PN Level 1 cheat sheet

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

Delegate only tasks within the UAP's training: vital signs on stable clients, ambulation, feeding, hygiene, intake/output. Never delegate assessment, teaching, evaluation, or nursing judgment.

RN assigns tasks; LPN/LVN scope typically includes stable-client meds, dressing changes, and data collection, but not initial teaching or care planning.

Chain of command: discuss with the charge nurse or provider first; escalate to supervisor or nurse manager, then to administration, documenting each step.

SBAR: Situation, Background, Assessment, Recommendation. Use for handoff and for urgent provider notification.

Informed consent requires capacity, disclosure of risks/benefits/alternatives, voluntariness, and the client's own signature (legal guardian if minor or incapacitated).

Five stages of the nursing process: assessment, diagnosis, planning, implementation, evaluation; evaluation loops back to reassessment.

Discharge planning begins on admission; Medicare requires a discharge plan and the client has the right to appeal a discharge.

Case management coordinates care across settings, controls cost, and monitors outcomes for high-risk or chronically ill clients.

Standard precautions apply to all clients: hand hygiene, gloves for contact with blood/body fluids, gown, mask, eye protection when splash risk exists.

Hand hygiene: soap and water when hands are visibly soiled or after C. difficile/norovirus exposure; alcohol-based rub otherwise, 20 seconds minimum.

Transmission-based precautions: contact (MRSA, C. diff, scabies), droplet (influenza, pertussis, meningitis; mask within 3 feet), airborne (TB, measles, varicella; N95 plus negative-pressure room).

Do not wear artificial nails or nail polish (including gel) when providing direct care to immunocompromised clients; keep natural nails under 1/4 inch.

Needlestick: wash with soap and water, report immediately, and start postexposure prophylaxis per protocol; HIV PEP is most effective within hours.

Fall risk interventions: bed in lowest position, call light within reach, nonskid footwear, hourly rounding, bed alarm; use restraints only for immediate safety and with a provider order.

Restraint rules: least restrictive device, time-limited order (typically 4 hours for adults), face-to-face evaluation, frequent circulation and skin checks, release and repositioning.

Fire safety RACE: Rescue, Alarm, Contain, Extinguish/Evacuate; PASS for extinguisher use: Pull, Aim, Squeeze, Sweep.

Sterile field: 1-inch border is contaminated; never turn your back or reach over the field; any item touching the border is contaminated.

Healthy People framework targets: physical activity 150 minutes/week moderate or 75 minutes/week vigorous, plus 2 days of strength training.

Adult immunizations: annual influenza, Tdap every 10 years (Tdap once in pregnancy, 27-36 weeks), COVID-19 per current schedule, shingles vaccine at 50+, pneumococcal at 65+.

Colorectal cancer screening starts at age 45 (average risk); mammography typically begins at 40-50 depending on guideline; cervical screening from age 21-25.

Growth and development: Erikson stages - trust vs mistrust (infant), autonomy vs shame (toddler), initiative vs guilt (preschool), industry vs inferiority (school age), identity vs role confusion (adolescent).

Piaget: sensorimotor (0-2), preoperational (2-7), concrete operational (7-11), formal operational (11+).

Prenatal care: folic acid 400 mcg daily before conception reduces neural tube defects; weight gain depends on prepregnancy BMI.

Normal newborn: weight 2.5-4 kg, heart rate 110-160, respirations 30-60, temperature 36.5-37.5 C axillary.

Screening: newborn hearing and metabolic screen before discharge; lead screening at 12 and 24 months for at-risk children.

Health belief model: perceived susceptibility, severity, benefits, barriers, cues to action, and self-efficacy predict health behavior.

Maslow hierarchy: physiological, safety, love/belonging, esteem, self-actualization; lower needs are met before higher ones.

Grief stages (Kubler-Ross): denial, anger, bargaining, depression, acceptance - not linear and not required in order.

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

Defense mechanisms: denial, projection, rationalization, displacement, regression, sublimation; identify the mechanism, do not confront it directly.

Suicide risk: direct asking does not increase risk; assess plan, means, intent, and history; contract for safety is not a substitute for observation.

Alcohol withdrawal: monitor CIWA score; risk of seizures and delirium tremens peaks 48-96 hours after last drink; treat with benzodiazepines and thiamine.

Anorexia nervosa: low BMI, fear of weight gain, body image distortion; refeeding syndrome risk means slow caloric increase and electrolyte monitoring.

Therapeutic milieu: consistency, safety, structure, and limit setting; seclusion/restraint requires an order, monitoring, and documentation.

Elder abuse signs: unexplained injuries, dehydration, poor hygiene, fear of caregiver; nurses are mandatory reporters in most jurisdictions.

Positioning: semi-Fowler's for dyspnea, high Fowler's for feeding, side-lying for unconscious clients to prevent aspiration, Trendelenburg rarely used.

Pressure injury staging: stage 1 nonblanchable erythema; stage 2 partial-thickness; stage 3 full-thickness with visible fat; stage 4 exposes bone/tendon; unstageable has eschar.

Turn and reposition at least every 2 hours; offload heels; use a validated risk scale (Braden) and document.

Pain scales: numeric (0-10) for adults, Wong-Baker FACES for children, PAINAD or FLACC for nonverbal or dementia clients.

Opioid side effects: constipation (stimulant laxative prophylaxis), respiratory depression, sedation, nausea; naloxone reverses overdose.

Nutrition: clear liquids (water, broth, gelatin), full liquids (milk, ice cream), soft, mechanical soft; advance diet as bowel sounds return.

Fluid balance: intake includes IV, oral, ice chips (count as half volume); output includes urine, emesis, drainage, stool.

Sleep hygiene: consistent schedule, limit caffeine and screens, quiet environment; assess for sleep apnea with snoring and daytime somnolence.

Oral care for unconscious clients: side-lying, suction available, no fluids by mouth, frequent cleansing.

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

Verify with two identifiers and check allergies before administration; question illegible or unusual orders.

IV flow rate (mL/hr) = total volume (mL) / time (hours). Drip rate (gtt/min) = (volume x drop factor) / minutes.

Dosage calculation: desired dose / have x quantity = amount to give; check pediatric doses against mg/kg and safe range.

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

IV push potassium is never given; concentrated KCl must be diluted and infused via pump with cardiac monitoring.

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

Digoxin: check apical pulse for 1 full minute; hold if adult pulse <60; monitor potassium; antidote digoxin immune Fab.

Insulin: rapid-acting (lispro, aspart) onset 15 min, peak 1-2 h; regular insulin IV is the only insulin given IV; check glucose before meals and at bedtime.

Parenteral nutrition: central line for high dextrose, monitor glucose, taper rate, never stop abruptly; check for refeeding syndrome.

Normal adult labs: Na 135-145, K 3.5-5.0, Ca 8.5-10.5, glucose 70-100 fasting, creatinine 0.6-1.2, BUN 10-20, Hgb 12-18, platelets 150,000-400,000.

Potassium: hyperkalemia causes peaked T waves and dysrhythmias; hypokalemia causes U waves, weakness, ileus.

Sodium: hyponatremia causes confusion and seizures; correct slowly to avoid osmotic demyelination.

Preoperative: verify consent, NPO status (typically 8 h for solids, 2 h for clear liquids), mark site, remove valuables, complete checklist.

Postoperative: monitor airway, vital signs, drainage, and urine output; early ambulation prevents DVT and pneumonia.

DVT prevention: sequential compression devices, early ambulation, anticoagulation per order; assess for unilateral calf pain and swelling.

Fall and pressure injury risk scales (Morse, Braden) guide interventions; reassess at intervals and after change in condition.

Latex allergy: assess for cross-reactivity with banana, kiwi, avocado, chestnut; use latex-free supplies.

Restraint and seclusion monitoring: circulation, skin, hydration, range of motion every 15-30 minutes; document.

Shock: tachycardia, hypotension, tachypnea, cool clammy skin, decreased urine output, altered mental status; treat cause, give oxygen, fluids, vasopressors as ordered.

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

Hypoglycemia: glucose <70 mg/dL; give 15 g fast-acting carbohydrate if conscious, glucagon or IV dextrose if unconscious, recheck in 15 minutes.

Acid-base: respiratory acidosis (low pH, high PaCO2), respiratory alkalosis (high pH, low PaCO2), metabolic acidosis (low pH, low HCO3), metabolic alkalosis (high pH, high HCO3).

Heart failure: assess for crackles, JVD, dependent edema, weight gain; daily weights and fluid restriction; sit upright and give oxygen.

Myocardial infarction: MONA is outdated; give aspirin, nitroglycerin (hold if systolic <90), oxygen only if hypoxic, morphine for unrelieved pain.

COPD: low-flow oxygen (1-2 L/min) titrated to target saturation 88-92%; pursed-lip breathing and tripod position.

Stroke: activate stroke team, note time of onset, obtain CT before thrombolytics; tPA window typically within 3-4.5 hours.

Burn care: rule of nines for TBSA, Parkland formula 4 mL x kg x %TBSA in 24 h (half in first 8 h), maintain urine output 0.5-1 mL/kg/hr.

Nurse practice acts define scope of practice and are enforced by the state board of nursing; they vary by state.

Advance directives: living will specifies treatments; durable power of attorney for health care names a surrogate; DNR requires a provider order.

HIPAA: share only minimum necessary information; exceptions include suspected abuse, communicable disease reporting, and court orders.

Mandatory reporting: suspected child, elder, or dependent adult abuse; communicable diseases; impaired colleagues per state law.

Informed consent is the provider's responsibility to obtain; the nurse witnesses the signature and clarifies, but does not explain risks.

Negligence elements: duty, breach, causation, damages. Malpractice is professional negligence.

Ethical principles: autonomy, beneficence, nonmaleficence, justice, veracity, fidelity, confidentiality.

Incident reports are completed for unusual events, are not placed in the medical record, and are not copied to the client.

Documentation: objective, timely, factual; correct errors with a single line, date, time, and initials; never alter a record.