NCLEX REVIEW NOTES
NCLEX Review Notes
The information contained within these notes is based on NCSBN publised NCLEX Test Plan Concepts at the time of
review (see below). For full NCLEX preparation to be successful, students should not depend on only the
information within these review notes Other sources of information are recommended based on nursing education
guidelines within the course of study in which the student is enrolled. These notes contain some key concepts useful
for study.
Priority
Maslow’s Hierarchy of Needs (prioritize from the lowest level upwards)
5th level-Self-actualization: This is a state of being or growth; when you meet a need it expands. These
needs are not transitional; these needs are met based on achievements and reflections in life. The specific
need is replaced with a new need that follows the continuum of growth and development.
3rd & 4th levels-Psychosocial, (3) love & belonging & (4) self-esteem/other-esteem: Whether fulfilling
personal emotional satisfaction or feeling part of a group, how we view ourselves and out relationships
guide behavior. These are needs that are transitional; when you meet a need it ends and can reappear.
These needs are third/fourth highest priority to satisfy.
2nd level-Safety & Security: Personal, familial, environmental, economic, etc…. These are needs that are
transitional; when you meet a need it ends and can reappear. These needs are second highest priority to
satisfy.
1st level-Physiological: This is about survival, physiological function, necessary components of living. This
is a need that is transitional; when you meet a need it ends and can reappear. These needs are highest
priority to satisfy.
Safety Topics
Fire Safety reminders:
RACE
R: rescue (the patient and others at risk; remove from possible harm)
A: (sound the; pull the) alarm
C: contain (the fire if possible; e.g., close fire doors)
E: extinguish (the fire if possible)
Pass
P: Pull (the pin from the fire extinguisher)
A: Aim (the device nozzle at the base of the flames)
S: Squeeze (the trigger to activate the extinguisher suppressant)
S: Sweep (the flames with suppressant agent)
Page 1 of 41
Reviewed: September-December 2021
,NCLEX REVIEW NOTES
Health Promotion
Prevention
*Primary Prevention– (i.e., prevention education) actions that prevent the onset of a condition
*Secondary Prevention– (i.e., diagnostic screening such as mammograms, diet modifications) actions to
determine pathologies or conditions and determine care or decrease risk factors
*Tertiary Prevention- (i.e., management of an established condition, pathology, or injury) actions that
promote improvement and stabilize conditions/pathologies and/or prevent worsening.
Legal Issues
Crimes are acts or behaviors that endanger or damage the well-being of the state and its people.
Some include:
oFalse Imprisonment (may also be a intentional tort) (e.g., preventing departure or freedom
of movement by choice) using restraints to limit freedom of movement can cause this to
occur.
oTheft
oDiversion of funds, goods, services, or resources
oDiversion of pharmacological substances or medications from intended or ordered use
oPrivacy Violation (HIPPA, etc)
Legal Torts (Intentional & Unintentional) are distinguished from crimes and are acts or omissions
that give rise to injury or harm to another which amounts to civil wrongs for which courts impose
liability. In that context
oInjury is invasion of any legal right
oHarm is a loss or detriment in fact that an individual suffers
Liability, when established, can result in court awarded damages (typically awarded as monetary
compensation), while less common remedies include restitution and injunction
Torts can include:
oCommon Types
Assault – Verbal threat
Battery – Physical harm
Infliction of Emotional Distress
False Imprisonment (keeping someone in an environment) preventing departure
when not authorized by legal authority to do so
Trespass (entering personal residence/property without permission)
Negligence (may lead to malpractice)
Failure to take proper care in doing something
Failure to use reasonable care, resulting in damage or injury to another
oOther Types of Torts
Defamation (i.e., …of character by gossip, social media, written word, etc….)
Libel-Written
Page 2 of 41
Reviewed: September-December 2021
,NCLEX REVIEW NOTES
Slander-Verbal
Nuisance
Invasion of Privacy (i.e., photographing, viewing possessions, etc….)
oAs well as
Economic Torts
Malpractice – occurs when a Nurse had a duty (a professional relationship established with a
client), was negligent (by action or omission) in that duty, and did not meet established
standards of practice (judgement or actions which another professional would do or not do in
similar or identical circumstances) which resulted in harm to the client (i.e., a patient, family,
group, or population).
Breach of Contract — One party fails to honour the contracted performs wrong to the other party.
This is not a tort, rather it is a Civil Wrong with awardable compensation award possible in a court
of law
72-hour Hold — A legally ordered medical process for preventing departure from an environment
with subsequent observation and limitations of free choice and behaviors due to intent that is
indicated or actual to harm self or others.
.Good Samaritan Law — A law enacted within a civic and legal system in which a licensed
professional or other person who is acting within a legal scope of practice but not in a professional
capacity (i.e., no duty is established and the person stops to help at the scene of a MVC) may not
be held to legal liability for injuries to a person when rendering aid in emergent circumstances
Jurisprudence – Application and interpretation of regulation, laws, and principles in the nursing
profession.
Incident Reports or Occurrence Reports — are internal tools to assist in determining the facts of
an occurrence and initiating investigations to decrease risk to clients and help prevent future
occurrences. These documents are NOT PART OF THE MEDICAL RECORD and ARE NIETHER
MENTIONED IN CHARTING, NOR ARE PLACED IN A MEDICAL RECORD (this is related to legal
protection). Examples include:
oMedication errors
oProcedure/Treatment errors – IV causes infection – needs Abx
oNeedle stick injury’s
oVolunteer/Visitor injury
oReports if losses occur- dentures, money, items.
oPatient fights with MD.
NOTE: The incident or occurrence report does not speculate or judge, assign guilt, contain
defensive language, rather it reports only the facts of the case as observed, communicated, and
acted upon.
Page 3 of 41
Reviewed: September-December 2021
, NCLEX REVIEW NOTES
NOTE: The medical record will contain a non-judgemental, specific, accurate, concise description
of the nurses observations, communications, and related actions in event of such occurrences.
Advanced Directives
Can be changed at any time by the patient, the legally appointed health surrogate, the client’s
power of attorney or court- appointed guardian (documentation of changed status may be
facilitated by nurses using available resources)
Are legal documents assigned by clients to the medical record which provide guidance on
decisions relating to the action of others in the absence of the client’s ability to do so of the wishes
of the client for response to specific circumstances (i.e., nutrition, hydration, pain control, and life
support measures)
Are reported to the healthcare team as needed within privacy guidelines
The nurse’s role is to:
oAsk the client about the status of advanced directives on admission and document
oPlace advance directives in the health record upon receipt from the client
DNR (Do Not Resuscitate)
DNR ONLY MEANS you DON’T do Compressions
If pt becomes SOA, put o2 on for comfort
If choking, Perform Heimlich maneuver
CODE status is provided by medical order
When no advance directives are present, and the code status has not been limited by medical
order, the healthcare team is legally bound to provide all available life-sustaining measures in the
event of an emergent condition.
Restraints
Require medical orders or emergent use under standing orders
oPrescription within specific time frame (facility protocol)
Must be documented per policy and procedure guidelines (minimum times or more frequent per
environment of use and type of use)
Least restrictive measure needs to be used first.(music on to distract pt prior to applying)
Last resort
Distractions used before restraints
Tie to an immovable part of bed
Assess skin integrity and neurovascular checks every 30 minutes
Release q 2 hours for ROM, toileting, and intake of food/liquids
2 fingers should be able to put between the restraint and the pt’s limb Priority
Sheets can be pulled up to hide tube that pt’s attempting to pull out before restraints are used
restraints include sheet being tucked, 4 bed rails being used, wheelchair with sheet tucked/tied
around pt.
Informed Consent
Page 4 of 41
Reviewed: September-December 2021
NCLEX Review Notes
The information contained within these notes is based on NCSBN publised NCLEX Test Plan Concepts at the time of
review (see below). For full NCLEX preparation to be successful, students should not depend on only the
information within these review notes Other sources of information are recommended based on nursing education
guidelines within the course of study in which the student is enrolled. These notes contain some key concepts useful
for study.
Priority
Maslow’s Hierarchy of Needs (prioritize from the lowest level upwards)
5th level-Self-actualization: This is a state of being or growth; when you meet a need it expands. These
needs are not transitional; these needs are met based on achievements and reflections in life. The specific
need is replaced with a new need that follows the continuum of growth and development.
3rd & 4th levels-Psychosocial, (3) love & belonging & (4) self-esteem/other-esteem: Whether fulfilling
personal emotional satisfaction or feeling part of a group, how we view ourselves and out relationships
guide behavior. These are needs that are transitional; when you meet a need it ends and can reappear.
These needs are third/fourth highest priority to satisfy.
2nd level-Safety & Security: Personal, familial, environmental, economic, etc…. These are needs that are
transitional; when you meet a need it ends and can reappear. These needs are second highest priority to
satisfy.
1st level-Physiological: This is about survival, physiological function, necessary components of living. This
is a need that is transitional; when you meet a need it ends and can reappear. These needs are highest
priority to satisfy.
Safety Topics
Fire Safety reminders:
RACE
R: rescue (the patient and others at risk; remove from possible harm)
A: (sound the; pull the) alarm
C: contain (the fire if possible; e.g., close fire doors)
E: extinguish (the fire if possible)
Pass
P: Pull (the pin from the fire extinguisher)
A: Aim (the device nozzle at the base of the flames)
S: Squeeze (the trigger to activate the extinguisher suppressant)
S: Sweep (the flames with suppressant agent)
Page 1 of 41
Reviewed: September-December 2021
,NCLEX REVIEW NOTES
Health Promotion
Prevention
*Primary Prevention– (i.e., prevention education) actions that prevent the onset of a condition
*Secondary Prevention– (i.e., diagnostic screening such as mammograms, diet modifications) actions to
determine pathologies or conditions and determine care or decrease risk factors
*Tertiary Prevention- (i.e., management of an established condition, pathology, or injury) actions that
promote improvement and stabilize conditions/pathologies and/or prevent worsening.
Legal Issues
Crimes are acts or behaviors that endanger or damage the well-being of the state and its people.
Some include:
oFalse Imprisonment (may also be a intentional tort) (e.g., preventing departure or freedom
of movement by choice) using restraints to limit freedom of movement can cause this to
occur.
oTheft
oDiversion of funds, goods, services, or resources
oDiversion of pharmacological substances or medications from intended or ordered use
oPrivacy Violation (HIPPA, etc)
Legal Torts (Intentional & Unintentional) are distinguished from crimes and are acts or omissions
that give rise to injury or harm to another which amounts to civil wrongs for which courts impose
liability. In that context
oInjury is invasion of any legal right
oHarm is a loss or detriment in fact that an individual suffers
Liability, when established, can result in court awarded damages (typically awarded as monetary
compensation), while less common remedies include restitution and injunction
Torts can include:
oCommon Types
Assault – Verbal threat
Battery – Physical harm
Infliction of Emotional Distress
False Imprisonment (keeping someone in an environment) preventing departure
when not authorized by legal authority to do so
Trespass (entering personal residence/property without permission)
Negligence (may lead to malpractice)
Failure to take proper care in doing something
Failure to use reasonable care, resulting in damage or injury to another
oOther Types of Torts
Defamation (i.e., …of character by gossip, social media, written word, etc….)
Libel-Written
Page 2 of 41
Reviewed: September-December 2021
,NCLEX REVIEW NOTES
Slander-Verbal
Nuisance
Invasion of Privacy (i.e., photographing, viewing possessions, etc….)
oAs well as
Economic Torts
Malpractice – occurs when a Nurse had a duty (a professional relationship established with a
client), was negligent (by action or omission) in that duty, and did not meet established
standards of practice (judgement or actions which another professional would do or not do in
similar or identical circumstances) which resulted in harm to the client (i.e., a patient, family,
group, or population).
Breach of Contract — One party fails to honour the contracted performs wrong to the other party.
This is not a tort, rather it is a Civil Wrong with awardable compensation award possible in a court
of law
72-hour Hold — A legally ordered medical process for preventing departure from an environment
with subsequent observation and limitations of free choice and behaviors due to intent that is
indicated or actual to harm self or others.
.Good Samaritan Law — A law enacted within a civic and legal system in which a licensed
professional or other person who is acting within a legal scope of practice but not in a professional
capacity (i.e., no duty is established and the person stops to help at the scene of a MVC) may not
be held to legal liability for injuries to a person when rendering aid in emergent circumstances
Jurisprudence – Application and interpretation of regulation, laws, and principles in the nursing
profession.
Incident Reports or Occurrence Reports — are internal tools to assist in determining the facts of
an occurrence and initiating investigations to decrease risk to clients and help prevent future
occurrences. These documents are NOT PART OF THE MEDICAL RECORD and ARE NIETHER
MENTIONED IN CHARTING, NOR ARE PLACED IN A MEDICAL RECORD (this is related to legal
protection). Examples include:
oMedication errors
oProcedure/Treatment errors – IV causes infection – needs Abx
oNeedle stick injury’s
oVolunteer/Visitor injury
oReports if losses occur- dentures, money, items.
oPatient fights with MD.
NOTE: The incident or occurrence report does not speculate or judge, assign guilt, contain
defensive language, rather it reports only the facts of the case as observed, communicated, and
acted upon.
Page 3 of 41
Reviewed: September-December 2021
, NCLEX REVIEW NOTES
NOTE: The medical record will contain a non-judgemental, specific, accurate, concise description
of the nurses observations, communications, and related actions in event of such occurrences.
Advanced Directives
Can be changed at any time by the patient, the legally appointed health surrogate, the client’s
power of attorney or court- appointed guardian (documentation of changed status may be
facilitated by nurses using available resources)
Are legal documents assigned by clients to the medical record which provide guidance on
decisions relating to the action of others in the absence of the client’s ability to do so of the wishes
of the client for response to specific circumstances (i.e., nutrition, hydration, pain control, and life
support measures)
Are reported to the healthcare team as needed within privacy guidelines
The nurse’s role is to:
oAsk the client about the status of advanced directives on admission and document
oPlace advance directives in the health record upon receipt from the client
DNR (Do Not Resuscitate)
DNR ONLY MEANS you DON’T do Compressions
If pt becomes SOA, put o2 on for comfort
If choking, Perform Heimlich maneuver
CODE status is provided by medical order
When no advance directives are present, and the code status has not been limited by medical
order, the healthcare team is legally bound to provide all available life-sustaining measures in the
event of an emergent condition.
Restraints
Require medical orders or emergent use under standing orders
oPrescription within specific time frame (facility protocol)
Must be documented per policy and procedure guidelines (minimum times or more frequent per
environment of use and type of use)
Least restrictive measure needs to be used first.(music on to distract pt prior to applying)
Last resort
Distractions used before restraints
Tie to an immovable part of bed
Assess skin integrity and neurovascular checks every 30 minutes
Release q 2 hours for ROM, toileting, and intake of food/liquids
2 fingers should be able to put between the restraint and the pt’s limb Priority
Sheets can be pulled up to hide tube that pt’s attempting to pull out before restraints are used
restraints include sheet being tucked, 4 bed rails being used, wheelchair with sheet tucked/tied
around pt.
Informed Consent
Page 4 of 41
Reviewed: September-December 2021
