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NCLEX Studying > Fundamentals: Easy > Flashcards

Fundamentals: Easy Flashcards

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1
Q

How should a patient’s fluid intake compare to their urine output?

A

They should be approximately equal

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2
Q

Name two breathing techniques a patient with COPD can use when they feel short of breath.

A
  1. Pursed lip breathing
  2. Diaphragmatic breathing
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3
Q

What fluids or meds are permitted to be given through a patient’s TPN line?

A

None

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4
Q

If a patient has an order to be “NPO” what does that mean?

A

Nothing by mouth

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5
Q

How should the nurse record ice chips when calculating a patient’s fluid intake?

A

Ice chips should be recorded as half of their volume (8 oz ice chips = 4 oz water)

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6
Q

How would hypoxemia be diagnosed in a patient?

A

With an arterial blood gas (ABG)

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7
Q

What oxygen delivery device provides the most precise oxygen delivery without intubation?

A

Venturi device

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8
Q

What kind of room does a patient on airborne precautions require?

A

Negative air flow room

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9
Q

How much of a sterile field’s border is considered non-sterile?

A

1 inch

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10
Q

What clothing material should be worn by patients receiving oxygen therapy?

A

Cotton

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11
Q

How often should a patient use an incentive spirometer?

A

10 times every hour while awake

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12
Q

How is the position of a chest tube verified after insertion?

A

Chest x-ray

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13
Q

What therapeutic intervention uses percussion, vibration, postural drainage, and breathing exercises to loosen respiratory secretions?

A

Chest physiotherapy

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14
Q

What part of the finger should the nurse puncture when taking a capillary blood glucose sample?

A

At the lateral, distal end of the finger tip (the side of the tip)

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15
Q

How should the patient’s dentures be stored?

A

In labeled denture cup with denture solution or water

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16
Q

When performing a fecal occult blood (FOB) test, what indicates the presence of blood in the patient’s stool?

A

The card turns blue if blood is present

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17
Q

The nurse expects the systolic blood pressure of an older adult to be affected in what way?

A

It may be elevated

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18
Q

The nurse educates a patient that dementia is an expected part of aging beginning at which age?

A

Never - dementia is not an expected part of aging

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19
Q

Which type of abuse is characterized by failure of a caretaker to provide for basic needs? (Medical care, nutrition, hygiene)

A

Neglect

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20
Q

What is the name for bilateral hearing loss that occurs with aging?

A

Presbycusis

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21
Q

Which spinal curvature is often present in older adults?

A

Kyphosis - hunchback

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22
Q

How does a patient’s anterior-posterior chest diameter change as they get older?

A

It increases

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23
Q

What is the term used to describe the concurrent use of five or more medications?

A

Polypharmacy

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24
Q

Which of the following integumentary system changes is unlikely to occur in an older adult?
A) Increased oil production
B) Decreased sweating
C) Presence of senile lentigines (age spots)
D) Paler skin

A

A) Increased oil production

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25
Q

Explain “sundowning” in patients with Alzheimer’s disease

A

Increased confusion or agitation in the evening

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26
Q

Which disorder of close vision is common in older adults?

A

Presbyopia - Difficulty focusing on close-up objects

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27
Q

Name two physiological changes of the GI system that occur in older adults

A

Any two of the following:
- Decreased salivation
- Weaker gag reflex
- Decreased appetite
- Decreased taste
- Decreased thirst
- Decreased bowel motility

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28
Q

Stiffening and calcification of blood vessels in older patients can lead to what disease, which may cause hypertension?

A

Atherosclerosis

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29
Q

Which style of leadership is characterized by a hands-off approach where the leader allows the team to make decisions for themselves?

A

Laissez-faire

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30
Q

What term is used to describe a medical error which results in temporary severe harm, permanent harm, or the death of a patient?

A

A sentinel event

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31
Q

A nurse respecting a patient’s right to refuse treatment for cancer is demonstrating which nursing ethical principle?

A

Autonomy

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32
Q

A nurse educating a patient about possible side effects of medication is demonstrating which nursing ethical principle?

A

Veracity - conformity to facts; truthfulness

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33
Q

What term is used to describe a bed positioned flat but tilted with the foot of the bed lower than the head?

A

Reverse Trendelenburg

34
Q

Which position is the patient in if the head of the bed is at a 30-45 degree angle?

A

Semi-Fowler’s

35
Q

The passage of antibodies to an infant via breast milk is considered which type of immunity?
A) Active Natural
B) Active Artificial
C) Passive Natural
D) Passive Artificial

A

C) Passive Natural

36
Q

Vaccination is considered which type of immunity?
A) Active Natural
B) Active Artificial
C) Passive Natural
D) Passive Artificial

A

B) Active Artificial

37
Q

Which legal document defines nursing scope of practice and governs nursing practice in each state?

A

Nurse Practice Act

38
Q

Which organization establishes the ethical standards for the nursing profession?

A

American Nurses Association (ANA)

39
Q

Which stage of infection is characterized by the appearance of infection-specific signs and symptoms?

A

Illness Stage

40
Q

Which stage of infection is characterized by the appearance of general, non-specific symptoms such as fever, fatigue, and malaise?

A

Prodromal Stage

41
Q

What legal documents communicate an individual’s choices regarding medical care should they become incapacitated?

A

Advance Directives

42
Q

What term describes an individual who is appointed to be responsible for a patient’s medical decision-making should the patient become incapacitated?

A

Durable Power of Attorney (DPOA)

43
Q

In the event of a tornado, where should the nurse relocate the patients?

A

Away from windows, ideally in the middle of the building or the hallway

44
Q

When lifting an object, how should the nurse position their feet?

A

Shoulder-width apart

45
Q

What is the law that protects a patient’s right to privacy and regulates how their health care information is used and disclosed?

A

Health Insurance Portability and Accountability Act (HIPAA)

46
Q

A nurse who performs multiple medication to avoid a medication error is demonstrating which nursing ethical principle?

A

Nonmaleficence

47
Q

Which position is a patient in if they are lying flat on their back?

A

Supine

48
Q

What is the belief that the views and practices of one’s own culture are superior to other cultures?

A

Ethnocentrism

49
Q

True or False; If a Spanish speaking patient’s spouse is fluent in English, they can be used to help with interpretation.

A

False

50
Q

When using a fire extinguisher, what are the steps in the proper order?

A

P: Pull the pin
A: Aim at the base of the fire
S: Squeeze the handle
S: Sweep side to side

51
Q

Which type of communication is characterized by an individual’s inner thoughts?

A

Intrapersonal

51
Q

True or False: Before reporting potential abuse, the nurse needs to collect evidence to provide proof to the authorities.

A

False

51
Q

Which theoretical model explains and predicts an individual’s health-related behaviors based on their perception of the severity of an illness, susceptibility to the illness, and benefits of/barriers to taking action?

A

Health belief model

51
Q

A patient’s report of sharp abdominal pain is an example of white tye of data?

A

Subjective data

51
Q

What is the best way for a nurse to be sure a patient understands teaching about how to perform an insulin injection?

A

Ask for a return demonstration (patient shows how they would self administer next dose as the nurse watches)

51
Q

A threat made against a patient that makes them fearful is considered which kind of tort?

A

Assault

52
Q

Name the five steps of the nursing process

A
  1. Assessment
  2. Diagnosis
  3. Planning
  4. Implementation
  5. Evaluation
52
Q

Which position should the patient be in for a gynecologic exam?

A

Lithotomy

53
Q

Which type of pain is organ-related?

A

Visceral pain

54
Q

Which type of pain is caused by injury to nerves and is described as “burning”, “shooting”, or “pins and needles”?

A

Neuropathic pain

55
Q

How many fingers should fit between a restraint and the patient?

A

Two fingers

56
Q

Which type of knot should be used when tying a restraint?

A

Quick release knot (slip knot)

57
Q

How does the nurse estimate the NG tube length needed prior to insertion?

A

Measure from the tip of the nose to the earlobe, then to the xiphoid process

58
Q

What is the best way to confirm NG tube location after insertion?

A

Abdominal x-ray

59
Q

Which interdisciplinary team member is responsible for helping the patient maintain their ability to perform activities of daily living ADLs?

A

Occupational therapist

60
Q

Which interdisciplinary team member is responsible for assisting the patient with swallowing issues?

A

Speech language therapist

61
Q

How much room should be between the axilla and underarm pad of a crutch?

A

2 inches

62
Q

On which side of the body should a cane be held?

A

The strong/unaffected side of the body

63
Q

Which macronutrient is important for building and repair of tissues, immune system support, and energy?

A

Protein

64
Q

When a patient is in restraints, how often does the nurse need to assess their status and behavior?

A

Every 15 minutes

65
Q

For a patient who has an ostomy, what are the qualities of a healthy stoma?

A

Pink/red and moist

66
Q

When should the nurse empty a patient’s ostomy bag?

A

When its 1/2 full

67
Q

When performing tracheostomy care, why should the nurse use pre split gauze instead of cutting a piece of gauze to place under the face plate?

A

Cutting gauze can cause lint or fuzz to enter the tracheostomy

68
Q

For tracheal suctioning, what size suction catheter should be used?

A

A suction catheter that is <50% the diameter of the tracheostomy or endotracheal tube

69
Q

How should the probe be positioned when performing a bladder scan?

A

Place 1” above the symphysis pubis and point towards the bladder

70
Q

What is key risk to a patient with an indwelling urinary catheter?

A

Catheter associated urinary tract infection (CAUTI)

71
Q

An individual’s response to an impending loss is which kind of grief?

A

Anticipatory grief

72
Q

During which stage of sleep does vivid dreaming occur?

A

Rapid eye movement (REM)

73
Q

What is the most important thing a nurse can do to prevent infection?

A

Hand hygiene

74
Q

When does discharge planning start for a patient in an acute care setting?

A

Upon admission

75
Q

What is an important intervention/teaching the nurse should provide during mealtime to a patient with dysphagia?

A

Any of the following:
- Provide thickened liquids
- Raise HOB
- Teach patient to tuck chin when swallowing

76
Q

Why should the patient be educated on removing scatter rugs from their house?

A

They are a trip hazard

NCLEX Studying (5 decks)

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