NLN NEX cheat sheet

Standard precautions apply to every client regardless of diagnosis; hand hygiene is the single most effective measure for preventing health care-associated infection.

The six rights of medication administration are right client, right drug, right dose, right route, right time, and right documentation.

Fire response follows RACE: Rescue, Alarm, Contain, Extinguish or Evacuate. Extinguisher use follows PASS: Pull, Aim, Squeeze, Sweep.

A physical restraint requires a provider's order, must be the least restrictive effective option, is reassessed at least every 15 to 30 minutes, and is released with range of motion every 2 hours.

A sentinel event is an unexpected death or serious permanent harm; it requires root-cause analysis and reporting to The Joint Commission within 5 business days.

Informed consent is valid only when the client is competent, receives full disclosure of risks, benefits, and alternatives, comprehends the information, and consents voluntarily.

Emergency Severity Index triage: level 1 requires immediate life-saving intervention, level 2 is high risk, and levels 3 to 5 are ranked by the number of resources needed.

Delegation to unlicensed assistive personnel is limited to predictable, routine tasks; assessment, teaching, evaluation, and initial client education remain with the registered nurse.

Incident reports record objective facts about an event and are not filed in the medical record; charting addresses only the client's condition and the care delivered.

Folic acid 400 mcg daily, begun at least 1 month before conception, reduces the risk of neural tube defects.

Between 20 and 36 weeks' gestation, fundal height in centimeters roughly equals gestational age in weeks; a discrepancy greater than 3 cm warrants evaluation.

Recommended pregnancy weight gain by prepregnancy BMI: underweight 12.5-18 kg, normal 11-16 kg, overweight 7-11.5 kg, obese 5-9 kg.

Exclusive breastfeeding is recommended for about the first 6 months, with iron-rich complementary foods added around 6 months and breastfeeding continued to 12 months or longer.

Developmental milestones: head control 3-4 months, sits unsupported about 8 months, walks independently about 12 months, two-word phrases about 24 months.

Hypertension is defined as blood pressure 130/80 mm Hg or higher; diabetes mellitus is diagnosed at hemoglobin A1c of 6.5% or higher.

Combined oral contraceptives are avoided in smokers older than 35, in clients with prior venous thromboembolism, and in migraine with aura.

Adult immunizations: influenza annually; Td or Tdap every 10 years; herpes zoster from age 50; pneumococcal from age 65 or earlier with risk conditions.

Erikson stages: infancy trust vs mistrust; toddler autonomy vs shame and doubt; preschool initiative vs guilt; school age industry vs inferiority; adolescence identity vs role confusion.

Kubler-Ross stages of dying - denial, anger, bargaining, depression, acceptance - are not linear and may overlap, recur, or be skipped.

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

Ask directly about suicidal ideation, plan, intent, and access to means; asking does not increase risk and determines the observation level required.

Alcohol withdrawal begins within hours of the last drink with tremor, diaphoresis, tachycardia, and anxiety, and can progress to hallucinations, seizures, and delirium tremens.

Refeeding syndrome shows falling phosphate, potassium, and magnesium after nutrition restarts in a malnourished client; feed slowly and monitor electrolytes.

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

Before electroconvulsive therapy: verify informed consent, keep the client NPO after midnight, give the ordered anticholinergic, and expect short-term confusion and memory loss.

Crisis intervention is short-term and targets the immediate stressor to restore the client's equilibrium rather than to change long-standing personality patterns.

Escalating aggression - pacing, clenched fists, loud speech, glaring - is managed with a calm tone, adequate personal space, and an unobstructed exit.

Normal arterial blood gases: pH 7.35-7.45, PaCO2 35-45 mm Hg, HCO3 22-26 mEq/L; oxygenation and acid-base status are interpreted separately.

Serum potassium is 3.5-5.0 mEq/L; hypokalemia flattens T waves and adds U waves, while hyperkalemia produces peaked T waves and QRS widening.

Suspect digoxin toxicity with anorexia, nausea, and yellow-green visual halos; the therapeutic level is about 0.5-2.0 ng/mL and hypokalemia increases toxicity.

Warfarin is monitored by INR, target 2-3 (2.5-3.5 for mechanical valves), with vitamin K as antidote; heparin is monitored by aPTT, with protamine sulfate as antidote.

Acute transfusion reaction: stop the transfusion, keep the vein open with normal saline through new tubing, notify the provider, and monitor vital signs.

Chest tube tidaling in the water seal with respiration is normal; continuous bubbling in the water seal indicates an air leak.

Normal intracranial pressure is 5-15 mm Hg; measures include head of bed at 30 degrees, head midline, and avoidance of hip flexion and Valsalva.

Hypovolemic shock presents with tachycardia, falling blood pressure, narrowed pulse pressure, cool clammy skin, and urine output below 0.5 mL/kg/hr.

Blood glucose below 70 mg/dL is hypoglycemia; a conscious client receives 15 g of fast-acting carbohydrate and is rechecked in 15 minutes.