NCLEX-RN cheat sheet

Delegation to UAP covers stable-client vital signs, ADLs, ambulation, intake/output, and specimen collection; assessment, teaching, evaluation, and initial care planning stay with the RN, who retains accountability.

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

SBAR (Situation, Background, Assessment, Recommendation) structures handoffs and urgent provider reports to reduce omissions.

Informed consent: the provider obtains and explains it, the nurse witnesses the signature and verifies the client is competent, informed, and acting voluntarily.

Mass-casualty triage tags: red = immediate, yellow = delayed, green = minor/walking wounded, black = deceased or expectant; clients are sorted by survivability, not arrival order.

The Patient Self-Determination Act requires hospitals to ask on admission whether the client has an advance directive and to document the response.

Incident (variance) reports are filed with risk management for unusual events and never become part of the medical record; nursing notes contain only objective facts.

Emancipated minors and unaccompanied adolescents may consent to certain care under state law; verify legal status before treatment.

Hand hygiene is the single most effective measure against health care–associated infection; use soap and water, not alcohol rub, for C. difficile and norovirus because alcohol does not kill spores.

Standard precautions apply to every client: gloves for body fluids, gown/mask/eye protection when splash is likely, hand hygiene before and after contact.

Contact precautions: private room, gloves and gown, dedicated equipment - MRSA, VRE, C. difficile, scabies, draining wounds.

Droplet precautions: private room, surgical mask within 3–6 feet - influenza, pertussis, mumps, rubella, meningococcal meningitis, diphtheria.

Airborne precautions: negative-pressure room with door closed plus N95 respirator - pulmonary TB, measles, varicella, disseminated shingles; only immune staff care for measles or varicella clients.

Restraint order limits: adults 4 hours, ages 9–17 2 hours, under 9 1 hour; face-to-face evaluation within 1 hour; circulation and ROM checks every 2 hours.

Fire response uses RACE (Rescue, Alarm, Contain, Extinguish/Evacuate); extinguishers use PASS (Pull, Aim, Squeeze, Sweep).

Needlestick: wash with soap and water, report immediately, and begin HIV postexposure prophylaxis as soon as possible, ideally within 2 hours.

Erikson stages: trust vs mistrust (0–1), autonomy vs shame/doubt (1–3), initiative vs guilt (3–6), industry vs inferiority (6–12), identity vs role confusion (adolescence), intimacy vs isolation, generativity vs stagnation, integrity vs despair.

Piaget stages: sensorimotor (0–2), preoperational (2–7), concrete operational (7–11), formal operational (11 and older).

Growth norms: birth weight doubles by 5–6 months and triples by 12 months; anterior fontanel closes at 12–18 months, posterior at 6–8 weeks.

Screening: colorectal cancer ages 45–75; cervical cytology starting at 21; mammography individualized beginning at 40–50; bone density from 65.

Adult activity target: 150 minutes of moderate or 75 minutes of vigorous activity weekly plus muscle strengthening twice weekly.

Tdap each pregnancy at 27–36 weeks; inactivated influenza any trimester; live vaccines (MMR, varicella, LAIV) contraindicated in pregnancy and immunocompromise.

Folic acid 400 mcg daily before conception reduces neural tube defects; higher doses are used after a previously affected pregnancy.

GTPAL: gravida, term births, preterm births, abortions, living children.

Therapeutic techniques: open-ended questions, reflection, restating, silence, clarifying, stating observations; avoid why questions, false reassurance, advice, and changing the subject.

Common defense mechanisms: denial, projection, displacement, rationalization, regression, reaction formation, sublimation.

Kübler-Ross stages are denial, anger, bargaining, depression, and acceptance; they are not linear and may recur.

A crisis lasts roughly 4–6 weeks; the goal is return to the pre-crisis level of functioning, and early active intervention is most effective.

Suicide risk: asking does not increase risk; the highest risk is a specific plan with access to lethal means, requiring direct observation and a hazard-free environment - a no-harm contract alone is inadequate.

Alcohol withdrawal: seizures at 6–48 hours, delirium tremens at 48–96 hours (tachycardia, hypertension, fever, tremor, hallucinations); benzodiazepines are first-line.

Anorexia nervosa refeeding: monitor phosphate, potassium, and magnesium; begin calories low and advance slowly.

Suspected abuse: mandatory reporting under state law; interview privately and document objective findings, using a body map when indicated.

Pressure injury prevention: reposition every 2 hours, keep head of bed at or below 30 degrees when possible, use pressure-redistribution surfaces, keep skin clean and dry.

Pain scales: 0–10 numeric for adults; Wong-Baker FACES from about age 3; FLACC for infants and nonverbal clients; PAINAD for advanced dementia.

Dysphagia: sit upright at 90 degrees during meals and for 30 minutes afterward, chin tuck, thickened liquids, small bites.

Enema positioning: left side-lying (Sims) so solution follows the descending colon; container about 12–18 inches above the client.

Sleep hygiene: consistent schedule, no caffeine after midday, limited naps, quiet and dark environment.

Fluid balance: 1 kg of body weight change approximates 1 L of fluid; record intake/output and weigh daily at the same time.

Perineal care is performed front to back; unconscious clients receive oral care in a side-lying position with suction available.

Ambulation: cane on the stronger side with the top at the greater trochanter; walker is advanced first, then the weaker leg.

Five rights (patient, drug, dose, route, time) plus documentation, reason, and client education.

gtt/min = (volume in mL × drop factor in gtt/mL) ÷ time in minutes; mL/hr = total volume ÷ number of hours.

Pediatric dose = (mg/kg/day) ÷ number of doses per day; always verify the ordered dose against the published safe dose range before administration.

High-alert medications (insulin, heparin, opioids, concentrated potassium, chemotherapy, neuromuscular blockers) require an independent double-check and standardized concentrations.

Never give potassium by IV push; usual peripheral infusion is 10 mEq/hr or less with cardiac monitoring at higher rates.

Antidotes: acetaminophen → acetylcysteine; warfarin → vitamin K; heparin → protamine sulfate; opioids → naloxone; benzodiazepines → flumazenil; digoxin → digoxin immune Fab; iron → deferoxamine.

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

Insulin timing: lispro/aspart onset about 15 minutes and peak 1–2 hours; regular onset 30–60 minutes and peak 2–4 hours; NPH peak 4–12 hours; glargine is peakless; only regular insulin is given IV.

Transfusion: two-nurse verification, 0.9% sodium chloride is the only compatible fluid, start slowly and remain with the client for the first 15 minutes.

Normal values: potassium 3.5–5.0 mEq/L, sodium 135–145 mEq/L, calcium 8.6–10.2 mg/dL, magnesium 1.3–2.1 mEq/L, BUN 10–20 mg/dL, creatinine 0.6–1.2 mg/dL, fasting glucose 70–100 mg/dL, platelets 150,000–400,000/mm³, WBC 5,000–10,000/mm³.

ABG norms: pH 7.35–7.45, PaCO2 35–45 mm Hg, HCO3 22–26 mEq/L, PaO2 80–100 mm Hg; ROME - respiratory opposite, metabolic equal.

Postoperative risk reduction: incentive spirometry every 1–2 hours, splinting the incision, early ambulation, and adequate analgesia limit atelectasis, pneumonia, and DVT.

Heparin-induced thrombocytopenia: platelet drop of 50% or more, or below 100,000, at 5–10 days after starting heparin - stop all heparin and use a non-heparin anticoagulant.

Nephrotoxic and ototoxic drugs such as vancomycin and aminoglycosides require peak/trough levels and serum creatinine monitoring.

Preoperative checklist: signed consent, NPO status, allergies, site marking, and a time-out before incision.

Radiation safety follows ALARA: minimize time, maximize distance, use shielding.

Fall precautions: Morse Fall Scale scoring, bed low and locked, call light within reach, non-skid footwear, hourly rounding.

Shock signs: tachycardia, hypotension, tachypnea, oliguria, altered mentation; hypovolemic and cardiogenic shock cause cool clammy skin, while septic and neurogenic shock may present warm and flushed early.

Sepsis bundle: draw lactate and cultures, give broad-spectrum antibiotics within 1 hour, and 30 mL/kg crystalloid for hypotension or lactate 4 mmol/L or greater.

Anaphylaxis: epinephrine 0.3–0.5 mg of 1:1000 IM in the vastolateral thigh first, then airway, oxygen, fluids, antihistamine, and corticosteroid.

DKA: hyperglycemia, ketones, anion-gap metabolic acidosis, Kussmaul respirations; treat with IV fluids, an insulin infusion, and potassium replacement when serum potassium is below about 5.5 mEq/L with adequate urine output.

HHS: glucose often above 600 mg/dL, serum osmolality above 320 mOsm/kg, minimal ketones, profound dehydration and neurologic symptoms.

Acute coronary syndrome: morphine, oxygen only if SpO2 is below 90%, nitroglycerin, aspirin; door-to-balloon time for STEMI is 90 minutes or less.

Heart failure: left-sided causes crackles, orthopnea, and pink frothy sputum; right-sided causes JVD, peripheral edema, and hepatomegaly.

Increased ICP: Cushing's triad of hypertension with widened pulse pressure, bradycardia, and irregular respirations; keep head midline, head of bed 30 degrees, avoid hip flexion and straining.

Burns: Parkland formula 4 mL × kg × %TBSA over 24 hours, with half given in the first 8 hours from the time of injury.