CPNRE / REx-PN cheat sheet

Five rights of delegation: right task, right circumstance, right person, right direction/communication, right supervision/evaluation.

RN delegates to UCP/PCP tasks that are predictable, routine, and have a stable outcome; RN retains accountability for assessment, teaching, and evaluation.

SBAR handoff: Situation, Background, Assessment, Recommendation - use for any transfer of care.

Prioritization: use ABC (airway, breathing, circulation) first; then Maslow (physiological before safety before psychosocial); then acute over chronic, unstable over stable.

Discharge planning begins on admission; include client, family, and interprofessional team.

Conflict resolution: address behavior, not personality; use 'I' statements; escalate to manager if unresolved.

Informed consent: provider obtains; nurse witnesses and verifies client understanding and voluntariness.

Chain of command: charge nurse → nurse manager → house supervisor → administrator; use when scope or safety is unclear.

Standard precautions apply to all clients: hand hygiene, gloves, gown, mask, eye protection based on anticipated exposure.

Transmission-based: contact (MRSA, C. difficile, scabies) - gown/gloves, dedicated equipment; droplet (influenza, pertussis, meningococcal) - surgical mask, 3–6 ft; airborne (TB, measles, varicella) - N95, negative-pressure room.

Hand hygiene: alcohol-based rub for non-soiled hands; soap and water for visible soil, C. difficile, and norovirus.

Seizure precautions: padded side rails, bed low, suction and O2 at bedside, nothing in mouth during seizure, turn to side after.

Fall risk: Morse or Hendrich scale; bed low, call light within reach, non-skid footwear, hourly rounding.

Restraints: require provider order, time-limited, least restrictive, frequent monitoring (circulation, skin, needs), never PRN or punitive.

Needlestick: wash with soap and water, report immediately, source testing and post-exposure prophylaxis per protocol.

Sterile field: 1-inch border is contaminated; keep field above waist; never turn back to sterile field.

Screening: BP annually from 18; colorectal cancer from 50; mammogram 50–74 every 2 years (varies); cervical cancer from 21 every 3 years.

Immunizations: influenza annually; Tdap every 10 years; shingles from 50; pneumococcal from 65.

Stages of change: precontemplation, contemplation, preparation, action, maintenance, termination.

Antepartum: folic acid 400 mcg daily; weight gain based on BMI; kick counts from 28 weeks.

Newborn: vitamin K at birth, erythromycin eye ointment, hepatitis B vaccine within 24 hours.

Developmental milestones: sits unsupported 6–8 months, walks 12–15 months, two-word phrases by 2 years.

Health literacy: use teach-back, plain language, and limit to 3 key points per session.

Therapeutic communication: open-ended questions, reflection, silence, clarification; avoid 'why' questions, false reassurance, and advice.

Grief stages (Kübler-Ross): denial, anger, bargaining, depression, acceptance - not linear.

Suicide risk: direct asking does not increase risk; assess plan, means, intent, and history; remove means; never leave alone.

Alcohol withdrawal: CIWA-Ar; monitor for tremors, tachycardia, hallucinations, seizures; benzodiazepines per protocol.

Delirium vs dementia: delirium is acute, fluctuating, with altered attention; dementia is chronic and progressive.

Anxiety: stay with client, calm environment, breathing techniques; PRN anti-anxiety per order.

Abuse: mandatory reporting; assess in private; document verbatim; do not confront the abuser.

Pressure injury prevention: reposition every 2 hours, Braden scale, moisture management, nutrition (protein, vitamin C, zinc).

Pain assessment: numeric scale 0–10 for adults; Wong-Baker FACES for children; PAINAD for dementia.

Opioid side effects: constipation (stimulant laxative), respiratory depression (monitor RR, sedation scale), nausea (anti-emetic).

Sleep: promote dark, quiet, cool room; cluster care; avoid caffeine and screens before bed.

Nutrition: clear liquid → full liquid → soft → regular; advance as tolerated; monitor bowel sounds.

Urinary catheter care: keep bag below bladder, empty every 8 hours, perineal care daily, remove ASAP.

Mobility: log-roll for spinal precautions; dangle before ambulation; use gait belt.

Six rights: right client, drug, dose, route, time, documentation; plus right reason and right to refuse.

IV flow rate (gtt/min) = (volume × drop factor) / time in minutes.

Dosage calculation: desired dose / have × quantity = amount to administer.

Insulin: rapid-acting (lispro) onset 15 min; regular onset 30–60 min; NPH peak 4–12 h; glargine peakless.

Heparin: monitor aPTT; antidote protamine sulfate. Warfarin: monitor INR; antidote vitamin K.

Digoxin: hold if apical HR <60 in adults; monitor potassium; therapeutic level 0.5–2 ng/mL.

Blood transfusion: first 15 minutes at slow rate, stay with client, monitor for febrile and allergic reactions; stop and maintain IV access if reaction.

TPN: central line, dedicated lumen, monitor glucose and electrolytes; never stop abruptly - taper.

Post-op: monitor for atelectasis (incentive spirometer), DVT (early ambulation, SCDs), infection (temperature, wound), hemorrhage (vitals, dressing).

Lab values: K+ 3.5–5.0; Na+ 135–145; glucose 70–110 fasting; Hgb 12–18; platelets 150–400 K; INR 0.8–1.2.

Hypoglycemia: blood glucose <70; give 15 g fast-acting carb, recheck in 15 min; glucagon if unconscious.

Fall precautions: bed alarm, non-skid socks, hourly rounding, toileting schedule.

Pressure injury staging: stage 1 intact with non-blanchable redness; stage 2 partial-thickness; stage 3 full-thickness; stage 4 to bone/tendon.

DVT prevention: SCDs, compression stockings, anticoagulants; do not massage legs.

Pediatric weight-based dosing: always verify with second nurse for high-alert meds.

Shock: tachycardia, hypotension, tachypnea, cool clammy skin, decreased urine output; treat cause, give O2, fluids, vasopressors.

MI: MONA - morphine, oxygen (if <94%), nitroglycerin, aspirin; monitor for arrhythmias.

DKA: hyperglycemia, ketosis, metabolic acidosis, Kussmaul respirations; treat with IV fluids, insulin drip, potassium replacement.

Heart failure: sit upright, O2, diuretics, monitor daily weight and lung sounds.

COPD: low-flow O2 (1–2 L/min) to maintain SpO2 88–92%; pursed-lip breathing.

Stroke: thrombolytic window 3–4.5 h; assess using NIHSS; keep NPO until swallow screen.

Acute kidney injury: monitor BUN, creatinine, urine output; avoid nephrotoxins; prepare for dialysis if indicated.