NCLEX-RN cheat sheet

• Assignment covers routine care within a team member's normal scope; delegation hands off a task outside that routine role to someone with extra training and checked competence.
• The five rights of delegation are right task, right circumstance, right person, right directions and communication, and right supervision and evaluation.

The RN keeps accountability after delegating, not the delegatee alone.

• Acceptable identifiers include the client's full name, date of birth or hospital identification number; the room number is never an identifier.
• Barcode scanning adds a layer of safety but never replaces checking two identifiers and the rights.

Barcode scanning is an extra layer, not a substitute for checking two identifiers and the rights.

• Apgar is scored at 1 and 5 minutes; if the 5-minute score is below 7, it is repeated at 10 minutes.
• Heart rate above 100/min scores 2, below 100/min scores 1, and absent scores 0; heart rate is the most important Apgar sign.

Resuscitation starts as soon as the baby is apneic, gasping or has a heart rate below 100/min, not after the 1-minute Apgar is totaled.

• Latent phase: 0–6 cm, contractions 30–45 seconds every 5–10 minutes. Active phase: 6–10 cm, contractions 40–90 seconds every 2–5 minutes.
• The second stage runs from 10 cm to birth; the third stage runs from birth to delivery of the placenta, which should occur within 30 minutes.

Early decelerations from head compression are common in active labor, not a sign of fetal hypoxia like late decelerations.

• In every state, nurses must report suspected child abuse or neglect, either as named health care professionals or because the state requires all persons to report.
• Reporters share the facts that led to their suspicion; they do not have to prove that abuse or neglect happened.

Report the suspicion, not proof; investigating is the protective agency's job, not the nurse's.

• Appropriate reasons include urinary retention or outlet obstruction, hourly output in critical illness, selected surgeries, healing sacral or perineal wounds with incontinence, prolonged immobilization, and end-of-life care.
• Incontinence care alone, getting a culture from a client who can void, and long postoperative use without an indication are not appropriate reasons.

Keep the drainage bag below the bladder, not on the bed or the floor.

• Protamine sulfate neutralizes heparin and partly neutralizes enoxaparin; it is given by very slow IV injection, no more than 50 mg over 10 minutes.
• Vitamin K reverses warfarin; IV and IM injection can cause fatal hypersensitivity, so subcutaneous is preferred and IV runs no faster than 1 mg per minute.

Leave the air bubble in a prefilled enoxaparin syringe, not expel it.

• Adult ranges used here (Open RN): pulse 60–100/min, respiratory rate 12–20/min, SpO2 95–100%, oral temperature 96.4–99.1°F (35.8–37.3°C), normal blood pressure below 120/80 mm Hg.
• A new change in respiratory rate is one of the earliest clues that a client is declining; overlooking it can lead to harm.

A normal blood pressure does not rule out shock; a rising heart rate and anxiety can come first.

• Normal ABG ranges used here: pH 7.35–7.45, PaCO2 35–45 mm Hg, HCO3 22–26 mEq/L, PaO2 80–100 mm Hg.
• ROME: Respiratory Opposite (PaCO2 moves opposite to pH), Metabolic Equal (HCO3 moves the same way as pH).

Vomiting and gastric suction cause alkalosis, not acidosis; diarrhea causes acidosis.

• Sodium 136–145 mEq/L is the main extracellular electrolyte; where sodium goes, water follows.
• Hyponatremia (often from excess water, hypotonic IV fluids or SIADH) causes headache, confusion, seizures and coma; treatment is limiting water or, if severe, hypertonic saline.

Hyponatremia usually means too much water for the sodium present, not simply too little salt in the diet.