Assessment & Diagnosis
39%of exam
Vital SignsLab ValuesDiagnosticsElectrolytesNeuro Checks
Planning, Implementation, Evaluation
40%of exam
InterventionsMedication SafetyComplicationsPatient TeachingSepsis Bundle
Professional Role
21%of exam
CommunicationDelegationEthicsEvidence-Based Practice
Quick Facts
- Exam
- MEDSURG-BC
- Credential
- ANCC Med-Surg RN-BC
- Questions
- 150 (125 scored)
- Time
- 3 hours
- Pass
- 350 scaled (100-500 scale)
- Format
- CBT at Prometric
- Level
- Specialty RN certification
- Blueprint
- Oct 29, 2025
FAST Stroke Screen
Face, Arms, Speech, Time to call
Face: droopArms: driftSpeech: slurredTime: call now
DKA vs HHS
DKA
- Type 1 diabetes
- Glucose above 250
- Ketones strongly positive
HHS
- Type 2 diabetes
- Glucose above 600
- Ketones minimal or absent
Ketones vs extreme glucose only
Lab Value Escalation Points
- K+ above 6.5→Emergency treatment now(Cardiac risk)
- Na+ below 120→Slow correction, notify provider(Prevent demyelination)
- Glucose below 54→Treat immediately, recheck often(Severe hypoglycemia)
- Lactate above 4→Suspect septic shock(Start fluid bolus)
- INR above 5, bleeding→Hold warfarin, reverse agent(Vitamin K or PCC)
- Troponin rising, chest pain→Treat as ACS(Serial troponins ordered)
Cardiovascular Assessment Findings
- BNP
- Elevated indicates heart failure
- Troponin
- Rises in MI, peaks 24h
- STEMI
- ST elevation needs emergent PCI
- NSTEMI
- Elevated troponin, no ST elevation
- HF decompensation
- Rapid weight gain, crackles, edema
- Orthostatic hypotension
- BP drop 20 mmHg standing
DKA Warning Signs
Kussmaul breathing, fruity breath, dehydration
Kussmaul: deep rapidFruity: acetone breathDehydration: dry mucosaConfusion: late sign
Hyperkalemia vs Hypokalemia
Hyperkalemia
- K+ above 5.0
- Peaked T waves
- Widened QRS complex
Hypokalemia
- K+ below 3.5
- Flattened T waves
- U waves appear
Opposite EKG patterns
Respiratory Assessment Findings
- ABG pH
- Normal 7.35-7.45
- PaCO2
- Normal 35-45 mmHg
- HCO3
- Normal 22-26 mEq/L
- PaO2
- Normal 80-100 mmHg
- COPD SpO2 target
- 88-92%, avoid over-oxygenation
- PE classic signs
- Sudden dyspnea, pleuritic pain, tachycardia
Prerenal vs Intrarenal AKI
Prerenal AKI
- Caused by hypoperfusion
- Reversible with fluids
- High BUN Cr ratio
Intrarenal AKI
- Direct kidney damage
- Fluids may not help
- Lower BUN Cr ratio
Perfusion vs structural damage
Endocrine Assessment Findings
- DKA glucose
- Above 250 mg/dL with ketones
- HHS glucose
- Above 600 mg/dL, minimal ketones
- DKA pH
- Below 7.3 with low HCO3
- Hypoglycemia
- Below 70, treat if symptomatic
- HbA1c diagnostic
- 6.5% or higher confirms diabetes
- Thyroid storm
- Fever, tachycardia, agitation, high T4
- Myxedema coma
- Hypothermia, bradycardia, altered mentation
Delirium vs Dementia
Delirium
- Sudden onset
- Fluctuating attention
- Often reversible cause
Dementia
- Gradual onset
- Stable attention
- Usually irreversible course
Onset speed is key
Renal & Electrolyte Values
- Potassium normal
- 3.5-5.0 mEq/L
- Hyperkalemia EKG
- Peaked T waves, widened QRS
- Sodium normal
- 135-145 mEq/L
- Hyponatremia correction
- Max 8-10 mEq/L per day
- Calcium normal
- 8.5-10.5 mg/dL total
- Hypocalcemia signs
- Chvostek and Trousseau signs
- Magnesium normal
- 1.5-2.5 mEq/L
- BUN:Cr ratio
- Above 20:1 suggests prerenal AKI
Hypervolemia vs Hypovolemia
Hypervolemia
- Crackles and edema
- Rapid weight gain
- JVD present
Hypovolemia
- Tachycardia and hypotension
- Recent weight loss
- Poor skin turgor
Fluid overload vs deficit
GI & Hepatic Assessment
- Melena
- Black tarry stool, upper GI bleed
- Hematochezia
- Bright red blood, lower GI
- Lipase
- More specific than amylase, pancreatitis
- Cirrhosis complication
- Ascites, varices, hepatic encephalopathy
- Hepatic encephalopathy sign
- Asterixis, confusion, rising ammonia
- Esophageal varices risk
- Portal hypertension, high bleed risk
Neurological Assessment Findings
- FAST stroke screen
- Face, arm, speech, time
- Ischemic stroke
- About 85% of strokes
- Hemorrhagic stroke
- About 15%, higher mortality
- tPA window
- 3 to 4.5 hours onset
- tPA contraindication
- Active bleeding or hemorrhagic stroke
- Seizure priority
- Protect airway, time the seizure
- GCS scale
- 3 to 15, lower worse
Core Lab Value Ranges
- Hemoglobin
- 13.5-17.5 male, 12-15.5 female
- WBC
- 4,500 to 11,000 per mcL
- Platelets
- 150,000 to 450,000 per mcL
- Creatinine
- 0.6 to 1.2 mg/dL
- Glucose fasting
- 70 to 100 mg/dL
- INR normal
- 0.8 to 1.1 untreated
Sepsis 1-Hour Bundle
Lactate, cultures, antibiotics, fluids, vasopressors
Lactate: measureCultures: before antibioticsAntibiotics: broad-spectrum fastFluids: 30 mL/kgVasopressors: if still hypotensive
STEMI vs NSTEMI
STEMI
- ST segment elevation
- Full-thickness infarction
- Emergent PCI needed
NSTEMI
- No ST elevation
- Partial-thickness infarction
- Troponin still elevated
ECG pattern differs
First Action in Emergencies
- STEMI symptoms→12-lead ECG, activate protocol(Time is muscle)
- Severe hypoglycemia, alert patient→15g fast carbohydrate now(Recheck in 15 min)
- Peaked T waves, K+ high→Calcium gluconate first(Stabilize cardiac membrane)
- Sepsis criteria met→Cultures, antibiotics, fluids fast(Within first hour)
- Stroke symptoms, onset unclear→CT scan before tPA(Rule out hemorrhage)
- Rising CO2, somnolence→Reassess airway, notify provider(Impending ventilatory failure)
- GI bleed, unstable vitals→IV access, type and crossmatch(Prepare for transfusion)
Cardiac Intervention Priorities
- STEMI first action
- 12-lead ECG, activate protocol fast
- Beta-blocker hold
- HR below 50, SBP below 90
- Digoxin toxicity
- Visual halos, bradycardia, nausea, confusion
- Digoxin level
- Therapeutic 0.8-2.0 ng/mL
- K+ before digoxin
- Low potassium raises toxicity risk
- Afib priority
- Rate control then anticoagulation
Hyperkalemia Treatment Order
Stabilize, shift, then eliminate potassium
Stabilize: calcium gluconateShift: insulin plus glucoseEliminate: kayexalate or dialysis
Ischemic vs Hemorrhagic Stroke
Ischemic
- About 85% of strokes
- tPA may be given
- Permissive hypertension allowed
Hemorrhagic
- About 15% of strokes
- tPA is contraindicated
- Tighter BP control
CT scan guides treatment
Oxygen & Ventilation Decisions
- COPD patient, hypoxic→Titrate to 88-92%(Avoid over-oxygenation)
- Acute MI, normal SpO2→No routine supplemental oxygen(Only if hypoxic)
- PE confirmed→Oxygen plus anticoagulation(Monitor for deterioration)
- ARDS, severe hypoxemia→High FiO2, consider intubation(Prone positioning helps)
- Post-op, decreased breath sounds→Incentive spirometry, ambulate(Prevent atelectasis)
Respiratory Intervention Priorities
- Rising CO2 + somnolence
- Reassess airway, notify provider now
- COPD oxygen
- Titrate carefully; avoid blunting drive
- PE treatment
- Anticoagulation, oxygen, monitor perfusion
- Pneumonia priority
- Antibiotics, oxygen, fluid support
- Incentive spirometry
- Prevent post-op atelectasis
- Chest tube drainage
- Watch tidaling, bubbling, output
Endocrine Intervention Priorities
- Alert hypoglycemia
- 15g fast carb, recheck 15min
- DKA treatment
- IV fluids first, then insulin
- HHS treatment
- Aggressive fluids, correct osmolality slowly
- Insulin + K+
- Check potassium before insulin drip
- Sick day rule
- Never stop insulin when ill
Renal Intervention Priorities
- Severe hyperkalemia
- Calcium gluconate stabilizes cardiac membrane
- Hyperkalemia shift
- Insulin plus glucose, albuterol
- Potassium IV rule
- Never give potassium IV push
- CKD staging
- By GFR, stage 5 dialysis
- Fluid overload
- Restrict fluids, daily weights, diuretics
GI Intervention Priorities
- Variceal bleed
- Octreotide, endoscopy, blood products
- Hepatic encephalopathy treatment
- Lactulose lowers serum ammonia
- Pancreatitis care
- NPO, IV fluids, pain control
- GI bleed priority
- IV access, type and crossmatch
Musculoskeletal Assessment & Care
- Compartment syndrome
- Pain out of proportion, pallor
- 6 Ps compartment
- Pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia
- Fat embolism
- Petechiae, hypoxia, long-bone fracture
- Hip fracture priority
- Neurovascular check, pain control, immobilize
- Osteoporosis risk
- Fall risk, fracture risk, calcium
Infection & Sepsis Bundle
- qSOFA criteria
- Fast RR, low SBP, altered mentation
- Sepsis bundle 1hr
- Cultures, antibiotics, then fluids fast
- Septic shock fluids
- 30 mL/kg crystalloid bolus
- Lactate critical
- Above 4 mmol/L, poor perfusion
- Antibiotic timing
- Give within 1 hour
- C. diff precaution
- Contact precaution, soap and water
Pain & Medication Safety
- Opioid overdose sign
- Respiratory rate below 8
- Naloxone
- Reverses opioid-induced respiratory depression
- High-alert meds
- Insulin, opioids, anticoagulants, potassium
- Warfarin INR
- Therapeutic range 2 to 3
- Heparin aPTT
- 1.5 to 2.5 times control
- Pain scale use
- Match tool to patient's ability
SBAR Handoff
Situation, Background, Assessment, Recommendation in order
Situation: what's happeningBackground: relevant historyAssessment: your readRecommendation: what you need
Professional Role & Communication
- SBAR
- Situation, background, assessment, recommendation
- Delegation rule
- RN keeps assessment and judgment
- Informed consent
- Physician explains, nurse witnesses signature
- Restraint order
- Time-limited, renewed per policy
- Evidence-based practice
- Best research, expertise, patient values
- Patient advocacy
- Voice patient's wishes and safety
Common Traps
Fluid restrict vs resuscitate
HF needs restriction ≠ Sepsis needs resuscitation
Potassium IV push
Never IV push K+ ≠ Always dilute, use pump
High-flow oxygen in COPD
Can blunt respiratory drive ≠ Titrate to 88-92% instead
Digoxin toxicity signs
Visual halos appear early ≠ Not just bradycardia alone
NG tube placement check
pH testing confirms placement ≠ X-ray required after insertion
Restraint documentation timing
Time-limited orders only ≠ Reassess and renew per policy
Antibiotics before cultures return
Cultures drawn first ≠ Do not delay antibiotics
Last Minute
- 1.Domain weights: 39, 40, 21 percent
- 2.Potassium normal: 3.5 to 5.0
- 3.Sodium normal: 135 to 145
- 4.DKA has ketones; HHS does not
- 5.Never give potassium IV push
- 6.COPD oxygen target: 88 to 92%
- 7.Sepsis: cultures then antibiotics fast
- 8.FAST screens for stroke symptoms
- 9.Calcium gluconate stabilizes cardiac membrane
- 10.Warfarin INR target: 2 to 3
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