UNB IDR Entrance cheat sheet

Scope of practice: LPN/RPN duties are defined by provincial legislation and employer policy; performing acts beyond legislated scope (e.g., independent IV push, initial health assessment) is a legal violation regardless of competence.

Informed consent requires three elements: capacity (patient can understand and appreciate consequences), voluntariness (free of coercion), and adequate disclosure (risks, benefits, alternatives, consequences of refusal).

Consent for a minor: age of majority and mature-minor doctrine vary by province; emancipated or mature minors may consent independently, and emergency treatment proceeds under implied consent when life-threatening.

Confidentiality exceptions: duty to report child abuse, credible threats of serious harm to an identifiable person, communicable disease reporting, court order, and suicide risk requiring protective intervention.

Negligence requires four elements: duty of care, breach of the standard, causation, and damages; the standard is what a reasonable, similarly trained nurse would do in similar circumstances.

Advance directives and substitute decision-makers: hierarchy is typically spouse/partner, adult children, parents, siblings; a capable patient's wishes override all substitute decision-makers.

Mandatory reporting of incompetent or impaired colleagues is an ethical and often legal duty; report to the regulatory body and follow employer chain of command.

Ethical principles: autonomy (self-determination), beneficence (do good), nonmaleficence (avoid harm), justice (fair allocation), veracity (truthfulness), fidelity (keeping promises).

Documentation is a legal record: chart objectively, contemporaneously, in black ink, with time, date, and signature; late entries are labeled as such and never altered or obliterated.

The five steps are assessment, diagnosis, planning, implementation, and evaluation (ADPIE); evaluation loops back to reassessment and revision of the plan.

Assessment comprises subjective data (symptoms reported by the patient) and objective data (signs observed or measured); both are required before a nursing diagnosis.

Nursing diagnoses describe human responses (e.g., impaired gas exchange), not medical diseases; medical diagnoses describe pathology and are made by physicians or nurse practitioners.

SMART outcomes: specific, measurable, attainable, realistic, and time-bound; each outcome states a patient behavior, a criterion, and a target time.

Maslow's hierarchy prioritizes physiologic needs (airway, breathing, circulation) before safety, love/belonging, esteem, and self-actualization when ordering interventions.

Clinical judgment models (e.g., noticing, interpreting, responding, reflecting) emphasize cue recognition, hypothesis generation, and evaluation of the response to intervention.

Triage decision rules: life-threatening conditions (airway compromise, shock, severe hemorrhage) are seen first regardless of arrival order; use a validated acuity scale.

SBAR (Situation, Background, Assessment, Recommendation) structures escalation of a deteriorating patient to a physician or rapid response team.

Evaluation compares actual outcomes with expected outcomes; if unmet, reassess data, revise the diagnosis, or change the intervention rather than repeating it unchanged.

Inspection precedes palpation, percussion, and auscultation in most systems; the exception is the abdomen, where auscultation precedes palpation and percussion to avoid altering bowel sounds.

Normal adult vital signs: temperature 36.1-37.8 C oral, pulse 60-100 beats/min, respirations 12-20/min, blood pressure under 120/80 mmHg, SpO2 95-100% on room air.

Pulse grading: 0 absent, 1+ weak/thready, 2+ normal, 3+ bounding; document rate, rhythm, amplitude, and equality bilaterally.

Lung sounds: vesicular over peripheral fields, bronchovesicular centrally, bronchial over the trachea; adventitious sounds include crackles (fluid), wheezes (narrowed airways), and pleural friction rub.

Heart sounds: S1 (AV valves closing, start of systole) and S2 (semilunar valves closing, start of diastole); S3 in adults suggests volume overload, S4 suggests stiff ventricle.

Murmurs are graded I-VI by intensity; grade I is barely audible, grade IV is loud with a thrill, grade VI is audible without a stethoscope.

Neurologic: Glasgow Coma Scale ranges 3-15 (eye 1-4, verbal 1-5, motor 1-6); a score of 8 or less generally indicates need for airway protection.

Pupils assessed as PERRLA (pupils equal, round, reactive to light, accommodating); pinpoint pupils suggest opioid effect, fixed dilated pupils suggest severe brain injury.

Edema is graded 1+ (2 mm) to 4+ (8 mm) pitting; measure abdominal girth and limb circumference at a marked reference point for comparability.

The rights of medication administration: right patient (two identifiers), right drug, right dose, right route, right time, right documentation, right reason, and right to refuse.

The five-plus rights are verified at three checkpoints: when removing the medication from storage, when preparing it, and at the bedside before administration.

High-alert medications (insulin, heparin, opioids, potassium chloride concentrate, chemotherapy) require independent double-check by a second nurse per policy.

IV push rate for most adult medications is limited by drug-specific maximum rates; rapid push of undiluted potassium chloride, phenytoin, or vancomycin causes serious harm.

Pharmacokinetics: absorption, distribution (protein binding, blood-brain barrier), metabolism (mostly hepatic CYP enzymes), and excretion (mostly renal); half-life determines dosing interval.

Narrow therapeutic index drugs (digoxin 0.5-2.0 ng/mL, phenytoin 10-20 mcg/mL, lithium 0.6-1.2 mEq/L, warfarin INR 2-3) require serum level monitoring.

Antidotes: naloxone for opioids, flumazenil for benzodiazepines, protamine sulfate for heparin, vitamin K for warfarin, acetylcysteine for acetaminophen, N-acetylcysteine/ sodium bicarbonate for salicylates.

Insulin: rapid-acting (lispro, aspart) peaks 1-3 h, short-acting regular peaks 2-4 h, intermediate NPH peaks 4-12 h, long-acting glargine has no peak; only regular insulin is given IV.

Heparin monitoring uses aPTT (therapeutic roughly 1.5-2.5 times control) or anti-Xa; low-molecular-weight heparin is monitored less often and is renally cleared.

Heart failure: left-sided failure causes dyspnea, orthopnea, crackles, and frothy sputum; right-sided failure causes jugular venous distension, hepatomegaly, ascites, and dependent edema.

Acute coronary syndrome: MONA is outdated as a blanket order; current priorities are aspirin, nitroglycerin (contraindicated with sildenafil or right ventricular infarct), oxygen only if hypoxemic, and reperfusion.

Postoperative care: early ambulation, incentive spirometry, and adequate analgesia prevent atelectasis, pneumonia, and venous thromboembolism; assess return of bowel sounds before advancing diet.

DKA versus HHS: DKA shows glucose usually 250-600 mg/dL, ketones, anion gap acidosis, Kussmaul respirations; HHS shows glucose often over 600 mg/dL, hyperosmolality, minimal ketosis.

Hypoglycemia is treated with 15-20 g fast-acting carbohydrate if conscious and alert; if unconscious, give IV dextrose or glucagon and recheck glucose in 15 minutes.

Burns: the rule of nines assigns 9% each to head, each arm, and each leg's front and back, 18% to anterior trunk and 18% to posterior trunk, 1% to perineum; use Lund-Browder for children.

Acute kidney injury: oliguric phase shows rising creatinine, hyperkalemia, and fluid overload; monitor for peaked T waves and treat potassium above 6.5 mEq/L with calcium, insulin/dextrose, and dialysis.

Increased intracranial pressure: early signs include altered level of consciousness and headache; Cushing triad (hypertension, bradycardia, irregular respirations) is a late, ominous sign.

Respiratory: COPD targets SpO2 88-92% to avoid oxygen-induced hypercapnia; asthma exacerbation is treated with bronchodilators, systemic corticosteroids, and oxygen.

Fetal heart rate baseline is 110-160 beats/min; late decelerations indicate uteroplacental insufficiency and require repositioning, oxygen, IV fluids, and provider notification.

Variable decelerations indicate umbilical cord compression; interventions include changing maternal position, amnioinfusion, and discontinuing oxytocin.

Stages of labor: first stage from onset to full dilation, second stage from full dilation to birth, third stage from birth to placental delivery, fourth stage the first 1-2 hours postpartum.

Postpartum hemorrhage is blood loss over 500 mL after vaginal birth or 1000 mL after cesarean; causes are uterine atony (most common), retained placenta, trauma, and coagulopathy.

APGAR scores at 1 and 5 minutes assess appearance, pulse, grimace, activity, and respiration; each 0-2, total 0-10, with 7-10 generally reassuring.

Newborn: expect weight loss up to 10% in the first week, regain by 2 weeks; physiologic jaundice appears after 24 hours, pathologic jaundice within 24 hours.

Pediatric weight-based dosing: verify dose by mg/kg with a maximum dose cap; pediatric maintenance fluids use the 4-2-1 rule (4 mL/kg/h for first 10 kg, 2 for next 10, 1 for each kg thereafter).

Pediatric assessment: infants and toddlers use the parent as a comfort source; obtain respiratory rate and heart rate before disturbing the child, and count respirations for a full minute.

Pregnancy-induced hypertension: magnesium sulfate is given for seizure prophylaxis; monitor deep tendon reflexes, respiratory rate, and urine output, with calcium gluconate as the antidote for toxicity.

Therapeutic communication techniques include silence, open-ended questions, reflection, clarification, and summarizing; avoid false reassurance, advice-giving, and why-questions.

Suicide risk assessment: direct asking about ideation, plan, intent, and means does not increase risk; highest risk periods are within 90 days of discharge and after a recent attempt.

Safety precautions for suicidal or violent patients include ligature-resistant environment, frequent or continuous observation, and removal of sharps, belts, and cords.

Neuroleptic malignant syndrome: fever, muscle rigidity, autonomic instability, and elevated creatine kinase; stop the antipsychotic and treat supportively with dantrolene or bromocriptine.

Serotonin syndrome: agitation, hyperreflexia, clonus, hyperthermia, and diarrhea after serotonergic drugs; stop the agent and give supportive care, benzodiazepines, and cyproheptadine if severe.

Extrapyramidal symptoms include acute dystonia (treat with benztropine or diphenhydramine), akathisia, parkinsonism, and tardive dyskinesia (may be irreversible).

Alcohol withdrawal: monitor with a validated scale (e.g., CIWA); treat with benzodiazepines, thiamine before glucose, and monitor for seizures and delirium tremens.

Lithium toxicity signs: coarse tremor, vomiting, diarrhea, ataxia, and confusion; therapeutic level 0.6-1.2 mEq/L, and dehydration or NSAIDs raise levels.

Eating disorders: refeeding syndrome causes hypophosphatemia, hypokalemia, and hypomagnesemia; monitor electrolytes during nutritional rehabilitation.

Levels of prevention: primary (immunization, seat belts), secondary (screening, early detection), tertiary (rehabilitation, chronic disease management).

Incidence counts new cases in a period; prevalence counts all existing cases at a point or over a period; prevalence rises with longer disease duration.

Herd immunity threshold depends on the basic reproduction number; measles requires roughly 95% two-dose coverage, while influenza requires lower coverage.

Reportable communicable diseases must be reported to public health authorities; the nurse reports the disease, not the patient's identity, unless required by statute.

Epidemiologic measures: attack rate (new cases divided by population at risk), mortality rate, infant mortality rate, and case fatality rate express different burdens.

Screening test properties: sensitivity detects true positives, specificity detects true negatives; positive predictive value depends on disease prevalence in the population.

Community assessment frameworks examine demographics, environment, health status, and resources; windshield surveys and key informant interviews gather qualitative data.

Outbreak investigation steps: verify the diagnosis, define and find cases, describe by person/place/time, form a hypothesis, implement control measures, and communicate findings.

Vulnerable populations (homeless, uninsured, rural, older adults) face barriers of access, transportation, cost, and health literacy; outreach and mobile services reduce these barriers.

Handoff communication should use a standardized tool (SBAR, I-PASS) and include a read-back of verbal or telephone orders to confirm accuracy.

Verbal orders are limited to emergencies or specific circumstances per policy and must be documented, read back, and countersigned by the prescriber within the required timeframe.

Objective documentation uses measurable descriptions (e.g., '2 cm x 3 cm wound, red, warm') rather than conclusions ('wound looks bad').

Documentation must be timely, accurate, complete, and legible; chart only care you personally provided or directly observed, and never chart in advance.

Errors are corrected with a single line, the word 'error,' initials, and date; never use white-out, erase, or destroy any part of the record.

Interprofessional collaboration requires role clarity, mutual respect, shared goals, and closed-loop communication; conflict is addressed directly and escalated through the chain of command.

Patient confidentiality applies to all formats including verbal hallway conversations, screens, and social media; minimum necessary information is shared on a need-to-know basis.

Therapeutic communication with cognitively impaired or aphasic patients uses yes/no questions, pictures, and allowing extra response time; validate understanding with teach-back.

Teach-back confirms comprehension by asking the patient to explain or demonstrate the information in their own words, not by asking 'Do you understand?'

Standard precautions apply to all patients: hand hygiene, gloves for contact with blood or body fluids, gown, mask, and eye protection when splash risk exists.

Hand hygiene is the single most effective measure to prevent health care-associated infection; use alcohol-based rub unless hands are visibly soiled, then soap and water.

Additional precautions: contact (MRSA, C. difficile, scabies), droplet (influenza, pertussis, meningococcus), airborne (tuberculosis, measles, varicella) with N95 and negative-pressure room.

C. difficile requires soap and water handwashing because alcohol does not kill spores; use dedicated equipment and bleach-based cleaning.

The chain of infection has six links: infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host; break any link to prevent transmission.

Fall prevention: Morse Fall Scale or similar tool, bed in low position, call bell in reach, non-skid footwear, hourly rounding, and bed alarms for high-risk patients.

Pressure injury staging: stage 1 non-blanchable erythema, stage 2 partial-thickness loss, stage 3 full-thickness loss with visible fat, stage 4 full-thickness with exposed muscle or bone; unstageable when eschar covers the wound.

Quality improvement uses PDSA (Plan-Do-Study-Act) cycles and root cause analysis for sentinel events; report near misses and adverse events through the incident reporting system without blame.

National Patient Safety Goals include correct patient identification, safe use of medications, prevention of surgical site infection, and reducing harm from falls and alarms.