- CMSRN
- Certified Medical-Surgical Registered Nurse — the most widely held med-surg credential, awarded by the MSNCB to RNs who pass the medical-surgical nursing certification exam.
- MSNCB
- Medical-Surgical Nursing Certification Board — the credentialing arm of the Academy of Medical-Surgical Nurses (AMSN), which owns the CMSRN exam.
- Five rights of medication administration
- Right patient (two identifiers), right drug, right dose, right route, and right time — expanded sets add documentation, reason, response, education, and the right to refuse.
- High-alert medication
- A drug with a heightened risk of serious harm if given in error (insulin, anticoagulants, opioids, concentrated electrolytes); requires an independent double-check.
- IV potassium chloride administration
- Always diluted and infused slowly by pump (≤10 mEq/hr peripherally) with cardiac monitoring — NEVER given IV push and never undiluted, because a rapid bolus can be fatal.
- Standard precautions
- Infection control applied to every patient at all times; treat all blood and body fluids as potentially infectious. Hand hygiene is the single most important measure.
- Contact precautions
- Gown and gloves and dedicated equipment for organisms spread by touch — MRSA, VRE, C. difficile, RSV, and scabies.
- Droplet precautions
- A surgical mask within about 6 feet for organisms spread by respiratory droplets — influenza, pertussis, and meningococcus.
- Airborne precautions
- An N95 respirator and a negative-pressure room with the door closed for airborne organisms — tuberculosis, measles, and varicella.
- C. difficile hand hygiene
- Use soap and water (and bleach cleaning), not alcohol-based rub — alcohol does not kill C. difficile or norovirus spores.
- Restraint rules
- A last resort after least-restrictive alternatives fail; requires a provider order (never PRN), is time-limited and monitored, and is tied with quick-release knots to the movable bed frame.
- Sentinel event
- A patient-safety event causing death, permanent harm, or severe temporary harm; it triggers a root cause analysis.
- Just culture
- A safety culture that distinguishes honest human error from at-risk and reckless behavior, encouraging non-punitive reporting of errors and near-misses.
- Root cause analysis (RCA)
- A reactive, retrospective method used after an adverse event to find the underlying system causes — 'why did this happen?'
- Failure Mode and Effects Analysis (FMEA)
- A proactive method used before a process launches to identify and reduce risk — 'what could go wrong?'
- Braden Scale
- A validated tool that predicts pressure-injury risk by scoring sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
- Unstageable pressure injury
- An injury whose base is obscured by slough or eschar, so its depth — and therefore its stage — cannot be determined until the wound bed is exposed.
- Multimodal analgesia
- Combining analgesics with different mechanisms (a non-opioid plus an opioid plus an adjuvant) to maximize relief and lower the opioid dose.
- Opioid safety: sedation vs respiratory depression
- Sedation precedes respiratory depression — monitor sedation level and respiratory rate; naloxone is titrated to respirations.
- Universal Protocol
- The Joint Commission process to prevent wrong-site surgery: pre-procedure verification, site marking, and a time-out before incision.
- Nurse's role in informed consent
- The provider explains the procedure and obtains consent; the nurse witnesses the signature, confirms understanding, and verifies it is voluntary.
- Evisceration first action
- Cover the protruding viscera with sterile saline-soaked gauze, position low-Fowler's with knees flexed, keep NPO, and notify the surgeon — never push the organs back in.
- Post-op urinary retention
- Bladder-scan first to confirm distension before catheterizing; perform intermittent catheterization if needed.
- Enteral tube placement verification
- An X-ray is the gold standard before first use of a blind tube; keep the head of the bed at 30–45°. Auscultating an air 'whoosh' does NOT verify placement.
- Refeeding syndrome
- Dangerous drops in phosphate, potassium, and magnesium when nutrition is reintroduced to a severely malnourished patient; start low, go slow, replace electrolytes, give thiamine.
- Two patient identifiers
- Verifying a patient with two pieces of identifying information (name plus date of birth or MRN) before any med, procedure, specimen, or transfusion — never the room number.
- Dysphagia precaution before oral intake
- In a stroke or neuro patient, screen for dysphagia and keep NPO until the swallow screen passes to prevent aspiration.
- Falls prevention after a fall
- Assess the patient for injury FIRST, then notify the provider, document objectively, and file an incident report (never charted in the medical record).
- Acute coronary syndrome (ACS) priorities
- Obtain a 12-lead ECG within 10 minutes; troponin is the most specific marker; a STEMI needs door-to-balloon PCI within 90 minutes.
- When to hold nitroglycerin
- Hold nitro if systolic BP is below 90, in right-ventricular/inferior MI, or with a PDE-5 inhibitor (e.g., sildenafil) in the past 24–48 hours.
- Left-sided vs right-sided heart failure
- Left-sided = pulmonary congestion (crackles, orthopnea, dyspnea); right-sided = systemic congestion (jugular venous distention, peripheral edema, ascites).
- Heart failure key teaching
- Daily weights at the same time — report a gain over 2–3 lb in a day or 5 lb in a week; restrict sodium and fluids as ordered.
- Digoxin toxicity
- Worsened by hypokalemia; shows nausea, yellow-green halos, and bradycardia. Hold for an apical pulse below 60; antidote is digoxin immune Fab.
- COPD oxygen target
- Titrate oxygen to an SpO2 of about 88–92% to avoid suppressing the hypoxic drive; teach pursed-lip and diaphragmatic breathing.
- Silent chest in asthma
- A silent chest with diminishing wheezing signals impending respiratory failure — an ominous emergency sign.
- Chest tube continuous bubbling
- Continuous bubbling in the water-seal chamber means an air leak; expect intermittent tidaling with respiration as normal.
- Dislodged chest tube
- If the tube is pulled out, cover the site with an occlusive dressing taped on three sides; if it disconnects, submerge the end in sterile water.
- Tension pneumothorax
- Tracheal deviation away from the affected side, absent breath sounds, and hypotension — needs immediate needle decompression.
- ROME (acid-base)
- Respiratory Opposite (pH and CO2 move opposite ways), Metabolic Equal (pH and bicarbonate move the same way).
- Pancreatitis
- Epigastric pain radiating to the back with elevated lipase (more specific than amylase); keep NPO to rest the pancreas.
- AV fistula protection
- No blood pressure or venipuncture in the fistula arm; check the thrill (palpate) and bruit (auscultate) to confirm patency.
- Most life-threatening AKI complication
- Hyperkalemia is the most life-threatening complication of acute kidney injury and chronic kidney disease.
- DKA management order
- IV isotonic fluids first, then a continuous regular-insulin infusion, with potassium replacement (hold insulin if K is below 3.3); add dextrose at glucose ~200 mg/dL.
- Rapid-acting insulin (lispro, aspart)
- Onset ~15 min, peak ~1 hour, duration 3–5 hours — give with food.
- Regular (short-acting) insulin
- Onset ~30 min, peak 2–3 hours, duration 5–8 hours; it is the ONLY insulin that can be given IV.
- Long-acting insulin (glargine, detemir)
- Onset 1–2 hours, no pronounced peak, duration up to 24 hours; do not mix with other insulins.
- Mixing regular and NPH insulin
- Draw up the clear (regular) before the cloudy (NPH) — 'clear before cloudy.'
- Ischemic stroke first step
- An immediate non-contrast CT to rule out a hemorrhage before giving tPA; 'time is brain.'
- Earliest sign of increased intracranial pressure
- A change in level of consciousness is the earliest sign; Cushing's triad (hypertension with widening pulse pressure, bradycardia, irregular respirations) is late and ominous.
- Increased ICP positioning
- Keep the head of the bed at about 30°, head midline, to promote venous drainage; avoid neck flexion and Valsalva.
- Compartment syndrome early sign
- Pain out of proportion and pain on passive stretch; do NOT elevate the limb above heart level — prepare for fasciotomy.
- Transfusion reaction first action
- STOP the transfusion immediately, keep the line open with normal saline through new tubing, then notify the provider and blood bank.
- Acute hemolytic transfusion reaction
- Usually ABO incompatibility — the most dangerous reaction; fever, flank/back pain, dark urine, and hypotension within minutes.
- Hypokalemia ECG and signs
- Serum K below 3.5 mEq/L; flat T waves, U waves, muscle weakness, and worsened digoxin toxicity. Replace diluted by pump — never IV push.
- Hyperkalemia ECG and treatment order
- Serum K above 5.0; peaked T waves → widened QRS. Order: calcium gluconate (stabilize) → insulin + dextrose/albuterol (shift) → diuretics/resin/dialysis (remove).
- Hypocalcemia signs
- Positive Trousseau's and Chvostek's signs, tetany, and tingling; a positive Trousseau's sign (carpal spasm with BP cuff inflation) indicates hypocalcemia.
- Surviving Sepsis hour-1 bundle
- Measure lactate, draw blood cultures before antibiotics, give broad-spectrum antibiotics, start 30 mL/kg crystalloid, and add vasopressors (norepinephrine first) to keep MAP ≥ 65.
- Heparin
- High-alert anticoagulant monitored by aPTT; antidote is protamine sulfate. Watch platelets for heparin-induced thrombocytopenia (HIT).
- Heparin-induced thrombocytopenia (HIT)
- An immune platelet drop ~5–10 days into heparin therapy that paradoxically causes clotting; stop all heparin and switch to argatroban or bivalirudin.
- Warfarin
- Anticoagulant monitored by INR (target 2.0–3.0); antidote is vitamin K. Teach a consistent — not zero — vitamin-K intake.
- Atelectasis
- A common post-op complication (diminished breath sounds, low fever POD 1–2); prevent with incentive spirometry, early ambulation, and splinted coughing.
- Neutropenic fever
- An absolute neutrophil count below 500 with fever is an oncologic emergency requiring prompt broad-spectrum antibiotics and protective measures.
- Flail chest
- Paradoxical, asymmetrical chest-wall movement after blunt trauma from multiple adjacent rib fractures — a recognition clue for chest trauma.
- Patient-centered care
- Care that respects and responds to individual patient preferences, needs, and values, with mutual, patient-driven goals; the patient is the locus of control.
- Responding to a patient complaint
- Listen and acknowledge feelings FIRST, then apologize for the experience, act to resolve it, and escalate or document — never defend the staff first.
- Qualified medical interpreter
- Required for any patient with limited English proficiency or who is deaf — never family, friends, children, or untrained staff, for accuracy, confidentiality, and legal reasons.
- Implicit bias
- Unconscious attitudes that can affect care; recognize it and assess each patient's actual cultural, religious, and linguistic needs rather than assuming them.
- Teach-back method
- Confirm understanding by having the patient explain the instructions in their own words; a nod to 'do you understand?' is not adequate evidence of learning.
- Readiness to learn
- Assess it first — manage pain or anxiety before teaching — and address barriers such as language, literacy, and sensory deficits.
- Spiritual care request
- Facilitate the chaplain or spiritual-care visit and incorporate the patient's spiritual needs into the plan of care; accommodate rituals with privacy.
- Advance directive
- A legal document stating a patient's treatment wishes or naming a decision-maker; it takes effect only when the patient loses decision-making capacity.
- Living will
- A written advance directive stating which treatments a person does or does not want under specific end-of-life conditions.
- Durable power of attorney for health care
- An advance directive naming a health care proxy to make medical decisions once the patient loses capacity; while capable, the patient's own wishes govern.
- Patient Self-Determination Act
- Requires hospitals to inform adult patients of their right to make health care decisions and to formulate an advance directive, and to document whether one exists.
- DNR (Do Not Resuscitate)
- An order that CPR will not be attempted; it does NOT mean 'do not treat' — comfort and other care continue.
- Palliative care
- Relieves symptoms and improves quality of life at any stage of serious illness; can run alongside curative treatment, with no prognosis requirement.
- Hospice care
- Comfort-focused care for a terminal prognosis of about six months or less; curative treatment is stopped. All hospice care is palliative, but not all palliative care is hospice.
- Health literacy
- A patient's ability to obtain and understand health information; use plain language at about a 5th–6th-grade level and confirm with teach-back.
- ADPIE (nursing process)
- Assessment, Diagnosis, Planning, Implementation, Evaluation — a continuous cycle; assessment is always first and evaluation closes the loop.
- Clinical judgment model steps
- Recognize cues, analyze cues, prioritize hypotheses, generate solutions, take action, evaluate outcomes — the NCSBN framework for safe decision-making.
- First step with new patient data
- Recognize and analyze the cues — gather and interpret more data before acting — except in a true airway, breathing, or circulation emergency.
- TeamSTEPPS
- An AHRQ teamwork framework: leadership, situation monitoring, mutual support, and communication, used to improve safety and reduce errors.
- Two-challenge rule
- Voice a safety concern at least twice and escalate if it is not acknowledged — never stay silent and never follow an unsafe order.
- CUS words
- An escalation script: 'I'm Concerned, I'm Uncomfortable, this is a Safety issue' — a TeamSTEPPS tool to stop an unsafe action.
- Medication reconciliation
- Comparing a patient's current medications to new orders at every transition (admission, transfer, discharge) to catch omissions, duplications, and interactions.
- Discharge planning timing
- Begins on admission; integrate PT/OT for functional status and the safest destination, and screen social determinants to prevent readmission.
- Documentation correction (paper)
- Draw a single line through the error, label it 'error,' and add your date, time, and initials — never erase or obscure the original entry.
- Incident report charting
- Never chart in the medical record that an incident report was filed; the report is a separate risk-management document.
- EHR downtime procedure
- Initiate the facility's downtime procedures, document care on paper forms, and enter it into the EHR once systems return.
- Alarm fatigue
- Desensitization from frequent alarms; manage it with appropriate, individualized alarm settings — never by silencing or disabling safety alarms.
- Social determinants of health
- Conditions such as housing, food security, transportation, and income that affect a patient's ability to follow the plan and must inform discharge and resource planning.
- ANA Code of Ethics
- The nursing profession's nonnegotiable ethical standard, organized into nine provisions with interpretive statements.
- Autonomy
- The ethical principle of respecting a patient's right to self-determination; a competent patient's informed refusal is honored even over beneficence.
- Beneficence
- The ethical principle of acting in the patient's best interest — doing good.
- Nonmaleficence
- The ethical principle of 'do no harm,' including avoiding undue risk and reporting unsafe practice.
- Veracity
- The ethical principle of truth-telling, including honest disclosure of an error to the patient.
- Justice
- The ethical principle of fairness and equitable distribution of resources — equal care regardless of ability to pay.
- Fidelity
- The ethical principle of keeping promises and being loyal — following through on what you told the patient.
- Patient advocacy
- Acting to protect and promote a patient's rights, values, and best interests within the health care system.
- HIPAA
- The federal law protecting the privacy and security of patient health information; PHI may be used for treatment, payment, and operations on a minimum-necessary basis.
- EMTALA
- The federal law requiring an emergency medical screening exam and stabilization regardless of ability to pay.
- Scope of practice
- Defined by the state Nurse Practice Act and Board of Nursing; the nursing process and nursing judgment cannot be delegated.
- Mandatory reporter
- The nurse must report a reasonable suspicion of abuse or neglect to the proper authority — even without proof, as required by law.
- Nursing-sensitive indicators
- Outcomes shaped by nursing care — falls, pressure injuries, CAUTI, and CLABSI rates — benchmarked through the NDNQI.
- PDSA cycle
- Plan-Do-Study-Act — an iterative, small-cycle quality-improvement method to test a change before spreading it.
- Evidence-based practice (EBP)
- Integrating the best available evidence with clinical expertise and patient values to guide care; framed with a PICO(T) question.
- PICOT
- Population, Intervention, Comparison, Outcome, Time — the framework for an answerable evidence-based-practice question.
- Strongest level of evidence
- A systematic review or meta-analysis of randomized controlled trials is the highest level of evidence.
- EBP vs research vs quality improvement
- Research generates new generalizable knowledge, EBP applies existing evidence, and quality improvement refines a local process.
- Informed consent in research
- Human-subjects research requires voluntary informed consent from participants and Institutional Review Board (IRB) review and approval.
- Delegation
- Transferring the authority to perform a task while the RN retains accountability for the outcome.
- Five rights of delegation
- Right task, right circumstance, right person, right direction/communication, and right supervision/evaluation.
- Tasks the RN never delegates
- Assessment, nursing diagnosis, planning, evaluation, the initial teaching, triage, and the care of an unstable patient — they require nursing judgment.
- UAP (unlicensed assistive personnel)
- May perform ADLs, vital signs on stable patients, intake and output, daily weights, transfers, and routine specimen collection — never anything requiring judgment.
- Assignment vs delegation
- Assignment shifts tasks already within a person's existing job role; delegation transfers a specific task normally within the RN's scope while the RN keeps accountability.
- LPN/LVN scope
- Reinforces teaching the RN started, cares for stable patients, gives most routine meds (state-dependent), and does dressing changes — not the initial assessment, care plan, or unstable patient.
- Delegating aspiration-risk feeding
- Feeding a patient at risk for aspiration stays with the nurse — it requires ongoing assessment and judgment and is not delegated to a UAP.
- Supervision (the right supervision)
- Monitor, stay available, intervene as needed, follow up to confirm the task was done correctly, and evaluate the patient's response.
- SBAR
- Situation, Background, Assessment, Recommendation — a structured handoff and escalation format so nothing critical is omitted.
- SBAR 'Recommendation'
- The clear request or action you need — e.g., 'I think the patient needs to be evaluated now and a 12-lead ECG ordered.'
- Closed-loop communication
- A check-back in which the receiver repeats the message and the sender confirms it; used for verbal orders and critical values.
- Chain of command
- The hierarchy for escalating an unresolved patient-safety concern; keep escalating up until the patient is safe.
- Rapid response team
- A bedside team summoned for a deteriorating, non-arrest patient to prevent a code; a 'nurse is worried' gut feeling is a valid trigger.
- Transformational leadership
- A style that inspires and motivates change through a shared vision; the Magnet-preferred style (autocratic is appropriate only in a true emergency).
- Conflict resolution
- Address the conflict directly and collaboratively, focused on the shared goal of patient safety, rather than avoiding it or going around the person.
- Mentor vs coach vs preceptor
- A mentor guides long-term career growth, a coach builds a specific skill, and a preceptor guides the clinical orientation of a new nurse.
- Safety huddle
- A brief team stand-up to establish a shared mental model of the unit's plan and proactively identify safety risks.
- Team nursing
- The most common med-surg care-delivery model, in which an RN leads a team (LPNs/LVNs and UAPs) caring for a group of patients.
