NCLEX-PN cheat sheet

Delegation to unlicensed assistive personnel (UAP) may include vital signs on stable clients, ADLs, ambulation, and intake/output; it may not include initial assessment, care planning, teaching, or evaluation.

The five rights of delegation are right task, right circumstance, right person, right direction/communication, and right supervision/evaluation.

LPN/LVN practice includes collecting data for the RN, administering medications, performing sterile and invasive procedures, and reinforcing teaching; the initial comprehensive assessment and care plan remain with the RN.

Hand-off communication uses SBAR: Situation, Background, Assessment, Recommendation.

An incident report is completed factually and objectively, is never photocopied, and is not referenced in the client's progress notes.

Informed consent is obtained by the provider performing the procedure; the nurse witnesses the signature and verifies the client's understanding and voluntariness.

Violent or self-destructive restraints require a face-to-face provider evaluation within 1 hour and assessment of circulation, sensation, and safety every 15 minutes.

When a provider gives an unsafe order, the nurse withholds the order and follows the chain of command: charge nurse, nursing supervisor, then provider.

Sentinel events (wrong-site surgery, retained foreign body, client abduction, transfusion reaction death) require immediate reporting through the facility risk-management system.

Expected growth: birth weight doubles by 5–6 months and triples by 12 months; length increases about 50% during the first year.

Gross motor sequence: sits unsupported 6–8 months, crawls 8–10 months, pulls to stand 10–12 months, walks alone 12–15 months.

Fine motor sequence: palmar grasp around 5 months, pincer grasp 9–10 months, stacks two cubes around 15 months.

Exclusive breast milk or iron-fortified formula is the sole nutrition for about the first 6 months; honey is withheld until 12 months because of infant botulism risk.

Folic acid 400 mcg daily, begun at least 1 month before conception and continued through the first trimester, reduces neural tube defects.

AAP recommends rear-facing car seats until at least age 2 or until the child reaches the seat's height or weight limit.

Expected pregnancy weight gain: about 1–4.5 kg (2–5 lb) in the first trimester, then roughly 0.4 kg (1 lb) per week thereafter.

Adult screening intervals: colorectal cancer screening from age 45, cervical cytology from age 21, and blood pressure measured at every health visit.

Dietary reference values: fat no more than 30% of total calories, saturated fat under 10%, sodium under 2,300 mg/day, and fiber 25–30 g/day.

Kübler-Ross stages - denial, anger, bargaining, depression, acceptance - are not sequential; clients may move back and forth among stages.

Alcohol and benzodiazepine withdrawal can be fatal; monitor the CIWA-Ar score and anticipate benzodiazepine therapy plus seizure precautions.

Delirium tremens typically peaks 48–96 hours after the last drink, with tachycardia, hypertension, diaphoresis, tremor, agitation, and hallucinations.

Lithium therapeutic range is 0.6–1.2 mEq/L; toxicity shows coarse tremor, vomiting, diarrhea, ataxia, slurred speech, and confusion.

Neuroleptic malignant syndrome presents with fever, lead-pipe rigidity, altered mental status, autonomic instability, and elevated creatine kinase.

In anorexia nervosa, restarting nutrition risks refeeding syndrome - watch phosphorus, potassium, and magnesium and monitor for fluid overload.

Therapeutic communication uses open-ended questions, reflection, restating, clarifying, and silence; it avoids 'why' questions, false reassurance, and personal advice.

Suicide risk is assessed by asking the client directly; the highest-risk indicators are a specific plan, a prior attempt, and access to lethal means.

During a crisis, the priority is physical safety and lethality assessment before exploration of feelings or coping history.

For tube feedings, elevate the head of the bed 30–45 degrees during the feeding and for 30–60 minutes afterward; check residual per facility policy.

Reposition an immobile client at least every 2 hours and use a pressure-redistribution mattress to reduce pressure injury risk.

Braden Scale subscales are sensory perception, moisture, activity, mobility, nutrition, and friction/shear; a total of 18 or less indicates increased risk.

Cold application is used for acute injury in the first 24–48 hours; heat is used later for muscle spasm and is avoided over fresh bleeding, edema, or impaired sensation.

Dysphagia interventions include upright positioning, chin tuck, small bites, and the prescribed thickened-liquid and texture-modified diet level.

Pain tools: 0–10 numeric rating scale for adults, Wong-Baker FACES for children, PAINAD for clients with advanced dementia.

Urinary drainage bags are kept below bladder level and off the floor to prevent urine reflux and infection.

Stage 1 pressure injury is intact skin with non-blanchable erythema; stage 2 is partial-thickness skin loss with a blister or shallow open ulcer.

Constipation management uses increased fluids, fiber, and mobility; stimulant laxatives are contraindicated in suspected bowel obstruction.

Dose formula: (desired ÷ have) × quantity = amount to give; IV rate in gtt/min = (volume in mL × drop factor) ÷ time in minutes.

Conversions: 1 kg = 2.2 lb, 1 tsp = 5 mL, 1 oz = 30 mL, 1 g = 1,000 mg, 1 mg = 1,000 mcg.

Regular insulin is the only insulin given intravenously; when mixing, draw the clear (regular) insulin into the syringe before the cloudy (NPH) insulin.

Antidotes: acetaminophen → N-acetylcysteine; warfarin → vitamin K; heparin → protamine sulfate; opioids → naloxone; benzodiazepines → flumazenil.

Digoxin: hold and notify the provider when the adult apical pulse is below 60/min; hypokalemia increases the risk of digoxin toxicity.

Warfarin therapy targets an INR of 2–3 (2.5–3.5 for mechanical valves); unfractionated heparin targets an aPTT 1.5–2.5 times control.

Therapeutic serum levels: digoxin 0.5–2 ng/mL, phenytoin 10–20 mcg/mL, lithium 0.6–1.2 mEq/L.

Blood transfusion: two-nurse bedside verification, 0.9% sodium chloride as the only compatible fluid, and the first 15 minutes run slowly with the nurse at the bedside.

Aminoglycosides such as gentamicin are nephrotoxic and ototoxic; monitor peak and trough levels plus serum creatinine.

Fall precautions: bed in lowest locked position, call light and belongings within reach, non-skid footwear, clear path, and hourly rounding with toileting assistance.

The surgical time-out occurs immediately before incision, with the team confirming client identity, procedure, site, and side.

Postoperative complications to monitor: atelectasis (fever, decreased breath sounds), DVT, hemorrhage, and wound evisceration.

Evisceration: cover the wound with sterile dressings moistened with 0.9% sodium chloride, position low Fowler's with knees flexed, keep the client NPO, and notify the surgeon.

Standard precautions apply to every client; airborne precautions (negative-pressure room, N95) apply to tuberculosis, measles, and varicella.

Neutropenic precautions: private room, no fresh flowers or plants, no raw fruits or vegetables, visitor screening, and strict hand hygiene.

Early hypovolemic shock: restlessness, tachycardia, narrowing pulse pressure, delayed capillary refill, and decreasing urine output.

Normal adult values: sodium 135–145 mEq/L, potassium 3.5–5.0 mEq/L, WBC 5,000–10,000/mm³, hemoglobin 12–17 g/dL.

High-alert medications - insulin, heparin, opioids, and chemotherapy - require an independent double-check by a second nurse before administration.

Hyperkalemia: tall peaked T waves widening into a prolonged QRS; treat with IV calcium gluconate, insulin with glucose, and a potassium binder.

Hypokalemia: flattened T waves, U waves, and dysrhythmias; replace potassium by infusion pump, never IV push, and confirm adequate urine output.

Metabolic acidosis shows pH below 7.35 with bicarbonate below 22 mEq/L and compensatory Kussmaul respirations; respiratory acidosis shows pH below 7.35 with PaCO₂ above 45 mmHg.

DKA criteria: glucose above 250 mg/dL, arterial pH below 7.3, bicarbonate below 18 mEq/L, and ketones; begin with IV 0.9% sodium chloride, then insulin, and replace potassium.

Hypoglycemia below 70 mg/dL is treated with the 15-15 rule: 15 g of fast-acting carbohydrate, recheck in 15 minutes, and repeat if still low.

Cushing's triad - hypertension with widened pulse pressure, bradycardia, and irregular respirations - is a late sign of increased intracranial pressure.

Prioritization follows ABC: airway, breathing, circulation, then disability; unstable clients are seen before stable ones regardless of report order.

Parkland formula: 4 mL × weight in kg × %TBSA burned; half is given in the first 8 hours from the time of injury and half over the next 16 hours.

MI: troponin rises within 3–6 hours and peaks at 12–24 hours; a 12-lead ECG is obtained within 10 minutes of arrival.