Comprehensive Nursing Exam Prep Notes – Modules 1-3

Critical Thinking vs. Clinical Judgement

• Definitions & Relationship

  • Critical thinking = analytical process of recognizing cues, questioning assumptions, evaluating evidence → foundation for all nursing decisions.

  • Clinical judgement = application of critical-thinking insights at the bedside to make safe, timely decisions.

• Conceptual Model ("What? / So What? / Now What?")

  • What? → Identify the clinical cue or problem.

  • So What? → Analyze relevance; compare to norms, pathophysiology.

  • Now What? → Decide & act; evaluate outcome.

• Rationale & Significance

  • Strong critical thinking ↓ errors; robust clinical judgement ↑ patient safety & outcomes.

  • Links to QSEN competencies (safety, EBP) and Benner’s novice-to-expert model.

Evidence-Based Practice (EBP) & Quality Improvement (QI)

• EBP Triad
  $\text{Best Research} + \text{Clinical Expertise} + \text{Patient Preferences}$

• QI Cycle – PDSA (Plan → Do → Study → Act)

  • Iterative, data-driven; closes the loop between evidence and local performance gaps.

• Levels of Evidence (Highest → Lowest)

  1. Systematic reviews & meta-analyses

  2. Randomized controlled trials

  3. Cohort studies

  4. Case-control studies

  5. Descriptive/qualitative research

  6. Expert opinion

• Evidence-Based vs. Evidence-Informed Care

  • Evidence-informed = "close enough" when resources, patient limits, or context prevent full EBP implementation.

• Why It Matters

  • Keeps practice current, safe, cost-effective; fulfills Magnet & ANA Professional Scope standards.

Healthy People $2030$ & Health Literacy

• Healthy People $2030$

  • $359$ national objectives → health equity, SDOH (social determinants of health), literacy.

  • Benchmarks for community health assessments, grant writing, policy.

• Health Literacy Strategies

  • Plain language (< $6$-grade reading level), teach-back, culturally tailored visuals, use of interpreters.

• Outcome Rationale

  • ↑ understanding → ↑ adherence → ↓ readmissions & costs (value-based purchasing incentive).

Health Equity

• Definition – Fair, just opportunity for everyone to attain full health potential.

• Action Domains

  • Address income, education, housing, food security, environment.

  • Employ upstream interventions (e.g., screening for SDOH, community partnerships).

• Impact – Reduces disparities in morbidity/mortality; aligns with IHI Triple Aim.

Ethics, Bioethics & Legal Concepts

• Ethical Principles

  • Beneficence (do good)

  • Non-maleficence (do no harm)

  • Autonomy (self-determination)

  • Justice (fairness/allocation)

  • Veracity (truth-telling)

  • Fidelity (promise-keeping)

• Applications/Scenarios

  • End-of-life DNR vs. patient autonomy.

  • Resource triage → justice.

• Mandatory Reporting

  • Abuse/neglect (children, elders, disabled) & specified wounds → legal duty supersedes confidentiality.

• Malpractice Elements
  $\text{Duty} \rightarrow \text{Breach} \rightarrow \text{Causation} \rightarrow \text{Harm}$

• Scope of Practice – Defined by Nurse Practice Act; exceeding scope → liability.

Cultural Competence & Watson’s Caritas

• Avoid Ethnocentrism – Use qualified interpreters, not family; avoid stereotypes.

• Cultural/Spiritual Assessment Tools
  FICA: Faith, Importance, Community, Address in care.

• Watson’s $10$ Caritas Processes

  1. Loving-kindness

  2. Faith-hope

  3. Sensitivity to self/others

  4. Helping-trusting relationship

  5. Express positive/negative feelings

  6. Creative problem-solving (scientific)

  7. Teaching-learning

  8. Healing environment

  9. Assistance with basic needs

1. Spiritual-existential care (openness to miracles)

• Outcome – Holistic healing, ↑ patient satisfaction (HCAHPS linkage).

Fluid Volume Imbalances

• Hypovolemia (FVD)

  • Causes: vomiting, diarrhea, burns, hemorrhage, diuretics.

  • S/S: orthostatic hypotension, tachycardia, poor skin turgor, oliguria < $0.5\,mL/kg/hr$, confusion (older adults).

  • Interventions: isotonic IV (NS or LR), monitor $I$ & $O$, daily weights (>> $1\,kg$ = $1$ L water).

• Hypervolemia (FVE)

  • Causes: heart/renal failure, SIADH, excessive IV fluids.

  • S/S: JVD, peripheral edema, crackles, bounding pulse.

  • Interventions: fluid restriction, diuretics, HOB ↑ $30$°–$45$°, auscultate lungs.

• Rationale – Early recognition prevents hypovolemic shock or pulmonary edema.

Electrolyte Imbalances

Acid-Base Disorders

• Key Interventions

  • Metabolic acidosis: IV sodium bicarbonate if pH $<7.1$.

  • Respiratory alkalosis: coach slow breathing, rebreathe into paper bag.

Intravenous Therapy

• Benefits – Rapid drug action, parenteral nutrition, blood products.

• Systemic Risks – Fluid overload, speed shock, anaphylaxis, septicemia, air embolism.

• Local Risks – Hematoma, thrombosis, phlebitis, infiltration, extravasation, infection.

• Types of Infusion

  • Continuous: $250$–$1000$ mL over $2$–$24$ h.

  • Intermittent primary: small volume < $1$ h (flush pre/post).

  • IV push: $1$–$10$ min bolus.

  • Secondary (“piggyback”): hung above primary.

  • PCA: patient-controlled with lock-out.

• Delivery Calculations

  • Gravity formula:
    $\text{gtt/min}= \dfrac{\text{Total Volume (mL)} \times \text{Drop Factor (gtt/mL)}}{\text{Total Time (min)}}$
    • Example: $\dfrac{1000\times15}{480}=31$ gtt/min.

  • Pump formula:
    $\text{mL/hr}= \dfrac{\text{Total Volume (mL)} \times 60}{\text{Total Time (min)}}$
    • Example: $\dfrac{250\times60}{30}=500$ mL/hr.

• Geriatric Notes

  • ↓ cardiac/renal reserve → start at KVO $\approx30$ mL/hr, daily weight > $1$ kg/$24$ h = alert.

Surgical Techniques

• Laser surgery → precise, minimal bleeding.

• Endoscopic (lap/thoracoscopic) → small ports, faster recovery.

• Robotic surgery → 3-D view, enhanced dexterity; may ↑ OR time but ↓ LOS.

Preoperative Care

• Teaching Points – Arrival time, NPO after midnight, bowel prep, chlorhexidine bath, what to bring/leave.

• Informed Consent – Voluntary, witness signature, surgeon explains risks/benefits before sedatives.

• Safety Prep – Allergy check, site marking, surgical time-out per Joint Commission.

Peri-Anesthesia (PACU)

• Primary Survey (\"ABC\") every $15$ min

  • Airway patency, end-tidal $CO_2$, O\/2 sat.

  • Breathing pattern; provide O₂ until awake.

  • Circulation: HR, BP, temp.

• Thermoregulation – Room ≈ $75$ °$F$, warm blankets; shivering ↑ O₂ demand.

• Assess – Surgical site, drains, lines; report bleeding > $50$ mL/hr.

Postoperative Complications

• Malignant Hyperthermia Clue – Rapid $\uparrow$ CO₂, muscle rigidity, temp > $104$ °$F$ → give dantrolene $2.5$ mg/kg.

Pain Management

• Multimodal: opioids, NSAIDs, acetaminophen, local blocks, non-pharm (massage, heat/ice, music).

• Reassess pain within $30$ min IV or $60$ min PO; titrate; watch for respiratory depression (< $8$ breaths/min).

Discharge Criteria

• From PACU – Stable VS, $SpO_2>90\%$ RA, pain controlled, minimal bleeding.

• From Ambulatory Surgery – Oral fluids tolerated, voided if GU surgery, no IV opioids x $30$ min, ambulates, understands instructions, has responsible adult escort.

Quality Control & Safety

• Universal Protocol – Pre-op verification, site mark, time-out → prevents wrong-site events.

• DVT Prophylaxis – Early ambulation < $24$ h, SCDs, LMWH unless contraindicated.

• Infection Prevention – Antibiotic within $60$ min before incision, normothermia, glucose < $200$ mg/dL, remove Foley ASAP.

Documentation & Maslow’s Safety Needs

• Chart VS, neurovascular checks, wound/drain output, interventions, education; use SBAR for handoff.

• Safety measures: bed low/locked, $\ge 2$ side rails, call bell, assist first ambulation.

Integrative & Ethical Reflections

• EBP, cultural competence, and ethics converge to honor patient autonomy, ensure justice, and foster holistic well-being.

• Nurses act as knowledge brokers—translating research into compassionate bedside care while safeguarding legal and moral obligations.

• "Five Main Rights" of Medication Administration:

  1. Right Patient

  2. Right Drug

  3. Right Dose

  4. Right Route

  5. Right Time

• Safety Considerations:

  • Always perform a triple check: when getting the medication, when preparing it, and just before administering it.

  • Double-check high-alert medications (e.g., insulin, heparin, opioids) with another nurse.

  • Be aware of look-alike/sound-alike drugs.

  • Educate patients about their medications and potential side effects.

  • Document medication administration immediately after giving it.

    
    

Documentation & Maslow’s Safety Needs - Chart VS, neurovascular checks, wound/drain output, interventions, education; use SBAR for handoff. - Safety measures: bed low/locked, $\ge 2$ side

DVT Prophylaxis – Early ambulation, sequential compression devices (SCDs), low molecular weight heparin (LMWH) or unfractionated heparin.