NHRA Nurse Exam cheat sheet

ABCDE priority sequence: Airway, Breathing, Circulation, Disability (neuro), Exposure - reassess after every intervention.

Normal adult vital sign ranges: HR 60-100/min, RR 12-20/min, BP <120/80 mmHg, SpO2 94-100%, temp 36.1-37.2 C (97-99 F).

Early warning triggers: RR >20 or <8, SpO2 <92%, SBP <90 or drop >40 mmHg from baseline, HR >100 or <50, new confusion, urine output <0.5 mL/kg/h.

Level of consciousness: use AVPU (Alert, responds to Voice, responds to Pain, Unresponsive) or Glasgow Coma Scale 3-15; GCS <=8 indicates need for airway protection.

Pain assessment scales: 0-10 numeric rating for adults, Wong-Baker FACES for children, PAINAD or Abbey for patients unable to self-report.

Hypoglycemia is a reversible cause of altered mental status; check glucose in any patient with new confusion, seizure, or focal deficit.

Focused respiratory assessment: rate, depth, symmetry, accessory muscle use, breath sounds (crackles, wheeze, absent), and tracheal deviation.

Shock index = HR / SBP; a value >0.9 suggests occult hypoperfusion even when blood pressure appears normal.

Pulse pressure narrowing (SBP minus DBP <30 mmHg) plus tachycardia is an early sign of compensated hypovolemia.

Oxygen delivery: nasal cannula 1-6 L/min (24-44%), simple mask 5-10 L/min (35-55%), nonrebreather 10-15 L/min (up to 95%), Venturi for precise FiO2.

Isotonic crystalloid bolus for adult hypovolemia is typically 500-1000 mL normal saline or lactated Ringer's, reassessing perfusion after each bolus.

Urine output targets: 0.5-1 mL/kg/h in adults; pediatric minimum 1 mL/kg/h; infants 2 mL/kg/h.

Pressure injury staging: stage 1 nonblanchable erythema, stage 2 partial-thickness loss, stage 3 full-thickness loss, stage 4 exposed bone/tendon/muscle; unstageable when eschar obscures.

Reposition immobile patients at least every 2 hours and use a validated risk tool (Braden) to direct prevention.

Enteral feeding: confirm tube placement by pH or imaging per policy; elevate head of bed 30-45 degrees during and 30 minutes after feeding to reduce aspiration.

Postoperative care priorities: airway patency, oxygenation, pain control, early ambulation, incentive spirometry, and wound assessment.

Fall-risk interventions include bed in lowest position, call light in reach, nonskid footwear, and assisted toileting on a scheduled rounding interval.

Standard precautions apply to all patients: hand hygiene, gloves, gown, mask, eye protection based on anticipated exposure to blood or body fluids.

Hand hygiene moments: before patient contact, before aseptic task, after body fluid exposure risk, after patient contact, after touching patient surroundings.

Transmission-based precautions: contact (MRSA, C. difficile, scabies), droplet (influenza, pertussis, Neisseria meningitidis), airborne (TB, measles, varicella).

N95 or higher respirator with negative-pressure room is required for airborne precautions; surgical mask suffices for droplet.

C. difficile requires soap-and-water handwashing because alcohol rub does not reliably kill spores; gown and gloves for contact precautions.

Needlestick injury: wash immediately with soap and water, report, and initiate post-exposure evaluation; do not squeeze or scrub the site.

The Joint Commission's universal protocol for procedures: verify patient and site, mark the site, and conduct a time-out before incision.

High-alert medications (insulin, heparin, opioids, concentrated electrolytes) require independent double-check and standardized labeling.

Restraint use requires a provider order, time-limited monitoring, and least-restrictive alternatives documented first.

Six rights: right patient, drug, dose, route, time, and documentation; many settings add reason and response.

Therapeutic index = toxic dose / therapeutic dose; narrow-index drugs (digoxin, warfarin, lithium, phenytoin) require serum monitoring.

Digoxin: therapeutic level roughly 0.5-2 ng/mL; early toxicity signs include nausea, visual halos or yellow-green vision, and bradycardia.

Warfarin: monitor INR, target usually 2-3 for most indications; antidote is vitamin K plus prothrombin complex concentrate for major bleeding.

Heparin: monitor aPTT or anti-Xa; antidote is protamine sulfate; monitor platelets for heparin-induced thrombocytopenia.

Opioid overdose triad: pinpoint pupils, respiratory depression, and decreased consciousness; antidote is naloxone.

Insulin onset: rapid-acting lispro/aspart 10-15 min, short-acting regular 30-60 min, intermediate NPH 1-2 h, long-acting glargine 1-2 h with no peak.

IV push rate for most adult medications is limited by manufacturer and policy; verify compatibility and flush between incompatible drugs.

High-risk pediatric dosing is weight-based in kg; verify weight in kilograms, not pounds, before calculating dose.

Informed consent requires capacity, disclosure of risks/benefits/alternatives, voluntariness, and the patient's authorization; the provider obtains consent, the nurse witnesses.

A competent adult may refuse treatment even if refusal risks death; document capacity assessment, teaching, and the refusal.

Mandatory reporting duties typically include suspected child abuse, elder abuse, and certain communicable diseases, per jurisdiction.

Negligence elements: duty, breach of duty, causation, and damages; all four must be shown.

Nurse practice acts define scope of practice and delegation; unlicensed assistive personnel may perform tasks but not nursing assessment or judgment.

Ethical principles: autonomy (self-determination), beneficence (do good), nonmaleficence (avoid harm), justice (fair distribution), fidelity (keep promises).

Advance directives include living wills and durable power of attorney for health care; they take effect when the patient loses decisional capacity.

HIPAA permits disclosure of protected health information only for treatment, payment, operations, or as required by law or authorized by the patient.

SBAR handoff structure: Situation, Background, Assessment, Recommendation - used for provider calls and shift reports.

Documentation standards: objective, timely, accurate, complete, and legible; record facts and observations, not opinions or blame.

Late entries must be labeled as late, dated and timed with the actual entry time, and never alter an earlier note.

Teach-back confirms understanding: ask the patient to explain the plan in their own words; a nod is not evidence of comprehension.

Use a qualified medical interpreter for patients with limited English proficiency; family members, especially children, should not interpret.

Closed-loop communication: sender states the message, receiver repeats it back, sender confirms accuracy.

Discharge planning begins at admission and includes medication reconciliation, follow-up appointments, and written instructions.

Conflict resolution uses the chain of command; unresolved safety concerns escalate to charge nurse, supervisor, or rapid response.

Systolic murmur radiating to the carotids with a thrill suggests aortic stenosis; exertional syncope plus angina is a classic triad.

Cushing triad (hypertension, bradycardia, irregular respirations) signals rising intracranial pressure and impending herniation.

Orthostatic hypotension is a drop of at least 20 mmHg systolic or 10 mmHg diastolic within 3 minutes of standing.

Pulse deficit (apical minus radial rate) suggests atrial fibrillation and should be reported.

DVT assessment: unilateral calf pain, swelling, warmth, and erythema; avoid vigorous massage due to embolus risk.

Hypoxia may present first as restlessness or confusion, especially in older adults, before desaturation is measured.

A drop in level of consciousness is the most sensitive early indicator of neurologic deterioration.

Suction only when indicated, limit each pass to 10-15 seconds, and preoxygenate to prevent hypoxemia and vagal bradycardia.

Tracheostomy care: clean around the stoma, secure ties with two fingers of slack, and keep replacement and obturator at bedside.

Wound drainage documentation includes type (serous, sanguineous, serosanguineous, purulent), amount, odor, and surrounding skin.

Nasogastric decompression uses low intermittent suction; verify placement before use and monitor for electrolyte loss.

Blood transfusion: first 15 minutes run slowly with close observation for febrile, allergic, or hemolytic reactions.

Fever, chills, flank pain, and dark urine after transfusion suggest an acute hemolytic reaction; stop the transfusion immediately.

Early mobilization reduces postoperative complications including atelectasis, DVT, and ileus.

Surgical site infection prevention: prophylactic antibiotic within 60 minutes of incision, glucose control, normothermia, and hair removal with clippers.

Catheter-associated UTI prevention: avoid unnecessary catheters, maintain closed drainage, keep bag below bladder, and remove promptly.

Central line care: scrub the hub, use sterile dressing changes, and assess for line-related infection with new fever.

Fall risk increases with sedatives, antihypertensives, diuretics, and anticoagulants; review medications after any fall.

Do not recap needles; use the sharps container at the point of use and never overfill.

Isolation signage and patient transport rules must be followed; notify receiving departments before transporting a patient in precautions.

Elopement risk requires environmental assessment and identification of patients with cognitive impairment.

Beta-blocker teaching: do not stop abruptly; monitor for bradycardia, fatigue, and bronchospasm; hold parameters per order.

Loop diuretics (furosemide) require monitoring of potassium, magnesium, renal function, and daily weight.

ACE inhibitor adverse effects: dry cough and hyperkalemia; angioedema is an emergency.

Aminoglycosides (gentamicin) are nephrotoxic and ototoxic; monitor peak and trough levels and creatinine.

Vancomycin requires trough or AUC monitoring; rapid infusion causes flushing ('red man syndrome').

Anticoagulant reversal: warfarin-vitamin K, heparin-protamine, dabigatran-idarucizumab.

Corticosteroids can cause hyperglycemia, fluid retention, and infection risk; taper rather than stop abruptly.

Medication reconciliation compares home, admission, and discharge lists to prevent duplication and omission errors.

A nurse may not accept an assignment outside competence without seeking supervision or education; document the concern and notify the supervisor.

Patient identifiers must be verified with two identifiers before medication, transfusion, or procedure.

Good Samaritan laws protect off-duty emergency assistance in most jurisdictions; scope and conditions vary.

Assault is the threat of harm; battery is unauthorized touching. Restraints and forced care may constitute battery.

Documentation of an incident report goes into a separate risk-management system, not the patient's chart.

Breach of confidentiality includes discussing patients in public areas or on social media without authorization.

Ethical dilemma resolution uses a structured process: identify the problem, gather facts, consider options, act, and evaluate.

I-PASS handoff: Illness severity, Patient summary, Action list, Situation awareness, Synthesis by receiver.

Use plain language and limit teaching to 3-5 key points per session, with written reinforcement.

Cultural humility includes assessing health beliefs, decision-making roles, and language preference.

Care coordination requires accurate medication lists, allergy documentation, and identification of the durable power of attorney.

Documented discharge teaching should include who was taught, what was taught, and the patient's response.

Nurse-sensitive indicators include falls, pressure injuries, CAUTI, CLABSI, and medication errors.

Escalation of a deteriorating patient should not wait for physician availability; activate the rapid response team per protocol.

The first step in clinical judgment is recognizing and analyzing cues from assessment data, not acting immediately.

Triage acuity systems (ESI) assign level 1 to patients requiring immediate life-saving intervention.

Capillary refill >3 seconds, cool extremities, and mottling indicate poor peripheral perfusion.

Fever in a neutropenic patient is an emergency requiring immediate cultures and antibiotics.

Assess for orthostatic changes before ambulating patients at risk of falls.

Chest tube drainage: never clamp without an order; monitor for tidaling and >100 mL/h of bright red drainage.

Incentive spirometry is most effective when performed 10 times per hour while awake with sustained maximal inspiration.

CPR quality: compressions at 100-120/min, depth 5-6 cm in adults, full recoil, minimize interruptions to <10 seconds.

Defibrillation for VF or pulseless VT is delivered immediately upon recognition, with compressions resumed right after the shock.

Pain management uses multimodal analgesia to reduce opioid dose and adverse effects.

Medical asepsis reduces organism transfer; surgical asepsis eliminates all microorganisms from objects and the field.

Sterile field rules: only sterile items touch the field; any break in sterility requires replacement.

Two-person verification is required for blood products and for high-alert medication administration.

Electrical safety: never use equipment with frayed cords; avoid extension cords and keep liquids away from devices.

Environmental cleaning reduces transmission of C. difficile and MRSA; shared equipment must be disinfected between patients.

Pediatric safe dose range compares calculated dose to mg/kg/day or mg/kg/dose; report doses outside the range.

IV fluid rate in mL/h is calculated from volume divided by hours; gravity drip rate uses drop factor divided by minutes.

Enteral medications should be given separately with flushes; do not crush extended-release forms without verification.

Naloxone duration is shorter than most opioids, so repeat dosing and monitoring are required.

Antibiotic stewardship: narrow spectrum when culture results allow, and complete the ordered course.

A nurse's first duty in an unsafe situation is patient safety; document facts and notify the chain of command.

Delegation requires the right task, circumstance, person, direction and communication, and supervision.

Informed refusal must be documented with the patient's understanding of consequences.

Confidentiality exceptions include reportable diseases, suspected abuse, and court orders.

Professional boundaries prohibit personal financial or romantic relationships with current patients.

Active listening techniques include open-ended questions, reflection, and summarizing.

Written materials should be at or below a sixth- to eighth-grade reading level for patient education.

Interdisciplinary rounds improve coordination and reduce length of stay.

Documentation of critical values includes notification of the provider, orders received, and read-back confirmation.

Transition-of-care failures are a leading cause of readmission; medication reconciliation is a core countermeasure.