MNMC Nurses' Competency Exam cheat sheet

Incident report (occurrence report) documentation is not part of the medical record and is not referenced in the chart; the chart records objective findings and care given.

Sentinel event: an unexpected occurrence involving death, serious physical or psychological injury, or the risk thereof; requires immediate containment, disclosure per policy, and root cause analysis (RCA).

Root cause analysis asks what happened, why, and what system changes prevent recurrence; it focuses on systems and processes, not individual blame.

Failure mode and effects analysis (FMEA) is proactive: it scores severity × occurrence × detectability to prioritize high-risk processes before harm occurs.

National Patient Safety Goals core items: identify patients with two identifiers, improve staff communication, use medicines safely, prevent infection, identify safety risks, and prevent mistakes in surgery.

Two-patient-identifier rule: use full name plus date of birth or medical record number; never use room number or bed location as an identifier.

Fall risk tools (e.g., Morse Fall Scale) score gait, assistive devices, IV status, mental status, and history; higher scores trigger bed alarm, low bed, and hourly rounding.

Pressure injury staging: Stage 1 non-blanchable erythema; Stage 2 partial-thickness loss with dermis exposed; Stage 3 full-thickness loss with subcutaneous fat visible; Stage 4 full-thickness with fascia, muscle, or bone exposed.

Restraint use requires a time-limited order, face-to-face evaluation by a qualified clinician within one hour for violent restraints, and frequent circulation, skin, and range-of-motion checks.

Chain of infection: infectious agent → reservoir → portal of exit → mode of transmission → portal of entry → susceptible host; breaking any link prevents transmission.

Standard precautions apply to all patients regardless of diagnosis and include hand hygiene, gloves, gown, mask, eye protection, and safe sharps handling.

Hand hygiene is the single most effective intervention; use alcohol-based rub for non-soiled hands and soap and water when hands are visibly soiled or after caring for a patient with C. difficile.

Five moments for hand hygiene: before touching a patient, before a clean or aseptic procedure, after body fluid exposure risk, after touching a patient, and after touching patient surroundings.

Contact precautions (gown and gloves) apply to MRSA, VRE, C. difficile, and scabies; C. difficile also requires soap-and-water handwashing because alcohol does not kill spores.

Droplet precautions apply to influenza, pertussis, meningococcal meningitis, and mumps; a surgical mask is worn within about 3 feet (1 meter) of the patient.

Airborne precautions apply to tuberculosis, measles, varicella, and disseminated zoster; use an N95 or higher respirator and a negative-pressure room with the door closed.

Needlestick after bloodborne exposure: wash the site with soap and water, do not squeeze or scrub, report immediately, and start post-exposure prophylaxis evaluation as soon as possible.

Sterile field rules: sterile items contact only sterile items; any item below waist level or outside the field of vision is considered contaminated.

Six rights: right patient, right drug, right dose, right route, right time, and right documentation; many facilities add right reason and right to refuse.

The Joint Commission requires labeling of all medications and solutions on and off the sterile field, including drug name, strength, amount, diluent, and expiration.

High-alert medications (insulin, heparin, opioids, concentrated electrolytes, chemotherapy) require independent double-checks and standardized concentrations.

Heparin: monitor aPTT for unfractionated heparin and anti-Xa for low-molecular-weight heparin; protamine sulfate is the antidote for heparin.

Warfarin: monitor INR (target typically 2–3); vitamin K (phytonadione) reverses it; fresh frozen plasma is used for active bleeding.

Opioid overdose: give naloxone; titrate to respiratory rate rather than full arousal to avoid precipitating acute withdrawal or pain crisis.

Digoxin: therapeutic level roughly 0.5–2 ng/mL; monitor potassium because hypokalemia increases toxicity risk; digoxin immune Fab is the antidote.

Acetaminophen maximum adult dose is generally 4 g/day (lower in hepatic impairment or alcohol use); N-acetylcysteine is the antidote for overdose.

Insulin onset: rapid-acting (lispro, aspart) about 15 minutes; short-acting (regular) 30–60 minutes; give rapid-acting insulin with meals and never IV push long-acting insulin.

Normal adult vital signs: temperature 36.5–37.5 °C, heart rate 60–100/min, respiratory rate 12–20/min, blood pressure <120/<80 mmHg, SpO2 ≥95% on room air.

ABCDE assessment order: Airway, Breathing, Circulation, Disability (neuro), Exposure; reassess after every intervention.

Glasgow Coma Scale: eye (1–4) + verbal (1–5) + motor (1–6); score 15 is fully alert, ≤8 indicates severe injury and airway concern.

Pulse pressure and mean arterial pressure: MAP ≈ (SBP + 2×DBP)/3; MAP <65 mmHg indicates inadequate organ perfusion.

Orthostatic hypotension: drop of ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 minutes of standing.

Heart sound locations: aortic (2nd right intercostal), pulmonic (2nd left intercostal), Erb's point (3rd left), tricuspid (4th left), mitral (5th left, apex).

Bowel sounds: normal 5–30 per minute; absent sounds require listening up to 5 minutes per quadrant before documenting absence.

Pulse oximetry is unreliable with poor perfusion, motion, nail polish, or carbon monoxide exposure; treat the patient, not the number.

Pain assessment scales: numeric rating (0–10) for adults, Wong-Baker FACES for children, and PAINAD or Abbey for patients with dementia.

Nasogastric tube placement verification: measure pH of aspirate (gastric pH ≤5.5) and use chest X-ray as the definitive confirmation; auscultating air is not reliable.

Urinary catheter insertion: cleanse front to back, maintain sterile technique, insert until urine flows then advance about 2.5 cm more before inflating the balloon.

Tracheostomy suctioning: pre-oxygenate, limit each pass to 10–15 seconds, apply suction only on withdrawal, and allow recovery between passes.

Wound care: clean from least contaminated to most contaminated; irrigate with normal saline under pressure for contaminated or necrotic wounds.

Blood transfusion: verify with a second nurse, use a 0.9% sodium chloride prime, start slowly, and monitor closely for the first 15 minutes for a hemolytic reaction.

Central line care: scrub the hub, use sterile technique for dressing changes, and assess for catheter-related bloodstream infection signs such as fever and site redness.

Specimen collection: label at the bedside in the patient's presence, and collect blood cultures before starting antibiotics when feasible.

Oxygen delivery: nasal cannula 1–6 L/min, simple mask 5–10 L/min, Venturi mask provides precise FiO2, and non-rebreather delivers up to about 90–100%.

Informed consent requires capacity, voluntary decision, disclosure of risks and benefits, and understanding; the provider obtains consent and the nurse witnesses and confirms it.

A competent adult may refuse treatment, including life-sustaining treatment; document the refusal and notify the provider.

Advance directives include living wills and durable power of attorney for health care; a do-not-resuscitate order must be written by a provider to be actionable.

Nurse Practice Acts define scope of practice and are enforced by state boards of nursing; delegation follows the five rights of delegation (task, circumstance, person, direction, supervision).

Mandatory reporting includes suspected abuse or neglect of children, older adults, and dependent adults, and certain communicable diseases; reporting is not optional.

HIPAA permits disclosure of protected health information for treatment, payment, and operations, and for imminent threat or as required by law.

Negligence elements: duty, breach of duty, causation, and damages; the nurse must act as a reasonably prudent nurse in similar circumstances.

Ethical principles: autonomy (self-determination), beneficence (do good), nonmaleficence (do no harm), justice (fairness), and veracity (truthfulness).

Documentation is a legal record; chart objectively, contemporaneously, and never alter or destroy records after an incident.

SBAR: Situation, Background, Assessment, Recommendation; used for structured handoffs and escalation to a provider.

I-PASS: Illness severity, Patient summary, Action list, Situation awareness and contingency planning, Synthesis by receiver; used for shift handoffs.

Closed-loop communication: sender gives a message, receiver repeats it back, and sender confirms accuracy; essential in emergencies and high-risk handoffs.

Teach-back method: ask the patient to explain the teaching in their own words to confirm understanding, rather than asking "Do you understand?".

Health literacy: use plain language, limit to three key points, avoid jargon, and provide written materials at a fifth- to sixth-grade reading level.

Interpreter use: use a qualified medical interpreter, not a family member, for clinical discussions; avoid using children as interpreters.

Conflict resolution: address conflict directly, use "I" statements, focus on the patient's needs, and escalate through the chain of command when unresolved.

Chain of command escalation: notify the charge nurse, then the nursing supervisor, then the provider or administrator if the patient's condition is deteriorating.

Adult CPR: rate 100–120 compressions/min, depth 5–6 cm, full recoil, minimize interruptions to less than 10 seconds, and switch compressors every 2 minutes.

Compression-to-ventilation ratio is 30:2 for one or two rescuers in adults; for children and infants with two rescuers, use 15:2.

Defibrillation: shock immediately for VF or pulseless VT; biphasic dose typically 120–200 J, and resume compressions immediately after the shock.

Shockable rhythms are ventricular fibrillation and pulseless ventricular tachycardia; non-shockable are asystole and pulseless electrical activity.

Reversible causes (Hs and Ts): hypoxia, hypovolemia, hydrogen ion (acidosis), hypo/hyperkalemia, hypothermia; tension pneumothorax, tamponade, toxins, thrombosis, and trauma.

Anaphylaxis: give intramuscular epinephrine 0.3–0.5 mg (1:1000) into the anterolateral thigh, then support airway, oxygen, and IV fluids.

Sepsis bundle: measure lactate, obtain blood cultures before antibiotics, give broad-spectrum antibiotics and 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L.

Stroke: activate stroke protocol, obtain non-contrast CT, and note last known well time; thrombolysis window is generally up to 4.5 hours from onset.

Hypoglycemia: if conscious and able to swallow, give 15–20 g oral carbohydrate; if unconscious, give IV dextrose or IM glucagon and recheck glucose in 15 minutes.