Safety rules for the NCLEX

Post-stroke = NPO until dysphagia screened. The 3-oz water bedside test is gatekeeper. Family preference does not override safety screen.

Neutropenic precautions = reverse isolation: protect the patient FROM the environment. Different mindset from contact/droplet/airborne which protect others FROM the patient.

Diffuse, concave (upward-sloping) ST elevation with PR depression points to pericarditis, not STEMI. Pleuritic, positional pain (worse lying flat, better leaning forward) reinforces it. Avoid anticoagulation in pericarditis with effusion — it raises the risk of hemorrhagic tamponade.

A pacemaker spike without a following QRS is not a heartbeat. In a paced patient with new symptoms, calculate the TRUE ventricular rate by counting QRS complexes. Failure to capture is an emergency: bed rest, fall precautions, transcutaneous pacing setup, device interrogation — atropine has limited use because the problem is mechanical, not vagal.

Verbal warnings don't reduce fall risk. Prevention bundle: remove/secure throw rugs, install grab bars, brighten lighting, review high-risk meds (benzos on Beers list), verify walker/cane fit, ensure accessible phone or wearable alert. Engage family in home setup. PT/OT consult for home assessment.

75-80% of dietary sodium is in processed and restaurant food. Effective HF / HTN diet teaching addresses deli, soups, frozen meals, take-out, and condiments — not just the table salt shaker. Teach label-reading (<140 mg = low). Involve the cook + shopper. Daily weight + 2/3 rule (call if gain ≥ 2 lb/day or 3 lb/week). Caution salt substitutes (KCl) if patient is on K-sparing meds.

Suction MOUTH BEFORE NOSE (nose stimulation triggers gasp → aspiration). Apgar 7-10 = good, 4-6 = needs support, 0-3 = resuscitation. Skin-to-skin promotes thermoregulation + bonding + breastfeeding. Prophylaxis: vitamin K 1 mg IM, erythromycin eye ointment, hepatitis B vaccine. Delay first bath ≥ 6-24 hours.

Patients with visual / cognitive / language barriers + social isolation need adaptive teaching: home health, return demonstration, large-print materials, family engagement, phone-camera workarounds, and follow-up scheduling. Off-loading is the single biggest determinant of diabetic foot ulcer healing. A printed handout is documentation, not teaching.

Vancomycin trough: 30-60 min BEFORE next dose. Blood cultures: 2 sets, different peripheral sites, BEFORE antibiotics. 24-h urine: discard first void + collect all + final void at 24 h + keep on ice. AFB sputum x3 early morning + airborne precautions if TB suspected. Always label specimens AT BEDSIDE with 2 identifiers.

UTI in elderly often presents as confusion, falls, decreased appetite, change in baseline function — NOT classic dysuria/frequency. Always consider UTI for any acute change. Treat symptomatic UTI; do NOT treat asymptomatic bacteriuria in elderly (IDSA guidelines — causes resistance + side effects without benefit). Mental status returns to baseline after treatment.

UGIB = hematemesis + melena (source above Treitz; NSAIDs, varices, ulcer). LGIB = hematochezia (source below Treitz; diverticular, AVM, cancer). Both: 2 large-bore IVs + isotonic + type & cross + monitor + reverse anticoag if active bleed. UGIB → EGD + PPI; LGIB → colonoscopy. Resuscitate before scope.

Asterixis + confusion + elevated ammonia in cirrhosis. Treatment: lactulose titrated to 2-3 soft BMs per day (not fixed dose) + rifaximin secondary. IDENTIFY TRIGGER: GI bleed, infection (SBP, UTI, pneumonia), constipation, electrolytes (K + Mg), sedatives, TIPS. Maintain protein 1.0-1.5 g/kg — don't severely restrict (outdated). Diarrhea is goal, not side effect (titrate, don't stop).

Duodenal ulcer = pain 2-3 h after meals + at night (empty stomach, relieved by food). Gastric ulcer = pain with meals. Causes: H. pylori + NSAIDs. Treatment: triple therapy (PPI + clarithromycin + amoxicillin x 10-14 days) or quadruple. STOP NSAIDs. Watch complications: bleeding, perforation, obstruction, malignancy (gastric).

Periumbilical → RLQ pain + McBurney's tenderness + Rovsing's sign + low fever + leukocytosis. Treatment: NPO + IV fluids + IV antibiotic + IV analgesia + ICE (not heat — heat ruptures) + NO laxatives (rupture risk) + lap appendectomy within 24 h. Watch for perforation (sudden pain relief, then diffuse rigid abdomen + fever).

Vesicants (DOX, vincristine): STOP + ASPIRATE WITH IV in place + antidote (dexrazoxane DOX; hyaluronidase vinca). Drug-specific compress (cold for DOX, warm for vinca). Neutropenic precautions when ANC < 500. Body fluids hazardous 48 hr.

Norepi/epi/dopa/vasopressin extravasation = ischemic necrosis. STOP + aspirate + PHENTOLAMINE 5-10 mg SC around site + WARM compress. CENTRAL line preferred for sustained infusion. MAP ≥ 65 in septic shock.

Surgical timeout = correct patient (2 identifiers) + correct site (marked + visible) + correct procedure + position + allergies + antibiotic timing + equipment + imaging + fire risk. Time pressure NEVER overrides verification. Any identifier mismatch = stop until resolved. Any team member, including the nurse, has the authority + the duty to stop.

Cytotoxic spills require chemo spill kit, double-glove + gown + N95 + goggles + shoe covers. Isolate area + move bystanders. Skin contact = wash with soap + water for at least 15 minutes; eye contact = 15-min saline irrigation. Bag contaminated materials in cytotoxic waste container. Incident report + occupational health follow-up — never general housekeeping for cytotoxic.

MRSA, VRE, CRE all require contact precautions (gown + gloves all entry). Use dedicated equipment (stethoscope, BP cuff, thermometer) that stays in the room. Alcohol rub effective for MRSA/VRE/CRE; reserve soap-and-water for C. diff + visibly soiled. Do NOT cohort different MDROs (e.g., MRSA + VRE) in the same room — they can acquire each other. Same organism can be cohorted with infection control approval.

Surgical site infection prevention: pre-op chlorhexidine bath, hair removal with clippers (not razors — razors cause microabrasions), glucose target 80-180 (especially DM), antibiotic within 60 minutes of incision (verify redosing), maintain normothermia (≥ 36°C). Each element is independently linked to SSI risk.

DON: gown → mask → eye protection → gloves. DOFF: gloves → eye protection → gown → mask (mask removed OUTSIDE the room). Hand hygiene between every step. Touch only the inside / clean parts during removal. Never pull a gown over your head (drags contamination across face). Never reuse single-use masks between patients.

Comprehensive geriatric assessment includes cognition (Mini-Cog or MoCA), falls (TUG > 12 sec = high risk), depression (PHQ-9), polypharmacy (Beers list review with pharmacy), ADL + IADL, driving safety, vision + hearing, home safety, social support. Refer PT for balance + falls, SW for social + bereavement, pharmacy for med review.

Use symptom-triggered CIWA-based benzodiazepines (lorazepam) to control withdrawal. Always give thiamine 100 mg BEFORE any dextrose to prevent Wernicke's. Watch the trajectory: rising CIWA + autonomic + early visual hallucinations = pre-DT, treat now. Seizure precautions + sitter + low-stim; restraints are last resort.

Flashbacks are involuntary re-experiencing triggered by sensory stimuli. Step back; identify yourself by name + role; use the patient's name; low voice; orient to present time + place + situation. NEVER touch without permission during a flashback. Ask before flashback what triggers + what helps — apply to care plan + handoff. Restraint re-traumatizes.

Timeline: 6-12 hr minor → 12-24 hr hallucinations → 24-48 hr seizure → 48-96 hr DELIRIUM TREMENS (mortality 15%). CIWA-Ar guides benzodiazepine (lorazepam/chlordiazepoxide) symptom-triggered. THIAMINE 100 mg IV/PO BEFORE GLUCOSE (prevent Wernicke encephalopathy = ophthalmoplegia + ataxia + confusion → Korsakoff). Replace Mg/K/Phos. Seizure precautions. Long-term: naltrexone/acamprosate/disulfiram + AA + counseling.

PPH = EBL > 500 vag or > 1000 C-section. 4 T's: TONE (atony #1) — fundal massage + EMPTY BLADDER + oxytocin → methergine (AVOID in HTN) → carboprost (AVOID in asthma) → misoprostol → TXA → balloon (Bakri) → surgery. TRAUMA (laceration/hematoma). TISSUE (retained — D&C, look for accreta). THROMBIN (DIC — FFP/cryo/platelets). Massive transfusion if continued bleed.

Neonatal sepsis signs: temperature INSTABILITY (often hypothermia not fever), respiratory distress, poor feeding, lethargy, hypoglycemia, jaundice, hypotonia. Early-onset (< 72 hr): GBS, E. coli, Listeria. Workup + empirical AMPICILLIN + GENTAMICIN within 1 hr; don't wait for cultures. RDS in preterm: surfactant deficiency → CPAP first, then SURFACTANT via ETT + mechanical ventilation. Antenatal steroids prevent. Distinguish from TTN (term, post C-section, resolves 24-72 hr), meconium aspiration, pneumothorax, CHD.

Femur/pelvis fracture 24-72 hr post → respiratory (hypoxia, dyspnea) + neuro (confusion, restlessness) + petechial rash (upper body, axilla, conjunctiva). Treatment is SUPPORTIVE: supplemental O2, mechanical ventilation if needed, fluids, hemodynamic support. NO specific antidote. Anticoagulation does NOT treat FES (vs PE — clot vs fat). Differentiate from PE.

Alendronate/risedronate: take in MORNING on EMPTY stomach + FULL glass of water + remain UPRIGHT (sit/stand) ≥ 30 min + no food / other meds / calcium for ≥ 30 min after. Adverse: esophagitis, jaw osteonecrosis (notify dentist before invasive work), atypical femur fractures, hypocalcemia. Add calcium 1000-1200 mg + vit D 800-1000 IU + weight-bearing exercise + fall prevention.

tPA eligibility uses LKW — the last time the patient was confirmed neurologically normal — NOT when symptoms were found. Hypoglycemia is the major mimic; check glucose. Imaging (non-contrast CT) is first to differentiate ischemic from hemorrhagic. Aggressively dropping BP in ischemic stroke can worsen ischemia; allow permissive HTN up to 220/120 unless tPA is planned (then < 185/110).

Sudden 'worst headache of life' that peaks in seconds = SAH until proven otherwise. CT first (most sensitive within 6 h). If CT negative with high suspicion, LP for xanthochromia. SAH BP target SBP < 140–160 to reduce rebleed (UNLIKE ischemic stroke). Start nimodipine 60 mg q4h for 21 days to prevent vasospasm. Secure aneurysm (clip or coil) early.

Postpartum hemorrhage is EBL > 500 (vaginal) or 1000 (C-section) or any sign of hemodynamic compromise. First-line: fundal massage + bladder decompression + increase oxytocin. Second-line uterotonics by patient: methylergonovine NOT in HTN; carboprost NOT in asthma; misoprostol generally OK. Escalate to Bakri/surgery for refractory.

HELLP often mimics flu or indigestion. Look for Hemolysis (LDH, schistocytes, indirect bilirubin) + Elevated Liver enzymes + Low Platelets. Treat as severe-features preeclampsia + plan for delivery. Avoid empiric platelet transfusion without active bleeding/surgery indication.

Abruption = painful, dark bleeding, rigid tender uterus, often hidden volume loss. Previa = painless bright red bleeding. NEVER perform a digital vaginal exam in 3rd-trimester bleeding until placenta location confirmed by ultrasound — exam over previa can cause catastrophic hemorrhage.

Croup = viral, gradual URI prodrome, barking cough, inspiratory stridor, low-grade fever, child alert. Epiglottitis = bacterial (H. flu), sudden high fever, drooling, tripod position, toxic appearance, often unvaccinated. Treatment: croup = cool mist + nebulized racemic epinephrine + dexamethasone; epiglottitis = NO throat exam, keep upright with parent, immediate OR with anesthesia + ENT.

RSV bronchiolitis is viral. AAP guidelines: supportive care (O2 if hypoxic, nasal suction, hydration, isolation). Bronchodilators + steroids NOT routinely recommended. Antibiotics only for secondary bacterial infection. Admission criteria: SpO2 < 90%, severe distress, poor feeding/dehydration, apnea, < 3 mo, high-risk comorbidities.

Down (trisomy 21): hypotonia + flat face + upslanting + single palmar + protruding tongue. Screen: heart (AVSD common), hearing, vision, thyroid, leukemia, atlantoaxial (avoid contact sports if instability), sleep apnea, GI atresia. CP: non-progressive motor disorder; multidisciplinary (PT/OT/SLP/ortho/neuro/nutrition); botox/baclofen for spasticity; feeding/nutrition support. Autism: M-CHAT-R 18+24 mo; early intervention (ABA/SLP/OT) improves outcomes; visual schedules + sensory-friendly + predictable + avoid restraints + parent partnership.

Red flags: injuries inconsistent with mechanism or developmental stage (e.g., spiral femur in non-ambulatory), multiple injuries various healing stages, delay seeking care, story changes, unusual locations (torso/ears/neck/buttocks), patterned injuries (belt, hand, burn), retinal hemorrhage + subdural in infant (shaken baby/abusive head trauma). Nurses are MANDATED REPORTERS — report on REASONABLE SUSPICION (not proof). Skeletal survey + CT + retinal exam. Objective documentation (photos, body diagrams, exact quotes). Screen caregiver for IPV.

Upper airway obstruction in PACU differential: tongue (most common — jaw thrust + airway adjunct), laryngospasm (stridor — BVM positive pressure + jaw thrust ± succinylcholine + reintubation), aspiration (lateral + suction + O2), edema. NC alone can't overcome obstruction. Negative-pressure pulmonary edema can develop after relieved obstruction → O2 + diuretic + supportive vent.

Professional boundaries: decline gifts beyond token (often defined by agency policy), decline off-the-clock visits / dual relationships, decline witnessing patient wills or financial documents (appearance of undue influence). Underlying needs (loneliness, anxiety, isolation) get referred to social work, chaplain, community resources — not nurse extracurricular coverage.

Bladder scan to confirm. For volumes > 800-1000 mL, drain 500-1000 mL initially then clamp + pause 15-30 min before continuing (rapid drainage = mucosal hemorrhage + vasovagal hypotension). Prefer straight cath for one-time; Foley if recurrent. Monitor for post-obstructive diuresis (UO > 200 mL/hr) — replace fluids + monitor electrolytes.

WBC casts = upper tract (pyelonephritis). Fever + flank pain + CVA tenderness. Sepsis criteria + lactate ≥ 2 + hypotension = urosepsis. Sepsis bundle within 1 hr: cultures BEFORE antibiotics, broad-spectrum IV abx within 1 hr, 30 mL/kg crystalloid for hypotension/lactate ≥ 4, reassess. Source control: change/remove Foley if source. Admit for IV antibiotics + fluids.

An ABG read in isolation can mislead. Low pH + high CO2 in a sleepy, hard-to-arouse client is CO2 narcosis — even if SpO2 is acceptable. Do not increase oxygen; that can suppress the remaining respiratory drive. Anticipate non-invasive ventilation.

Dysphagic / stroke patients often aspirate WITHOUT coughing. Suspect aspiration when gastric residuals climb + tachypnea + new crackles + fever appear, even with no obvious cough. HOLD the feed, elevate HOB to ≥45°, verify NG placement, notify provider. Long-term: post-pyloric tube, smaller boluses, swallow re-evaluation.

Active or suspected pulmonary TB requires a negative-pressure room (door closed) with empiric isolation on clinical suspicion. Healthcare workers wear a fit-tested N95 (or PAPR). When the patient must leave the room, the PATIENT wears a surgical mask. Do not confuse contact and airborne; do not use a surgical mask as HCW PPE for TB.

Restraints are last-resort, applied only after less restrictive measures fail, with a specific provider order (type, indication, duration, max time), monitored q15 min for behavior, released q2 h per policy for ROM/skin/toileting. Tie to the bed FRAME with a quick-release knot — never to a side rail. Re-evaluate need every shift. Chemical restraint (sedation for behavior) follows the same rules.

Use 2 identifiers (name + DOB, or name + MR#) at every encounter — every med, every procedure, every specimen, every blood product. Have the patient ACTIVELY state name + DOB when possible (not yes/no to 'are you Mr. Brown?'). Room number and face recognition are NOT identifiers. Same-name patients deserve extra discipline + chart flagging.

Restraint requires SPECIFIC provider order (type + reason + duration + max time) — NO PRN restraint orders. Behavior assessment q15 min while restrained. Release q2h for ROM + skin + toileting + hydration + mental status. Re-evaluation each shift + at order expiration. Discontinue at earliest indication of safety — least-restrictive principle. Documentation must be real-time, not backfilled.