💊 Nursing · Fundamentals

Memory tricks for nursing fundamentals

Neurovascular checks, trauma assessment, infection control, vital signs, wound care, and core nursing skills.

💊 Nursing Fundamentals

Memory Tricks

Proven Mnemonics & Acronyms — fast to learn, hard to forget.

Circulatory Checks
5 P's
Pain · Paresthesia · Paralysis · Pulse · Pallor
Neurovascular check — assess these 5 every time
Use the 5 P's for every neurovascular check — especially when a patient has a cast, or has had an orthopedic or vascular procedure. Any abnormality signals compromised circulation and requires immediate intervention.
P
Pain — assess location, severity, quality
P
Paresthesia — tingling or numbness indicates nerve compromise
P
Paralysis — inability to move indicates serious compromise
P
Pulse — compare bilaterally, note strength
P
Pallor — paleness or mottling indicates poor perfusion
Trauma Assessment
ABCDEFGHI
Airway · Breathing · Circulation · Disability · Expose · Full vitals · Give comfort · Head-to-toe · Inspect posterior
Systematic trauma assessment — never skip a step
Always begin with ABC and patient safety. Once those are secured move through the framework systematically. Rapid assessment is essential to trauma patient survival — this framework keeps you focused under pressure.
A
Airway — open and patent?
B
Breathing — rate, depth, effort
C
Circulation — pulse, bleeding, perfusion
D
Disability — neuro status, GCS, pupils
E
Expose/Examine — remove clothing, look for injuries
F
Full set of vitals — BP, HR, RR, temp, SpO2
G
Give comfort measures — pain management
H
Head-to-toe assessment — systematic exam
I
Inspect posterior — roll patient, check back
Trauma Surgery History
AMPLE
Allergies · Medications · Past medical history · Last meal · Events surrounding injury
Medical history for every trauma patient before surgery
AMPLE is your rapid medical history tool for trauma patients — especially before they go to surgery. Gathering this information quickly can prevent life-threatening complications during and after the procedure.
A
Allergies — especially medications and latex
M
Medications — current prescriptions, OTC, supplements
P
Past medical history — conditions, surgeries, hospitalizations
L
Last meal — aspiration risk for anesthesia
E
Events surrounding injury — mechanism, timeline
Altered Mental Status
AEIOU TIPS
Alcohol · Endocrine · Insulin · Overdose · Uremia · Trauma · Infection · Psychiatric · Shock
Never assume AMS is neurological — check all causes
Altered mental status has many causes beyond neurological injury. AEIOU TIPS ensures you systematically explore every possibility before concluding the cause. Missing a treatable cause like hypoglycemia or infection can be fatal.
A
Alcohol/drugs — intoxication or withdrawal
E
Endocrine — thyroid, adrenal disorders
I
Insulin — hypoglycemia or hyperglycemia
O
Overdose — medications or substances
U
Uremia — renal failure, toxin buildup
T
Trauma — head injury, hemorrhage
I
Infection — sepsis, meningitis, encephalitis
P
Psychiatric — psychosis, severe depression
S
Shock — any type causing cerebral hypoperfusion
Environmental Health
I PREPARE
Investigate · Present work · Residence · Environmental concerns · Past work · Activities · Referrals · Educate
Assess environmental health risk factors systematically
I PREPARE guides you through a complete environmental health assessment — identifying exposures at work, home, and during daily activities. Environmental factors are often overlooked but can be the root cause of many chronic conditions.
I
Investigate potential exposures
P
Present work — current job hazards
R
Residence — home environment, location
E
Environmental concerns — local pollution, water
P
Past work — previous job exposures
A
Activities — hobbies, recreational exposures
R
Referrals/resources — connect to specialists
E
Educate — teach patient about reducing exposure
🎥 Watch Instead
Maya walks through I PREPARE step by step — 4:15.
Nursing Process
ADPIE
Assessment · Diagnosis · Planning · Implementation · Evaluation
A Delicious PIE — the 5 steps of the nursing process
ADPIE describes the complete nursing process from start to finish. Every patient encounter follows these five steps in order. Mastering ADPIE is essential for NCLEX and clinical practice.
A
Assessment — collect data holistically from the patient
D
Diagnosis — identify the nursing diagnosis from assessment data
P
Planning — create a long-term action plan with the medical team
I
Implementation — assist the patient in carrying out the plan
E
Evaluation — reassess the plan's effectiveness after the set timeframe
Acid-Base Balance
ROME
Respiratory Opposite · Metabolic Equal
Determine respiratory vs metabolic acidosis or alkalosis
ROME helps you interpret arterial blood gas results. Check the pH first, then compare to pCO2 (respiratory) or HCO3 (metabolic) to determine if the values move in opposite or equal directions.
R — Opposite
Respiratory: pH low + pCO2 high, OR pH high + pCO2 low
M — Equal
Metabolic: both pH and HCO3 low, OR both pH and HCO3 high
Health History
SAMPLE
Symptoms · Allergies · Medications · Past history · Last oral intake · Events
Collect a complete health history with SAMPLE
SAMPLE is your guide for collecting a thorough patient health history during assessment. Each letter ensures you don't miss a critical area that could affect diagnosis or treatment decisions.
S
Symptoms — what is the patient currently experiencing?
A
Allergies — what allergies does the patient have?
M
Medications — what is currently being taken?
P
Past medical history — related diagnoses or family history?
L
Last oral intake — when was last medication or food taken?
E
Events — what occurred before the symptoms began?
Level of Consciousness
AVPU
Alert · Voice · Pain · Unresponsive
Rapid consciousness assessment — a condensed Glasgow Coma Scale
AVPU is a quick tool to assess a patient's level of consciousness based on their eye, vocal, and motor responses. It's faster than the full Glasgow Coma Scale and used in rapid assessments and emergencies.
A
Alert — awake, opens eyes voluntarily, moves body
V
Voice — responds to verbal stimuli (sentences or sounds)
P
Pain — only reacts to pain stimuli
U
Unresponsive — no reaction or response of any kind
Sprains & Strains
RICE
Rest · Ice · Compression · Elevation
First-line treatment for sprains and strains
RICE is the standard first-line treatment for musculoskeletal injuries like sprains and strains. Simple, effective, and always testable on NCLEX — every nurse needs to know this cold.
R
Rest — stop activity, protect the injured area
I
Ice — apply for 20 min on, 20 min off to reduce swelling
C
Compression — wrap to reduce swelling
E
Elevation — raise above heart level to reduce edema
Electrolytes
PISO
Potassium Inside · Sodium Outside
Remember where potassium and sodium live in the body
PISO helps you remember the normal location of the two most important electrolytes. This is foundational knowledge for understanding fluid balance, cardiac function, and IV therapy.
P — Inside
Potassium (K+) is found inside the cell (intracellular)
S — Outside
Sodium (Na+) is found outside the cell (extracellular)
Bleeding Precautions
BEEP
Bleeding gums · Epistaxis · Ecchymosis · Petechiae
Minor bleeding precaution signs every nurse must recognize
BEEP helps you remember the four signs of minor bleeding that indicate a patient needs bleeding precautions. These are especially important when caring for patients on anticoagulants or with low platelet counts.
B
Bleeding gums — check during oral care
E
Epistaxis — nosebleeds
E
Ecchymosis — bruising
P
Petechiae — tiny red/purple spots under the skin
NCLEX Priority — ABC
ABC first: Airway → Breathing → Circulation. Then Safety. Then Maslow. 'Airway always wins.'
ABC Priority Framework
The foundational NCLEX priority rule — what to assess and treat first every time
When multiple patients or problems: always prioritize in order. Airway: most critical — no airway = dead in minutes. Breathing: respiratory rate, effort, SpO2. Circulation: pulse, blood pressure, perfusion. Safety: falls, restraints, environment. Then Maslow's hierarchy: physiological → safety → love/belonging → esteem → self-actualization. NCLEX tip: physiological needs always come before psychosocial. Exception: if patient says 'I want to kill myself' — safety overrides physical needs. Actual problems before potential problems. Acute before chronic.
Airway
First — no airway = death
Breathing
Second — rate, effort, SpO2
Circulation
Third — pulse, BP, perfusion
Safety
Fourth — falls, environment
Maslow
Physiological before psychosocial
SATA Strategy
Select All That Apply (SATA): treat each option as True/False independently. Don't look for patterns — every option stands alone.
SATA Questions
The most feared NCLEX question type — and the strategy that makes them manageable
SATA questions have no partial credit — all correct options must be selected. Strategy: cover other options, read each one independently as True/False. Avoid: looking for patterns (2 and 4, all of the above thinking). Each option is its own T/F question. If unsure about one option — ask 'would a safe nurse do this?' Common trap: including an intervention that's appropriate but NOT the priority or NOT related to the specific scenario. Always re-read the stem after selecting to make sure your answers make clinical sense together.
Step 1
Read the stem completely — identify what is being asked
Step 2
Predict correct options before reading choices
Step 3
Evaluate each option independently — TRUE or FALSE, not best of set
Step 4
Select ALL that are correct — no partial credit on NCLEX
Common error
Do NOT look for a magic number of correct answers
Maslow's Hierarchy
Maslow: Physiological → Safety → Love/Belonging → Esteem → Self-Actualization. 'Please Send Love Every Saturday.'
Maslow's Hierarchy of Needs
The framework NCLEX uses to prioritize nursing care — physical needs always come first
Physiological: oxygen, food, water, shelter, sleep, elimination — ALWAYS first priority. Safety: security, protection from harm, falls prevention. Love/Belonging: relationships, family, social connection. Esteem: self-confidence, achievement, respect. Self-Actualization: reaching full potential. NCLEX application: patient with breathing problem AND anxiety → treat breathing first. Patient with pain AND loneliness → treat pain first. Exception: immediate safety threat (suicidal ideation) → safety before some physiological needs.
Physiological
Oxygen, food, water — ALWAYS first
Safety
Protection from harm
Love/Belonging
Relationships, family
Esteem
Self-confidence, respect
Self-Actualization
Reaching full potential
Infection Control — Transmission Precautions
Contact (gloves+gown), Droplet (surgical mask), Airborne (N95 + negative pressure room). 'My Aunt Takes Careful, Droplet, Airborne steps.'
Transmission-Based Precautions
Three types of isolation — knowing which goes with which infection is essential NCLEX content
Standard precautions: for ALL patients — hand hygiene, gloves for body fluids. Contact precautions (gloves + gown): MRSA, VRE, C. diff, scabies, RSV. Private room preferred. Droplet precautions (surgical mask within 3 feet): influenza, pertussis, meningitis (meningococcal), mumps, rubella, strep pharyngitis. Airborne precautions (N95 + negative pressure room): TB, measles (rubeola), varicella (chickenpox), disseminated zoster. Mnemonic for airborne: MTV — Measles, TB, Varicella. N95 must be fit-tested. Patient wears surgical mask when transported.
Contact
Gloves + gown — MRSA, VRE, C. diff
Droplet
Surgical mask — flu, meningitis, mumps
Airborne
N95 + neg pressure — MTV: Measles, TB, Varicella
Vital Signs — Normal Ranges
Normal adult vitals: BP 120/80, HR 60–100, RR 12–20, Temp 36.5–37.5°C (97.7–99.5°F), SpO2 ≥95%.
Normal Adult Vital Signs
The baseline every nurse must know cold — and when to call the provider
Blood pressure: normal <120/80, hypertension ≥130/80, hypotension <90/60. Heart rate: 60–100 bpm. Tachycardia >100 (pain, fever, hypovolemia, anxiety). Bradycardia <60 (athletes normal, beta blockers, increased ICP). Respiratory rate: 12–20 breaths/min. Tachypnea >20 (fever, pain, anxiety, respiratory distress). Bradypnea <12 (opioids — hold medication). Temperature: 36.5–37.5°C. Fever >38°C (100.4°F). SpO2: ≥95% normal, <90% concerning, <88% critical. Pulse pressure: systolic - diastolic = 40 mmHg normal. Widening pulse pressure = increased ICP.
BP
Normal below 120/80 mmHg; Hypertensive crisis above 180/120
HR
Normal 60–100 bpm; Bradycardia below 60; Tachycardia above 100
RR
Normal 12–20 breaths/min; below 12 = bradypnea; above 20 = tachypnea
Temperature
Normal 36.1–37.2°C (97–99°F); Fever above 38°C (100.4°F)
SpO2
Normal 95–100%; Concerning below 92%; Critical below 90%
Pain Assessment
Pain: 5th vital sign. OLDCART — Onset, Location, Duration, Character, Aggravating, Relieving, Treatment. Always ask before giving meds.
Pain Assessment
Comprehensive pain assessment — NCLEX expects nurses to assess before and after every intervention
OLDCART: Onset (when did it start?), Location (where? does it radiate?), Duration (constant or intermittent?), Character (sharp, dull, burning, crushing?), Aggravating factors (what makes it worse?), Relieving factors (what helps?), Treatment (what have you tried?). Pain scales: NRS 0–10 (adults), FACES (children 3+), FLACC (infants/non-verbal — Face, Legs, Activity, Cry, Consolability). Reassess: 30–60 min after oral meds, 15–30 min after IV. Document: location, quality, severity, response to treatment. Pain is subjective — believe the patient.
O
Onset
L
Location + radiation
D
Duration
C
Character — quality
A
Aggravating factors
R
Relieving factors
T
Treatment tried
Fall Prevention
Fall risk: MORSE scale. High risk interventions: bed in lowest position, call light within reach, non-slip footwear, hourly rounding.
Fall Prevention
The most common adverse event in hospitals — preventing falls is a core nursing responsibility
MORSE Fall Scale risk factors: history of falls, secondary diagnosis, ambulatory aid (cane/walker), IV access, gait (weak/impaired), mental status (forgets limitations). High score = high risk. Interventions: bed lowest position and locked, call light within reach, non-slip footwear (socks with grips), keep personal items close, hourly rounding (4 Ps: Pain, Position, Potty, Personal items), bed alarm, yellow armband/door sign. High-risk medications: sedatives, opioids, antihypertensives, diuretics, antidiabetics. Do NOT restrain to prevent falls.
MORSE scale
History of falls, secondary diagnosis, ambulatory aid, IV line, gait, mental status
High risk interventions
Bed lowest, call light within reach, non-skid footwear, hourly rounding
Environment
Clear pathways, adequate lighting, side rails up x2, bed alarm on
Medications
Review sedatives, antihypertensives, diuretics — all increase fall risk
Restraints
Restraints: last resort, require MD order, release every 2 hours, neurovascular checks every 30 min, document every hour.
Restraint Use
Restraints are heavily regulated — the NCLEX tests safe and legal restraint use
Restraints: physical or chemical limitation of movement. Must have: MD order (time-limited), documented clinical justification, less restrictive alternatives tried first. Nursing responsibilities: restraint as LAST resort (try redirection, call family, sitter first). Check every 30 minutes: neurovascular status (circulation, sensation, movement). Release every 2 hours: reposition, ROM, toileting, skin care. Tie to bed frame (NOT side rail) with quick-release knot. Document every hour. Wrist restraints: keep 2 fingers under. Never restrain in prone position. Reassess need every shift.
Order requirement
MD order required; must specify type, reason, and duration
Release schedule
Release every 2 hours for ROM, toileting, skin assessment
Documentation
Check circulation, sensation, movement every 30–60 minutes
Least restrictive
Always try alternatives first — bed alarm, sitter, reorientation
Legal note
Restraints without order = false imprisonment; improper use = negligence
IV Access and Complications
IV complications: infiltration (swelling, cool), phlebitis (red, warm, cord), extravasation (vesicant leaks — tissue damage).
IV Complications
Three common IV complications — assess the site with every intervention
Infiltration: IV fluid leaks into surrounding tissue (non-vesicant). Signs: swelling, cool, pale, pain at site. Stop infusion, remove IV, elevate extremity, warm compress. Phlebitis: vein inflammation. Signs: redness, warmth, pain along vein, palpable cord. Stop infusion, remove IV, warm compress, document. Extravasation: vesicant (tissue-damaging drug) leaks — most serious. Signs: burning, blistering, tissue necrosis. STOP immediately, leave IV in place, aspirate, give antidote per protocol. Examples of vesicants: chemotherapy, calcium chloride, potassium (concentrated), dopamine, vancomycin. Document site every 1–2 hours.
Infiltration
Non-vesicant leak — swelling, cool, pale
Phlebitis
Vein inflammation — red, warm, cord
Extravasation
Vesicant leak — STOP, aspirate, antidote
Therapeutic Communication
Therapeutic communication: open-ended questions, reflection, clarification. AVOID: false reassurance, why questions, giving advice.
Therapeutic Communication
The communication techniques NCLEX tests — and the common mistakes to avoid
Therapeutic techniques: Open-ended questions ('Tell me more about...'), Reflection (repeat back feelings), Clarification ('I'm not sure I understand...'), Active listening, Silence (powerful — allows patient to process), Focusing, Summarizing. Non-therapeutic (AVOID): False reassurance ('Everything will be fine'), Why questions ('Why did you...?' — puts patient on defensive), Giving personal opinions/advice, Changing the subject, Closed questions (yes/no only). For mental health: never argue with delusions, set limits on behavior (not feelings), don't agree with hallucinations but don't argue.
Use
Open-ended, reflection, silence, clarification
Avoid
False reassurance, 'why?' questions
Avoid
Giving advice, changing subject
Documentation Principles
Documentation: if it's not written, it wasn't done. Objective, accurate, timely, complete. Use military time. Never falsify.
Nursing Documentation
The legal and professional rules of nursing documentation — what NCLEX always includes
Charting rules: factual and objective (what you see, hear, smell — not interpretations). Accurate: exact times, measurements, quotes. Timely: document as soon as possible after care. Complete: assessments, interventions, patient response, teaching, referrals. Correct errors: single line through error, write 'error,' date, initials — NEVER white-out or delete. Late entries: clearly label as 'late entry' with date/time of actual occurrence. Legal: medical record is a legal document. Patient quotes: use exact words in quotation marks. Avoid vague terms: 'seems better' → use objective data.
Objective
What you see, hear, measure — not interpretation or opinion
Timely
Document as soon as possible after care — never in advance
Accurate
Use exact quotes; never erase — single line through errors
Complete
If it was not documented, legally it was not done
Confidential
HIPAA — only document in authorized system; no personal devices
Delegation — RN, LPN, UAP
RN delegates to LPN/UAP based on: stability, complexity, predictability. RN cannot delegate assessment, teaching, evaluation, or care planning.
Delegation Framework
What the RN can and cannot delegate — a perennial NCLEX topic
5 Rights of Delegation: Right Task, Right Circumstance, Right Person, Right Direction/Communication, Right Supervision. RN scope: assessment, care planning, teaching, evaluation, complex interventions, unstable patients. LPN scope: stable patients, routine medications (some states IV), wound care, data collection, reinforcing teaching. UAP (CNA) scope: ADLs (bathing, feeding, ambulation), vital signs (stable patients), I&O, specimen collection, positioning. NEVER delegate to UAP: assessment, teaching, evaluation, care planning, unstable patients, complex procedures. RN remains accountable for all delegated tasks.
RN
Assessment, planning, teaching, evaluation
LPN
Stable patients, routine meds, wound care
UAP
ADLs, vital signs, I&O, specimens
Never delegate
Assessment, teaching, unstable patients
🩹 Wound Care
WOUND — Wash, Observe, Use sterile technique, Note drainage, Dress appropriately
WOUND ASSESSMENT AND DRESSING CHANGES
Wound assessment and dressing changes — what to document and when to escalate
Assess every wound: Location, Size (length x width x depth in cm), Edges (well-defined, undermining, tunneling), Color of wound bed (red = granulating/healing, yellow = slough/infection, black = necrotic/eschar), Exudate (color, amount, odor — purulent = infection), Surrounding skin (erythema, warmth, induration, maceration). Dressing principles: wet-to-dry (debrides — change q8h), hydrocolloid (moist healing, non-infected), alginate (heavy exudate), foam (moderate), transparent film (superficial/low exudate). Sterile technique for surgical/chronic wounds; clean technique for chronic wounds per facility policy. Irrigate with normal saline — never hydrogen peroxide (destroys granulation tissue). Document before and after every dressing change. Report: increasing pain, spreading erythema, fever, foul odor, new dehiscence.
Red
Granulating — protect, moist dressing
Yellow
Slough/infection — debride, treat
Black
Necrotic eschar — debride (except heel)
Pink
Epithelializing — nearly healed, protect
🧪 Sterile Technique
WET = CONTAMINATED — if in doubt, throw it out
SURGICAL ASEPSIS AND STERILE FIELD RULES
Sterile technique — the rules of a sterile field and how NCLEX tests them
Surgical asepsis = complete absence of microorganisms. Used for: sterile dressing changes, catheter insertion, IV starts, surgical procedures, LP, thoracentesis. Rules of a sterile field: Only sterile touches sterile — if unsure, it's contaminated. One-inch border around sterile field is considered contaminated. Sterile field must be kept in sight at all times — turn your back = contaminated. Moisture = contamination (wet = pathway for microorganisms). Sterile items below waist level = contaminated. Open sterile packages away from you (flap away first). Pour liquids from a distance — splashing contaminates. Never reach across a sterile field. NCLEX classic: glove tears, items fall below waist, field gets wet — always start over.
WET = CONTAMINATED
Any moisture on sterile field = contamination — discard and restart
If in doubt throw it out
Never rationalize a possibly contaminated item back
1-inch border rule
Edge of sterile field (1 inch) is considered contaminated
Below waist = contaminated
Sterile items held below waist level are contaminated
Sterile to sterile only
Only sterile objects may touch other sterile objects
🫁 Oxygen
NC → SM → NRM — Low to high FiO2 as respiratory need increases
OXYGEN DELIVERY DEVICES — FiO2 AND FLOW RATES
Oxygen delivery devices — matching the device to the patient's needs
Know the FiO2 each device delivers: Nasal Cannula (NC): 1–6 L/min = 24–44% FiO2 (each liter adds ~4%). Simple Mask (SM): 5–10 L/min = 35–50% FiO2 (minimum 5 L to prevent CO2 rebreathing). Partial Rebreather Mask: 6–10 L/min = 40–70% FiO2. Non-Rebreather Mask (NRM): 10–15 L/min = 60–100% FiO2 — highest non-invasive O2 delivery. Venturi Mask: precise FiO2 (24–50%) — best for COPD (prevents suppression of hypoxic drive). High-Flow Nasal Cannula (HFNC): up to 60 L/min, heated/humidified, up to 100% FiO2. NCLEX: COPD patient with hypoxia → Venturi mask (controlled FiO2). SpO2 target: 94–98% most patients; 88–92% for COPD. Humidify O2 at flows >4 L/min.
Nasal Cannula
1–6 L/min → 24–44% FiO2
Simple Mask
5–10 L/min → 35–50% FiO2
Non-Rebreather
10–15 L/min → 60–100% FiO2
Venturi Mask
Precise FiO2 — best for COPD
🚽 Catheter Care
CAUTI prevention — keep it closed, keep it below, keep it clean, remove it ASAP
URINARY CATHETER CARE AND CAUTI PREVENTION
Urinary catheter care — insertion, maintenance, and preventing the #1 HAI
CAUTI (Catheter-Associated Urinary Tract Infection) is the most common healthcare-associated infection. Insertion technique: sterile technique, smallest appropriate catheter size (14–16 Fr adults), cleanse urinary meatus with antiseptic (front to back in females), insert until urine flows then advance 1–2 inches more before inflating balloon. Maintenance: closed drainage system — never open. Catheter secured to inner thigh (female) or upper thigh (male) to prevent traction. Drainage bag always below bladder level — never on floor. Empty when 2/3 full or every 8 hours. Perineal care every shift with soap and water. NEVER disconnect tubing to obtain specimen — use needleless port. NCLEX: question the order — question any catheter order and advocate for removal ASAP. Straight catheter (in/out) preferred over indwelling when possible.
C — Closed system
Keep drainage bag and tubing closed and intact at all times
A — Always below
Drainage bag always below bladder — never on the floor
U — Urine monitoring
Monitor color, clarity, odor, output (report less than 30 mL/hr)
T — Tubing kink-free
Ensure no kinks, loops, or obstruction in tubing
I — Insertion technique
Sterile technique for insertion; clean meatus daily
🌡️ NG Tubes
NAVEL — Nose placement, Aspirate to check, Verify pH, X-ray confirms, Elevate HOB
NASOGASTRIC TUBE INSERTION AND VERIFICATION
NG tube placement and safety — the verification steps that prevent fatal errors
NG tubes are used for: gastric decompression, feeding (small bore), medication administration, lavage. Insertion: measure NEX (Nose-Earlobe-Xiphoid) + 6 inches for placement estimate. Lubricate tip, insert through naris, ask patient to swallow sips of water as tube advances. NEVER force — if coughing/cyanosis, tube is in lungs — withdraw immediately. Verification (NCLEX critical): Gold standard = X-ray confirmation before first use. pH of aspirate: <5 = gastric (safe), 6+ = intestinal or respiratory (do not use). Auscultation of air insufflation is NOT reliable — do not use alone. Mark tube at nostril and check mark each shift. Secure to nose, never forehead. HOB ≥30° during feeding. Check residual before each intermittent feeding — hold if >200–250 mL per facility policy.
N — Nose placement
Insert through naris, measure NEX (nose–ear–xiphoid) for depth
A — Aspirate to check
Aspirate gastric contents — pH less than 5 confirms gastric placement
V — Verify pH
Gastric pH <5; intestinal pH 6–7; respiratory pH >7
E — X-ray confirmation
Gold standard for initial placement verification
L — Low position risk
Never use if placement uncertain — aspiration pneumonia risk
⚖️ Ethics
BAJF — Beneficence, Autonomy, Justice, Fidelity (+ Non-maleficence)
NURSING ETHICAL PRINCIPLES
The four ethical principles — and how NCLEX applies them to patient care scenarios
Autonomy: patient's right to make informed decisions about their own care — even bad ones. Informed consent, right to refuse treatment, advance directives. Beneficence: do good — act in the patient's best interest. Advocate, promote health, prevent harm. Non-maleficence: do no harm — avoid actions that cause harm. Weighing risks vs benefits. Justice: fair, equal treatment — equitable distribution of resources, treating all patients fairly regardless of background. Fidelity: keep promises — follow through on commitments, maintain trust. Veracity: tell the truth — honest communication even when difficult. NCLEX applications: patient refuses blood transfusion (autonomy — respect it), family demands treatment patient declined (autonomy wins over beneficence), resource allocation (justice). Advance directives override family wishes when patient is incapacitated.
Patient refuses tx
Autonomy — respect the decision, document
Family overrides DNR
Advance directive/autonomy prevails
Scarce resources
Justice — fair allocation criteria
Nurse withholds bad news
Violates veracity — not appropriate
🕊️ End of Life
DABDA — Denial, Anger, Bargaining, Depression, Acceptance (Kübler-Ross stages)
DEATH, DYING, AND GRIEF
Kübler-Ross stages of grief — and the nursing response to each stage
Kübler-Ross five stages: Denial ("This can't be happening") — allow denial as coping, do not force acceptance. Anger ("Why me?") — do not take personally, set limits on harmful behavior, therapeutic presence. Bargaining ("If I recover, I'll...") — listen without judgment, allow expression. Depression (grief, withdrawal) — sit with patient, avoid false reassurance, assess for clinical depression. Acceptance (peace, readiness) — facilitate meaningful time, support family. Stages are NOT linear — patients move back and forth. NCLEX nursing priorities at end of life: comfort (pain/dyspnea/anxiety management), dignity, family support, communication. Signs of imminent death: Cheyne-Stokes respirations, mottling, cooling extremities, decreased urine output, loss of reflexes, inability to swallow. Hospice: comfort-focused, curative treatment stopped, family included in care.
D — Denial
This cannot be happening — protect the patient's timeline
A — Anger
Why me — do not take personally; therapeutic presence
B — Bargaining
If I just do X, maybe... — listen without judgment
D — Depression
Sadness and withdrawal — do NOT force positivity
A — Acceptance
Not happiness, but peace — focus on comfort and dignity
NCLEX note
Stages are not linear; patients move back and forth
🌍 Culture
RESPECT — Religion, Explanations, Social factors, Preferences, Empathy, Communication, Trust
CULTURAL COMPETENCE IN NURSING
Cultural competence — how NCLEX tests culturally sensitive nursing care
Cultural competence = providing care that meets social, cultural, and linguistic needs of patients. Key concepts: Cultural awareness (recognizing your own biases), Cultural knowledge (learning about other cultures), Cultural sensitivity (respecting differences), Cultural humility (ongoing learning — not assuming you "know" a culture). NCLEX applications: Always use a professional interpreter for non-English speakers — never use family members or children (privacy, accuracy). Respect religious practices: Jehovah's Witnesses refuse blood products (autonomy), some cultures require same-sex providers, dietary laws (halal/kosher/vegetarian), prayer and healing rituals. Pain expression varies by culture — do not make assumptions. Eye contact, personal space, and touch norms differ. Avoid stereotyping — individual assessment always. Acknowledge and incorporate beliefs into the care plan when safe.
R — Religion
Assess spiritual needs and practices affecting care
E — Explanations
Understand patient's own explanation for their illness
S — Social factors
Family structure, decision-making, social support
P — Preferences
Communication style, touch, eye contact vary by culture
E — Empathy
Non-judgmental listening; do not impose your own values
C — Cultural humility
Ongoing self-reflection — not a one-time competency
T — Trust
Build trust through consistency, respect, follow-through
Communication Tool
SBAR
Situation · Background · Assessment · Recommendation
The Gold Standard for Nurse-to-Provider Handoff
SBAR is the universal communication framework used during handoffs, phone calls to physicians, and critical situation reporting. Joint Commission endorses it as a patient safety tool. In real practice: state the Situation first ("My patient's BP just dropped to 80/50"), then Background, then your Assessment, then what you Recommend.
S
Situation — what is happening right now
B
Background — relevant history and context
A
Assessment — your clinical judgment of the problem
R
Recommendation — what you think needs to happen
Fire Safety
PASS · RACE
Pull · Aim · Squeeze · Sweep — Rescue · Alarm · Contain · Extinguish
Hospital Fire Response — Always on NCLEX
Two mnemonics, one fire emergency. RACE is the response priority order — Rescue patients in immediate danger FIRST before anything else. PASS is how to use the extinguisher. Always aim at the BASE of the fire, not the flames. Critical NCLEX rule: patient safety before property, always.
R
Rescue — remove patients from immediate danger
A
Alarm — activate the fire alarm
C
Contain — close all doors to slow fire spread
E
Extinguish — only if fire is small and contained
🎓 Common Exam Questions
Q: What are the normal adult vital sign ranges?
A: BP: normal below 120/80 mmHg; hypertensive crisis above 180/120. HR: normal 60-100 bpm. RR: normal 12-20 breaths/min. Temperature: normal 36.1-37.2°C; fever above 38°C (100.4°F). SpO2: normal 95-100%; below 92% is concerning; below 90% is critical.
Q: What is the correct procedure for confirming NG tube placement?
A: Aspirate gastric contents — pH below 5 confirms gastric placement. X-ray is the gold standard for initial placement. Do NOT use the auscultation (whoosh) method — no longer reliable. If any doubt — do not use the tube.
Q: What is the CAUTI bundle?
A: (1) Avoid unnecessary catheter insertion. (2) Insert with strict sterile technique. (3) Maintain closed drainage system. (4) Keep bag below bladder at all times. (5) Clean the meatus daily. (6) Remove catheter as soon as possible — reassess need daily.
Q: What are the legal implications of restraint use in nursing?
A: Restraints require a physician order. Release every 2 hours for ROM, repositioning, toileting. Check circulation, sensation, movement every 30-60 minutes. Restraints without order = false imprisonment. Improper use = negligence. Alternatives must be tried first.
Q: What are the five rights of medication administration?
A: Right Patient: check two identifiers. Right Drug: verify name carefully. Right Dose: calculate and double-check. Right Route: wrong route can be fatal. Right Time: critical for antibiotics, insulin, anticoagulants. Add: Right Documentation and Right to Refuse.