NCLEX-RN Study Guide
Comprehensive coverage of all six NCLEX client needs domains with clinical decision-making frameworks, high-yield pharmacology, lab values, and delegation rules.
🏆 Priority Frameworks — The Foundation of NCLEX
The NCLEX is fundamentally a test of clinical prioritization. Master these frameworks before anything else.
ABCs — Airway, Breathing, Circulation
| Priority Level | Category | Examples |
|---|
| 1st | Airway | Stridor, choking, epiglottitis, obstructed airway |
| 2nd | Breathing | Respiratory failure, pneumothorax, severe asthma, SpO2 <90% |
| 3rd | Circulation | Active hemorrhage, shock, severe hypotension, arrhythmias |
| 4th | Disability/Neuro | Altered consciousness, new neuro deficits (stroke symptoms) |
NCLEX Rule: When two patients both seem critical, ask: "Which one will die fastest without immediate intervention?" That's your first patient.
Maslow's Hierarchy for NCLEX
| Level | Needs | Clinical Examples |
|---|
| 1 — Physiologic | Oxygen, food, water, elimination, sleep | Hypoxia, hypoglycemia, urinary retention, dehydration |
| 2 — Safety | Physical safety, security | Fall risk, infection control, medication safety |
| 3 — Love/Belonging | Social, family support | Isolation precautions impact, family involvement in care |
| 4 — Esteem | Dignity, self-respect | Body image concerns, privacy |
| 5 — Self-Actualization | Fulfillment, growth | Patient teaching, discharge planning |
Key insight: On NCLEX, always address physiological needs first, then safety, then psychosocial. Teaching (self-actualization) is the lowest priority when a patient also has a physiologic need.
SATA Tips (Select All That Apply)
- Read each option independently — is this true for this patient?
- Don't look for patterns — SATA questions can have 2, 3, 4, or 5 correct answers
- For medication SATA: think about mechanism of action and what's affected
- For delegation SATA: ask "Is this within the scope of practice?"
- For assessment SATA: "Would I find/expect this in this condition?"
💊 Pharmacology High-Yield Topics
Critical Drug Classes
| Drug Class | Key Nursing Actions | Antidote/Reversal |
|---|
| Opioids (morphine, fentanyl) | Monitor RR, sedation; have naloxone available | Naloxone (Narcan) |
| Anticoagulants (heparin) | Monitor aPTT (60–100 sec therapeutic); watch for bleeding | Protamine sulfate |
| Warfarin | Monitor INR (2–3 for most); consistent vitamin K intake | Vitamin K, FFP |
| Digoxin | Hold if HR <60; monitor K+ (hypokalemia → toxicity) | Digibind (digoxin immune fab) |
| Magnesium sulfate | Monitor DTRs (absent = toxicity), RR (<12 = hold), UO (<30 mL/hr = hold) | Calcium gluconate |
| Insulin (Regular) | Only insulin for IV use; draw up CLEAR before CLOUDY | Dextrose, glucagon |
| Lithium | Narrow therapeutic range (0.6–1.2 mEq/L); toxic >1.5; maintain Na+ intake | No specific antidote; supportive care |
| ACE Inhibitors (-pril) | Monitor K+, BUN/Cr; educate on persistent dry cough | N/A — switch to ARB if cough |
| Beta-blockers (-olol) | Hold if HR <60 or BP <90/60; never abruptly stop in cardiac patients | Glucagon (beta-blocker overdose) |
| Aminoglycosides | Monitor peak/trough levels; watch for ototoxicity, nephrotoxicity | N/A — supportive care |
Insulin Types — Must Know
| Type | Onset | Peak | Duration |
|---|
| Rapid-acting (Lispro, Aspart) | 15 min | 30–90 min | 3–5 hr |
| Regular (Short-acting) | 30–60 min | 2–4 hr | 5–8 hr |
| NPH (Intermediate) | 1–2 hr | 4–12 hr | 14–24 hr |
| Glargine/Detemir (Long-acting) | 1–2 hr | No peak | 20–24 hr |
⚠️ Hypoglycemia symptoms: Diaphoresis, tremors, confusion, irritability, tachycardia. Treat with 15g fast carbs if conscious; IV dextrose or glucagon if unconscious.
🏥 Medical-Surgical Nursing
Cardiac Conditions
| Condition | Priority Signs/Symptoms | Nursing Actions |
|---|
| Myocardial Infarction (MI) | Crushing chest pain, diaphoresis, N/V, radiation to jaw/arm | MONA: Morphine, Oxygen, Nitrates, Aspirin |
| Heart Failure | Dyspnea, orthopnea, S3 gallop, peripheral edema, JVD | Elevate HOB, restrict fluids/sodium, diuretics, daily weights |
| Pulmonary Embolism | Sudden dyspnea, pleuritic chest pain, tachycardia, anxiety, hemoptysis | O2, IV access, anticoagulation, notify provider STAT |
| Hypertensive Crisis | BP >180/120, severe headache, visual changes, nausea | Quiet environment, IV antihypertensives, neurological monitoring |
Respiratory Conditions
COPD Oxygen Rule: Target SpO2 88–92%. High flow oxygen can suppress the hypoxic drive in some COPD patients. Titrate slowly with reassessment.
| Condition | Key Signs | Priority Action |
|---|
| Pneumothorax | Tracheal deviation (tension), absent breath sounds, sudden chest pain | Tension: immediate needle decompression. Simple: chest tube |
| Pulmonary edema | Pink frothy sputum, severe dyspnea, crackles bilaterally | High Fowler's, O2, IV diuretics (furosemide), morphine |
| Asthma attack | Expiratory wheezing, dyspnea, tachypnea | O2 first, then albuterol MDI/nebulizer, corticosteroids |
Critical Lab Values — NCLEX Must Know
| Lab | Normal Range | Critical Low | Critical High |
|---|
| Sodium (Na+) | 135–145 mEq/L | <120 (seizures) | >160 (altered mental status) |
| Potassium (K+) | 3.5–5.0 mEq/L | <2.5 (arrhythmias) | >6.0 (cardiac arrest risk) |
| Calcium (Ca2+) | 8.5–10.5 mg/dL | <6 (tetany, seizures) | >13 (cardiac, neurologic) |
| Glucose | 70–100 mg/dL (fasting) | <50 (hypoglycemia) | >500 (DKA/HHS) |
| BUN | 10–20 mg/dL | — | >100 (uremia) |
| Creatinine | 0.6–1.2 mg/dL | — | >4 (severe AKI) |
| pH (ABG) | 7.35–7.45 | <7.20 (severe acidosis) | >7.55 (severe alkalosis) |
| INR | 0.8–1.2 (normal); 2–3 (therapeutic anticoagulation) | — | >4 (high bleed risk) |
| Hemoglobin | 12–17 g/dL | <7 (transfusion threshold) | — |
| Platelets | 150,000–400,000 | <50,000 (bleed risk) | >1,000,000 (clot risk) |
👶 Maternal/Newborn Nursing
Fetal Heart Rate Patterns
| Pattern | Characteristics | Cause | Intervention |
|---|
| Early decelerations | Mirror contractions; gradual onset/recovery | Head compression — benign | Continue monitoring — normal |
| Late decelerations | Begin after peak of contraction; gradual recovery | Uteroplacental insufficiency — nonreassuring | Reposition left lateral, O2, stop oxytocin, IV fluids |
| Variable decelerations | Abrupt onset, V-shaped, variable timing | Cord compression | Reposition, O2; if persistent, amnioinfusion |
| Prolonged deceleration | >2 min but <10 min below baseline | Multiple causes including cord prolapse | Stop oxytocin, reposition, O2, notify OB STAT |
Postpartum Assessment (BUBBLE-HE)
Breasts — engorgement, mastitis signs
Uterus — fundal height, firmness, position
Bladder — voiding, distension
Bowel — bowel sounds, constipation
Lochia — color, amount, odor (rubra → serosa → alba)
Episiotomy/incision — REEDA: Redness, Edema, Ecchymosis, Drainage, Approximation
Homans' sign (unreliable) — assess for DVT symptoms
Emotional — assess for postpartum blues vs. depression vs. psychosis
Preeclampsia vs. Eclampsia
| Preeclampsia | Severe Preeclampsia / Eclampsia |
|---|
| BP | ≥140/90 on two readings | ≥160/110; eclampsia = seizures |
| Proteinuria | ≥300 mg/24 hr | ≥5 g/24 hr |
| Symptoms | Headache, visual changes, RUQ pain, edema | Severe headache, scotoma, HELLP syndrome |
| Management | Bed rest, antihypertensives, fetal monitoring | Magnesium sulfate, delivery if ≥34 weeks |
Magnesium toxicity signs: Absent DTRs → Respiratory rate <12 → Urine output <30 mL/hr → Respiratory arrest. STOP Mag and give CALCIUM GLUCONATE.
🧠 Mental Health Nursing
Therapeutic Communication
| Technique | Example | Purpose |
|---|
| Open-ended questions | "Tell me more about what you're experiencing." | Encourage expression |
| Reflection | "You sound really frustrated." | Validate feelings |
| Clarification | "Help me understand what you mean by that." | Prevent assumptions |
| Silence | (Remaining present without speaking) | Allow processing time |
| Focusing | "Let's go back to what you said about feeling unsafe." | Direct to important topics |
Non-Therapeutic Communication to AVOID
- False reassurance: "Everything will be fine."
- Giving advice: "You should try yoga."
- Changing subject: Redirecting when patient needs to be heard
- Why questions: "Why did you do that?" — puts patient on defensive
- Approval/disapproval: Judging patient's choices
Psychiatric Medications
| Drug Class | Common Drugs | Key Side Effects |
|---|
| Typical antipsychotics | Haloperidol, chlorpromazine | EPS (dystonia, akathisia, tardive dyskinesia), NMS |
| Atypical antipsychotics | Olanzapine, risperidone, quetiapine | Metabolic syndrome, weight gain, diabetes risk |
| SSRIs | Sertraline, fluoxetine, paroxetine | Sexual dysfunction, GI upset, serotonin syndrome risk |
| MAOIs | Phenelzine, tranylcypromine | Tyramine interactions (hypertensive crisis); strict dietary restrictions |
| Mood stabilizers | Lithium, valproate, carbamazepine | Lithium: narrow range; valproate: hepatotoxicity; CBZ: bone marrow suppression |
| Benzodiazepines | Lorazepam, diazepam, clonazepam | Sedation, respiratory depression, dependence; antidote: flumazenil |
⚖️ Management of Care — Delegation & Prioritization
Delegation Rules
Five Rights of Delegation: Right task · Right circumstances · Right person · Right direction/communication · Right supervision/evaluation
| Provider | Can Do | Cannot Do |
|---|
| RN | Assessment, planning, teaching, evaluation, complex care, all medications, care coordination | N/A — full scope |
| LPN/LVN | Stable patient care, routine medications (PO, SQ, IM in most states), wound care for stable wounds, data collection for known conditions | Initial assessment, care planning, teaching, IV push meds (state-dependent), unstable patients |
| CNA/UAP | ADLs (bathing, grooming, feeding stable pts), vital signs on stable patients, ambulation, routine tasks | Any assessment, medication administration, teaching, any skilled nursing task |
Never Delegate to LPN or CNA
- Initial assessment / nursing diagnosis
- Discharge planning and patient teaching
- IV push medications (LPN restrictions vary by state)
- Unstable or complex patients requiring nursing judgment
- Care planning
Infection Control — Transmission Precautions
| Type | Diseases | PPE Required | Room |
|---|
| Airborne | TB, measles, varicella, COVID-19 | N95 respirator, gown, gloves | Negative pressure private room |
| Droplet | Influenza, pertussis, meningitis, mumps, rubella | Surgical mask within 3 ft, gown, gloves | Private room; door may be open |
| Contact | MRSA, VRE, C. diff, wound infections | Gown and gloves for all contact | Private room or cohorting |
| Standard | All patients | Gloves for blood/body fluids; mask/gown PRN | Any room |
C. diff special note: Alcohol-based hand sanitizer does NOT kill C. diff spores. SOAP AND WATER ONLY for hand hygiene with C. diff patients.