Created by full-time nurse and part-time musician/artist, Ashley Miami.
Mostly correct but do your research. Happy learning.
You don't need a four-year degree to start working as a registered nurse in the United States. An Associate Degree in Nursing (ADN) is all you need to sit for the NCLEX-RN and start your career. Many nurses take this path through community college and are working within 2–3 years. A BSN is increasingly preferred by hospitals (especially Magnet-designated ones), but it can be completed while you're working.
2–3 years at a community college. Qualifies you to sit for the NCLEX-RN and work as a full RN in all 50 states. Lower cost, faster timeline. Many hospitals hire ADN nurses and offer tuition reimbursement for BSN completion.
Have a bachelor's in any field? Accelerated BSN programs get you to a nursing degree in 12–18 months of intensive coursework, or part-time over 2–3 years at many schools. Skip repeating general education — jump straight to nursing curriculum.
Standard bachelor's track at a university nursing program. Preferred by many hospitals and required for many leadership, advanced practice, and academic pathways. Magnet hospitals often require or prefer it.
The National Council Licensure Examination for Registered Nurses. Computer adaptive test (CAT format). As of 2023, uses the Next Generation NCLEX (NGN) — focuses heavily on clinical judgment, not just recall. Typically 85–150 questions. A score of "above passing standard" grants your RN license. Apply through your state's Board of Nursing (BON).
Many hospitals offer 12–24 month structured nurse residency programs (like those accredited by the ANCC). These provide mentored onboarding, dedicated preceptors, and protected learning time. Strongly recommended if you can get into one.
An ADN gets you working — often within 2–3 years for a fraction of the cost of a university program. Most nurses complete their BSN later while employed, often with employer tuition assistance. Don't let the BSN requirement keep you from starting. Get in, get experience, then level up on someone else's dime.
Medical-surgical nursing is the largest nursing specialty in the United States and the most common first placement for new graduates. You'll care for adult patients with a broad mix of medical diagnoses, surgical recovery, and multiple comorbidities — often all at once.
Patricia Benner's framework describes how nurses develop. As a new grad, you're a Novice — rule-dependent, needing structure. Around 6 months you become Advanced Beginner. By year 2–3, Competent. Expert nurses often can't explain why they know something is wrong — they just do. Trust the process. The learning curve is steep and then it flattens beautifully.
Your head-to-toe assessment is your foundation. Do it at the start of every shift, document it thoroughly, and use it to catch changes early. The patient's nurse the shift before will give you report — but your assessment is your own baseline. Never skip it, even if the prior nurse says everything is fine.
>0.5 mL/kg/hr — oliguria warrants investigationUse the PQRST framework to assess pain completely:
If it isn't documented, it didn't happen. Chart your assessment, interventions, patient responses, and any communications with providers contemporaneously — or as close to real-time as possible. Good documentation protects you legally and clinically.
Patients with COPD and chronic CO₂ retention have a hypoxic drive to breathe. Their target SpO₂ is often 88–92%, not ≥95%. Giving high-flow O₂ to a COPD patient can blunt their drive to breathe and cause hypercapnic respiratory failure. Always check the order and the patient's baseline. When in doubt, ask the provider.
Don't wait until a patient is coding to call for help. Early recognition and escalation save lives. Use this mental hierarchy:
Your first call for most concerns. They can help triage, provide experienced eyes, and advise on whether to escalate further. Never be afraid to pull in your charge nurse.
Attending, resident, PA, or NP — know who is covering your patients. Use SBAR format (see Section 5) to communicate efficiently. Have the chart open, vitals ready, and a clear ask.
If you feel something is seriously wrong and you're not getting traction — or if the patient is deteriorating fast — call the RRT. They come to you. You do not need provider permission to call. Trust your gut.
Cardiopulmonary arrest. Call immediately. Start CPR. The code team comes to you. Know your unit's code cart location, how to call a code, and your role during a code event.
The first sign of patient deterioration is often a change in mental status — confusion, restlessness, or increased agitation that wasn't there before. Before you see dramatic vital sign changes, the brain tells you something is wrong. Trust a family member who says "she just doesn't seem like herself."
Nursing is about managing competing demands under time pressure. These frameworks give you structure for deciding who to see first, what to do, and how to communicate.
Airway, Breathing, Circulation. When you don't know what to do first, default to ABCs. A patient without a patent airway is your most critical patient, full stop.
SBAR is the universal structure for clinical communication. Prepare before you call so you can deliver a concise, clear handoff. Providers respect nurses who are organized.
Use this every time you enter a room:
AIDET reduces patient anxiety, increases cooperation, and builds trust — fast.
You will see a rotating cast of these diagnoses throughout your career. Know the basics: why the patient is here, what you're watching for, and what to do.
Right Patient · Right Drug · Right Dose · Right Route · Right Time
Scan barcodes (BCMA). Do not override the scanner without a legitimate documented reason. More errors happen from overrides than almost any other cause.
| Drug | Class | Key Nursing Points |
|---|---|---|
| Metoprolol | Beta-blocker | Hold if HR <60 or SBP <90. Do not stop abruptly. |
| Carvedilol | Alpha/Beta-blocker | Take with food. Same holds as metoprolol. |
| Lisinopril | ACE Inhibitor | Watch for hyperkalemia, hypotension, dry cough. Contraindicated in pregnancy. |
| Amlodipine | CCB (dihydropyridine) | Can cause dependent edema. May worsen CHF at high doses. |
| Digoxin | Cardiac glycoside | Narrow therapeutic window. Current HF guidelines target 0.5–0.9 ng/mL (older references cite 0.5–2.0 ng/mL, which remains the assay reference range). Toxicity: nausea, visual changes (yellow-green halos), bradycardia. Check apical pulse 1 full minute before giving. Check K+ — hypokalemia potentiates toxicity. |
| Amiodarone | Antiarrhythmic | Multiple serious interactions. Monitor QTc, LFTs, TFTs, pulmonary function with long-term use. Amiodarone is a potent peripheral vein irritant (not a true vesicant) — prolonged peripheral infusion causes phlebitis; use a central line for infusions >2h when possible. |
| Drug | Notes |
|---|---|
| Furosemide (Lasix) | Loop diuretic. Wasting diuretic — watch K+ and Mg2+. Monitor I&Os and daily weights. IV onset faster than PO. |
| Bumetanide (Bumex) | More potent loop diuretic. 1 mg IV bumetanide ≈ 40 mg furosemide. |
| Spironolactone | Potassium-sparing. Hyperkalemia risk — avoid with K+ supplements, ACE inhibitors in AKI. |
| Drug | Monitor | Reversal |
|---|---|---|
| Heparin (IV drip) | aPTT q6h (therapeutic: 60–100 sec) or anti-Xa level. Weight-based dosing per protocol. | Protamine sulfate |
| Enoxaparin (Lovenox) | Anti-Xa level (if renal impairment, extremes of weight). If CrCl <30 mL/min: dose-reduce to once daily dosing for therapeutic use, or consider switching to IV UFH (which is renally safe and titratable). | Protamine sulfate (partial) |
| Warfarin (Coumadin) | INR — therapeutic range typically 2–3 (or 2.5–3.5 for mechanical valves). Many food/drug interactions. | Vitamin K, FFP, 4-factor PCC (Kcentra) |
| Apixaban / Rivaroxaban (NOACs) | No routine monitoring needed. Watch renal function — dose adjust per CrCl. | Andexanet alfa (apixaban/rivaroxaban) |
IV potassium chloride must always be diluted and infused slowly — maximum 10 mEq/hr peripheral, 20 mEq/hr central (with continuous monitoring). A direct IV push of concentrated potassium causes cardiac arrest. This is one of the most catastrophic medication errors in nursing. Concentrated electrolyte vials should not be on the floor — but if you encounter one, treat it as a controlled substance.
Respiratory depression risk. Monitor RR, sedation level (POSS or RASS). Naloxone (Narcan) must be accessible. Bowel regimen always.
Vancomycin: monitor AUC/MIC (area under the curve) per pharmacy. Piperacillin-tazobactam: renal dosing, watch for neutropenia with long courses.
Prednisone/methylprednisolone: watch glucose (will spike), immunosuppression, don't stop abruptly, adrenal insufficiency risk with long use.
Critical values require immediate provider notification. When the lab calls you with a critical value, you must notify the provider, document the notification, and document the provider's response. Don't sit on a critical lab.
| Lab | Normal Range | Critical Values | Notes |
|---|---|---|---|
| Sodium (Na⁺) | 136–145 mEq/L | <120 or >160 | Hyponatremia: confusion, seizures. Correct slowly — rapid correction → osmotic demyelination. |
| Potassium (K⁺) | 3.5–5.0 mEq/L | <2.5 or >6.5 | Directly affects cardiac rhythm. Hypo: muscle weakness, arrhythmia. Hyper: peaked T-waves, VF risk. |
| BUN | 7–20 mg/dL | >100 | Elevated in AKI, dehydration, GI bleed. BUN:Cr ratio >20:1 = prerenal. |
| Creatinine | 0.6–1.2 mg/dL | Rise >0.3 in 48h | Best marker of renal function. Compare to baseline — chronic CKD patients have elevated baseline. |
| Glucose | 70–100 mg/dL (fasting) | <40 or >500 | Treat hypoglycemia immediately. DKA: high glucose + acidosis + ketones. |
| Bicarbonate (HCO₃⁻) | 22–29 mEq/L | <15 or >40 | Low in metabolic acidosis. High in metabolic alkalosis. |
| Calcium | 8.5–10.5 mg/dL | <6.5 or >13 | Hypocalcemia: Trousseau/Chvostek signs, tetany. Hypercalcemia: bones, groans, stones, moans. |
| Magnesium | 1.7–2.2 mg/dL | <1.0 or >4.9 | Hypomagnesemia causes hypokalemia and hyponatremia that won't correct without replacing Mg first. |
| Lab | Normal Range | Critical Values | Clinical Notes |
|---|---|---|---|
| WBC | 4.5–11.0 K/µL | <2.0 or >30 | Elevated = infection, inflammation, or leukemia. Low = neutropenia (infection risk — isolation precautions). |
| Hemoglobin | M: 13.5–17.5 / F: 12.0–15.5 g/dL | <7.0 (transfusion often considered) | Acute drop = bleeding. Chronic low = anemia, bone marrow issues. Transfuse per order, not automatically. |
| Platelets | 150–400 K/µL | <50 = bleeding risk; <20 = spontaneous bleeding | Heparin-induced thrombocytopenia (HIT) — if platelets drop 50% on heparin, think HIT immediately. |
| Lab | Normal | Therapeutic / Critical |
|---|---|---|
| INR / PT | 0.8–1.2 / 11–13.5 sec | Therapeutic anticoagulation (warfarin): INR 2.0–3.0. Critical: >5.0 = high spontaneous bleed risk (critical threshold varies by institution — verify yours). |
| aPTT | 25–35 sec | Therapeutic heparin: 60–100 sec (1.5–2.5× normal). Critical: >120 sec. |
Arterial blood gases tell you the patient's acid-base status and ventilation. Use the mnemonic ROME: Respiratory Opposite, Metabolic Equal.
| Disorder | pH | PaCO₂ | HCO₃⁻ | Clinical Clues |
|---|---|---|---|---|
| Resp. Acidosis | ↓ <7.35 | ↑ >45 | Normal/↑ | Hypoventilation, COPD, sedation, airway obstruction |
| Resp. Alkalosis | ↑ >7.45 | ↓ <35 | Normal/↓ | Hyperventilation, anxiety, hypoxia, PE, pregnancy |
| Metabolic Acidosis | ↓ <7.35 | Normal/↓ | ↓ <22 | DKA, AKI, lactic acidosis, sepsis, GI losses (diarrhea) |
| Metabolic Alkalosis | ↑ >7.45 | Normal/↑ | ↑ >26 | NG suctioning, vomiting, diuretics, excess bicarb |
pH: 7.35–7.45 · PaO₂: 80–100 mmHg · PaCO₂: 35–45 mmHg · HCO₃⁻: 22–26 mEq/L · SpO₂: 95–100%
New grads consistently report that time management is the hardest part of the first year — harder than the clinical knowledge. The shift doesn't slow down for you to think. Here's how to build a framework.
Print or write out a patient summary sheet at the start of every shift. Include:
Many units have pre-made templates. Use or adapt them. This sheet is your external brain.
Nobody expects you to know everything in your first year. What they expect is that you ask when you don't know, that you care for your patients, and that you show up. The rest is learned.
Nursing is one of the most demanding and most meaningful things a person can do. It is hard in the beginning in a way that is hard to describe. And then, quietly, it becomes yours. The assessment becomes second nature. The interventions become instinct. The patients stop being overwhelming and start being people you can actually help. You will get there. Keep going.