Therapeutic communication rules for the NCLEX

MDRO transfers require advance communication + private room + transport precautions. Never transfer 'and figure it out later'.

Pink/red = healthy. Pale pink = monitor + workup (Hb, hydration). Purple/dusky = ischemia, notify surgeon STAT. Black = necrosis, surgical emergency. Always document color + size + output. Initial post-op output expected within 24-48 h; delayed output + dusky stoma = ischemia / obstruction.

Infiltration = non-vesicant fluid in tissue. Extravasation = VESICANT fluid in tissue (chemo, vasopressors, calcium, contrast — TISSUE NECROSIS RISK). For both: STOP infusion + remove IV + elevate + restart IV at a new site. Extravasation adds: drug-specific antidote + drug-specific compress (cold for anthracyclines, warm for vinca) + escalation.

Even a skilled, willing nurse must decline tasks outside their competency (e.g., a non-chemo-certified RN should not hang chemotherapy). The 'right person' has BOTH the license and the institutional competency. Refuse the specific task, escalate to find a credentialed nurse, and document — do not refuse the entire assignment.

Capacity is assessed at bedside, decision-specific, can vary day-to-day. 4 elements: UNDERSTAND, APPRECIATE, REASON, COMMUNICATE. Dementia diagnosis does NOT automatically remove capacity. Competence is a court determination — different concept. Cannot override a capable patient's autonomy, even by family. Engage ethics + palliative + chaplain for difficult conversations.

ACP = living will (wishes) + DPOA (decision-maker) + POLST/MOLST (portable medical orders). Do during stable time, NOT crisis. Use values-based questions: 'What matters most?' 'When is enough enough?' Engage family + chaplain + social work + palliative. Document + revisit (values can change). POLST travels with patient + EMS honors it.

Patient threats or visible/suspected weapons = withdraw to safe distance, maintain clear exit path, call workplace violence / security code, evacuate other patients + family, and verbally de-escalate while trained team responds. Never approach to 'investigate' an object. Never solo restraint. Document + follow up with manager + occupational health.

Two-step screening: PHQ-2 (≥ 3 = proceed to PHQ-9) + GAD-2 (≥ 3 = proceed to GAD-7). Always DIRECTLY assess suicide when concerning statement or positive screen — plan, means, intent, timeline. C-SSRS for risk stratification. Imminent SI = warm handoff to ED / psych emergency + safety plan + means restriction, NOT next-week appointment. Asking about suicide saves lives.

The provider performing the procedure obtains informed consent (procedure, risks, benefits, alternatives). The RN witnesses the signature, confirms the patient is alert/unsedated/uncoerced, and reinforces afterwards. If the patient is confused, doesn't understand, or has been sedated — STOP. RN does not substitute for the provider, does not 'just get the signature.'

When a patient cannot speak, the legally named healthcare proxy (DPOA) decides — using the patient's documented Living Will/advance directive as their guide. Other family members do NOT override. The RN's role is to advocate for the directive, facilitate family meetings with palliative + ethics consults, and document. The loudest voice in the room is not the legal authority.

After a medication error: (1) clinical response — assess, notify provider, monitor for harm; (2) ethical disclosure — patient and family told (typically with provider); (3) chart the clinical event in the medical record; (4) submit the incident report SEPARATELY to risk management/QI — it is NOT part of the medical record. Charge nurse preference cannot override disclosure duty; use chain of command if pressured.

'Stable' must be confirmed against the chart, not accepted at face value. Use structured SBAR (Situation, Background, Assessment, Recommendation) with a readback. Receiving RN owns verification: review meds, labs, lines, drips, recent events. Surface gaps to the sender and to your charge; document. Handoff failures are a top patient-safety event.

A competent adult has the right to refuse any treatment, even life-saving. The RN's job: ensure capacity (alert, oriented, free of coercion), confirm understanding of consequences (often with provider), document verbatim, coordinate transition (palliative, hospice, social work), and SUPPORT — not persuade or coerce. Treatment without consent = battery.

When the direct supervisor (charge nurse) won't act on a safety issue, the RN escalates: charge → house/nursing supervisor → medical director / administrator on call. Document every step (who, when, what was said, outcome). Patient-safety duty overrides hierarchy inertia. Skip a tier only when the immediate harm is imminent and the next tier is unreachable.

A discharge is safe only when ALL of: medical stability, functional ability (mobility + ADLs), social support (or home health arranged), affordable meds + DME, and verified med understanding (teach-back). RN advocates against premature discharge driven by bed pressure. Schedule follow-up before discharge — within 7 days for HF/COPD/post-procedure.

Therapeutic responses name the feeling and invite more (open-ended). They do not minimize, reassure, instruct, or redirect. Asking directly about suicide does NOT 'plant the idea' — it clarifies risk. Screen plan, means, intent, timeline. Engage the multidisciplinary team early.

Giving away possessions, securing pet care, writing goodbye notes, putting affairs in order — combined with a sudden mood improvement — is the most dangerous time. Do NOT take the calm at face value. Direct suicide screen: 'Are you thinking about ending your life?' Plan + means + intent + timeline. Warm handoff to inpatient psych. Asking does NOT plant the idea.

BPD patients may split staff into 'good' (you) vs 'bad' (colleague). Don't accept the praise; don't accept the criticism of teammate. Reflect back: 'I'm sure my colleague is following the same plan.' Hold the team line consistently. Acknowledge feelings + redirect to coping. Communicate to the team to maintain consistency.

Severe features: BP ≥ 160/110, plt < 100, LFTs 2× normal, Cr > 1.1, severe HA/visual, pulmonary edema, RUQ pain. Management: MgSO4 4-6 g load + 1-2 g/hr × 24 hr (SEIZURE prophylaxis, NOT antihypertensive). IV antihypertensive for SBP ≥ 160: labetalol 20 mg q10 min escalating, hydralazine 5-10 mg q15-20 min, nifedipine PO. DELIVERY definitive. Eclampsia (seizure): left side + Mg bolus + deliver. HELLP variant. Calcium gluconate antidote at bedside.

Convulsive status epilepticus = seizure > 5 minutes (or recurrent without recovery). Step ladder: airway/oxygen → IV access → IV benzo → 2nd-line load (levetiracetam / fosphenytoin / valproate) → general anesthesia. Don't keep giving benzos without escalating; don't insert bite blocks.

Hospice = comfort-focused care for life expectancy ≤ 6 months when curative treatment no longer effective. Palliative care = any stage, alongside treatment; hospice = end-of-life. Discussion: explore values, validate emotions, reframe as active comfort care, document advance directive + DNR, plan symptom management (pain, dyspnea, nausea, secretions, agitation), connect with hospice team, support family + cultural/spiritual needs. Avoid false reassurance.

STOP infusion immediately. Aspirate residual from catheter (do NOT flush). Apply drug-specific compress: COLD for anthracyclines (doxorubicin, daunorubicin); WARM for vinca alkaloids (vincristine, vinblastine). Anthracycline antidote = dexrazoxane within 6 h. Elevate, photograph, document, escalate. Future doses via central line.

SBAR: Situation + Background + Assessment + Recommendation. Bedside with patient when possible. Visual check of lines + drains + dressings. Read-back/verify by receiving RN. Document RN-to-RN hand-off. Include: VS trend, pain regimen + last dose, allergies, lines, drains, pumps, restrictions (NPO, activity), DVT prophylaxis, pending orders, family communication. Closed-loop communication prevents sentinel events.

Aldrete score (activity, respiration, circulation, consciousness, color/SpO2; ≥ 9). Same-day discharge add: stable VS, pain controlled oral, no/minimal nausea, voided (if criteria), adult driver + home support, written + verbal instructions + teach-back. Restrictions × 24 hr after general/sedation: NO driving, signing important documents, heavy machinery, alcohol, big decisions. Discharge teaching includes signs to call surgeon vs ED.

Telephone orders are a top medication-error source. Always READ BACK the order to the provider, clarify unclear or unusual doses (use pharmacy as a verification resource), document the conversation + time + read-back, and ensure provider co-signature per institutional policy (typically within 24 hours). Never enter a verbal order blindly to 'save time.'

When a patient has multi-domain barriers (housing, insurance, equipment, mental health, social support), case management is the lead role. The nurse facilitates handoff, documents barriers, ensures medical follow-up + teaching, and helps coordinate interim placement (e.g., subacute rehab) while case manager works longitudinal plan. Don't solo discharge a multi-barrier patient.

When a colleague's behavior repeatedly affects patient safety, the professional path is direct conversation first (private, supportive, specific examples), then documented escalation to manager if unchanged. Triangulation through gossip damages teams + doesn't fix the issue. Never just keep fixing it silently — both safety and team norms degrade.

Documentation reflects ACTUAL assessment + interventions — copy-forwarding without editing every changed field is documentation fraud + clinical risk. Alert fatigue is a system problem; raise tuning concerns with informatics rather than auto-dismiss. Downtime preparation: print MARs + active orders + downtime forms ahead of scheduled outages.

Cognitive performance after extended wakefulness is comparable to legal intoxication. Decline overtime that pushes you past your safety threshold (some states prohibit mandatory overtime). Offer a brief stay for safe handoff if helpful. Always do SBAR handoff — walking out without handoff is abandonment. Document staffing concerns through formal channels.

At end of life, the RN's role is presence at the bedside, clarification of medical terms the family heard from the team, explanation of the dying process and symptom-management plan (pain, secretions, dyspnea), advocacy for documented wishes (DNR/DNI), and coordination of chaplain / social work / palliative. The RN does not prognosticate — but does NOT deflect either.

New-diagnosis teaching is not one lecture. Use an interpreter when needed. Chunk by priority: safety red-flags first, then the patient's own questions, then medication, then lifestyle. Teach-back after each chunk. Provide written materials in the patient's language. Schedule follow-up. Documentation includes WHAT the patient could repeat back.

When a parent or patient is hesitant: acknowledge, ask permission, share evidence, RECOMMEND strongly, respect autonomy, document. Lecturing or dismissing increases reactance and damages trust. Offer partial steps if a full plan is declined (other vaccines today, follow-up scheduled).

Hospital uses HICS (Hospital Incident Command System). Mass casualty triage = greatest good for the greatest number (RED/YELLOW/GREEN/BLACK). If outside your training, communicate the gap + accept paired role rather than blanket refusal. Decon if hazmat. Family reunification area separate from clinical zones. Surge capacity through discharge/transfer of stable inpatients.

When floated, accept tasks within your scope + competency. For unfamiliar high-risk tasks (e.g., a drip you've never used), communicate the gap + request paired support from a unit RN. Never blanket refuse (abandons patients) + never accept outside scope to 'prove yourself' (license + safety risk). Document conversations.