treat congestion, not routine euvolemia.

Hypertension: stage 1 is 130–139/80–89 mm Hg; goal <130/80 for most adults, individualized for older adults or frailty. Start two drugs if BP ≥160/100 or ≥20/10 above goal.

Ischemic stroke: IV thrombolysis within 4.5 hours for eligible patients; thrombectomy up to 24 hours for selected large-vessel occlusion; check glucose and CT before thrombolysis.

COPD exacerbation: short-acting bronchodilators, systemic corticosteroids 5–7 days, antibiotics if increased purulence plus dyspnea or volume; target SpO2 88–92% in those at risk of hypercapnia.

Cirrhotic ascites: sodium restriction, spironolactone plus furosemide, therapeutic paracentesis for tense ascites; avoid NSAIDs and ACE inhibitors/ARBs in decompensated cirrhosis.

Vancomycin: target AUC24/MIC 400–600 for serious MRSA; avoid relying on trough alone; monitor renal function and adjust for obesity and renal impairment.

Warfarin: INR 2–3 for most AF and VTE; mechanical mitral valve 2.5–3.5; bridge with parenteral anticoagulant when thrombotic risk is high.

DOACs: dose by indication, renal function, age, weight, and interacting drugs; avoid in mechanical valves and moderate-severe mitral stenosis.

Metformin: do not initiate if eGFR <45; stop if eGFR ≤30; hold before iodinated contrast when eGFR 30–60 or with AKI risk.

ACE inhibitors/ARBs: monitor K+ and creatinine; stop with angioedema, pregnancy, bilateral renal artery stenosis, or symptomatic hypotension. Cough is more common with ACE inhibitors.

Opioid safety: co-prescribe naloxone for high overdose risk; combine with nonopioid multimodal analgesia; reassess sedation, respiratory rate, and bowel function.

Systemic corticosteroids: taper after >2–3 weeks of supraphysiologic dosing; abrupt withdrawal risks adrenal crisis; monitor glucose, blood pressure, and infection.

Nonpharmacologic care: CBT and motivational interviewing for behavior change; physical therapy for mobility; sleep hygiene and CPAP for OSA; DASH diet and sodium restriction for hypertension.

Colorectal cancer screening for average risk: start at 45 and continue to 75; colonoscopy every 10 years or annual FIT; earlier or interval screening for family history or symptoms.

Breast cancer screening: USPSTF recommends biennial mammography for ages 40–74; individualized shared decision-making for age 75 and older.

Cervical cancer screening: ages 21–29 cytology every 3 years; ages 30–65 cytology every 3 years, HPV testing every 5 years, or co-testing every 5 years.

Lung cancer screening: annual low-dose CT for ages 50–80 with ≥20 pack-year history who currently smoke or quit within 15 years.

Adult vaccines: annual influenza; Tdap every 10 years; zoster at age ≥50; pneumococcal at age ≥65 or with risk conditions; COVID-19 per current schedule.

Teach-back: ask the patient to restate the plan in their own words; this confirms understanding and identifies health literacy gaps.

Care transitions: medication reconciliation at admission, transfer, and discharge; written discharge plan; follow-up within 7 days for high-risk patients; clear warning signs.

SBAR: situation, background, assessment, recommendation; it standardizes handoffs and reduces communication errors.

APRN practice scope and prescriptive authority derive from state nurse practice acts; some states require collaborative agreements, while others allow independent practice.

Informed consent requires capacity, disclosure of diagnosis, treatment, risks, benefits, alternatives, and voluntary choice; emergencies may allow treatment without consent.

HIPAA permits disclosure for treatment, payment, and operations; the minimum necessary standard applies; suspected abuse is reported as required by law.

EMTALA: Medicare-participating emergency departments must provide a medical screening examination and stabilizing treatment regardless of insurance or ability to pay.

Ethical principles: autonomy, beneficence, nonmaleficence, and justice; for incapacitated patients, apply surrogate decision-making by substituted judgment.

MIPS: quality, cost, improvement activities, and promoting interoperability; scores affect Medicare payment adjustments.

Mandatory reporting: suspected child or elder abuse, certain communicable diseases, and specified injuries per state law; report in good faith.

Impaired colleague: protect patients first, report through the appropriate chain, and use employee assistance or state diversion programs when indicated.