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NCLEX Studying > Fundamentals: Moderate > Flashcards

Fundamentals: Moderate Flashcards

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1
Q

What are the five rights of delegation?

A
  • Right task
  • Right circumstance
  • Right person
  • Right direction
  • Right supervision
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2
Q

Which of the following should the nurse not delegate to a UAP?
A) Bathing
B) CPR
C) Wound Care
D) Charting patient I/Os

A

C) Wound care

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3
Q

Should the nurse prioritize a patient with inspiratory stridor, or one with severe abdominal pain?

A

Inspiratory stridor

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4
Q

Which of the following should the nurse not delegate to an LPN?
A) Blood transfusion
B) Tracheostomy care
C) Wound dressing change
D) NG insertion

A

A) Blood transfusion

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5
Q

What is the first step in the quality improvement process?
A) Collect data using an audit
B) Identify benchmark or standard of care
C) Perform root cause analysis for a performance gap

A

B) Identify benchmark or standard of care

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6
Q

True or False: It is important to include an incident report in the patient’s medical record.

A

False - An incident report is an internal document and should not be included or referenced in the patient’s chart

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7
Q

Which conflict management strategy produces the best outcome?
A) Compromising
B) Collaborating
C) Smoothing
D) Accommodating

A

B) Collaborating

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8
Q

Which stage of conflict is characterized by the individuals involved being unaware conflict is present or impending?

A

Latent conflict

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9
Q

If there is a fire, should the nurse first close the doors to the unit and patient rooms, or use the fire extinguisher to put out the fire?

A

Close the doors
R: Rescue
A: Alarm
C: Contain
E: Extinguish

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10
Q

Touching a patient without consent and causing harm is considered which kind of tort?

A

Battery

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11
Q

If a patient is involuntarily admitted, do they have the right to refuse medication?

A

Yes

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12
Q

Which of the following is NOT part of the nurse’s role in informed consent:
A) Ensure the patient is competent to provide consent
B) Answer patient questions about the procedure
C) Sign the consent form as a witness

A

B) Answer patient questions about the procedure - provider performing the procedure should answer the questions

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13
Q

The nurse is attempting to obtain informed consent from a patient who has questions about the planned procedure. What should be the nurse’s next step?

A

Call the provider to come answer the patient’s questions

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14
Q

According to Erikson’s stages of psychosocial development, what is the psychosocial crisis for adolescents? (12-18 years)

A

Identity vs role confusion

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15
Q

According to Erikson’s stages of psychosocial development, what is the psychosocial crisis for older age adults? (>65 years)

A

Integrity vs despair

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16
Q

What are two bloodborne pathogens that can be contracted with a needlestick injury?

A

Hepatitis (B or C) and HIV

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17
Q

What two things does the nurse need to wear when caring for a patient with an internal radiation device (brachytherapy)?

A

Dosimeter badge and lead apron

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18
Q

In the chain of infection, what term is used to describe how the agent goes from the reservoir to the new host?

A

Mode of transmission

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19
Q

In the chain of infection, what term is used to describe where the infectious agent lives and multiplies?

A

Reservoir

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20
Q

Medicating a patient with a sedative medication for the convenience of a nurse is considered which kind of tort?

A

False imprisonment

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21
Q

Which kind of tort occurs when a nurse fails to provide the standard of care required fo a patient, resulting in patient harm?

A

Malpractice

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22
Q

Is the following question therapeutic or non-therapeutic? “Why won’t you take your medication?”

A

Non-therapeutic - “Why” questions are typically not therapeutic

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23
Q

The nurse asks, “Do I understand you correctly when you say your stomach pain occurs before you get nauseous?” Which therapeutic technique is this?

A

Clarification or validation

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24
Q

Patient teaching on how to use an incentive spirometer involves which domain of learning?

A

Psychomotor learning

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25
Q

Name three forms of nonverbal communication

A

Any three of the following:
- Posture
- Facial expression
- Eye contact
- Gestures
- Touch
-Silence

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26
Q

Which of the following are non-modifiable risk factors for getting an illness?
A) Stress
B) Age
C) Ethnicity
D) Obesity
E) Genetics

A

B) Age
C) Ethnicity
E) Genetics

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27
Q

Which of the following nursing actions is inappropriate for a patient who wants to leave AMA?
A) Notify the provider
B) Call security
C) Educate patient on the risks of leaving AMA
D) Have patient sign an AMA form

A

B) Call security

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28
Q

Name two types of food a Kosher-observant patient may not consume

A

Any two of the following:
- Pork products
- Shellfish
- Meat with dairy

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29
Q

True or False? An ethics committee collects data regarding an ethical dilemma from the treatment team and family, decides the best course of action, and enforces that decision.

A

False

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30
Q

Name the six components of the chain of infection

A
  1. Infectious agent
  2. Reservoir
  3. Portal of exit
  4. Mode of transmission
  5. Portal of entry
  6. Susceptible host
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31
Q

Which type of anxiety may enhance learning?

A

Mild anxiety

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32
Q

What is the nurse’s priority action if a patient’s chest tube becomes disconnected from the drainage system?

A

Place the end of the tube in sterile water to maintain the water seal

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33
Q

What time of day should a patient receive chest physiotherapy?

A

Before meals or 1-2 hours after meals

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34
Q

Name three important teaching points to give a female patient in order to prevent a UTI

A

Any three of the following:
- Wipe front to back
- Wear cotton underwear
- Avoid bubble baths
- Avoid sitting in a wet bathing suit
- Avoid tight clothing
- Urinate after intercourse
- Drink ~ 3L of fluid per day

35
Q

What key symptom is common in older adults who present with a UTI?

A

Confusion

36
Q

How does the nurse collect a sterile urine specimen from a patient with an indwelling catheter?

A

Collect urine sample from the designated sampling port on the catheter, not from the drainage bag.

37
Q

What is the nurse’s priority action if a patient’s urine output is less than 30mL/hr?

A

Notify the provider

38
Q

When changing a patient’s ostomy appliance, how big should the nurse cut the skin barrier or wafer?

A

No more than 1/2” wider than the measured stoma size

39
Q

Does asthma affect a patient’s ventilation, diffusion, or perfusion?

A

Ventilation

40
Q

What is the maximum length of time a nurse should spend on a suction pass?

A

No longer than 15 seconds

41
Q

What is the maximum number of suctioning passes a nurse should perform in one session?

A

No more than three passes per session

42
Q

Which of the following is not appropriate patient education regarding diabetic foot care?
A) Wear professionally fitted shoes
B) Inspect feet daily
C) Cut nails in a rounded shape
D) Wear cotton socks

A

C) Cut nails in a rounded shape - nails should be cut straight across

43
Q

When irrigating a wound, what irrigation force should be used?

A

~ 8-15 psi

44
Q

True or false: If a patient is violent, the nurse can place restraints on a patient without an order.

A

True; an order must be obtained from the provider ASAP after application

45
Q

Name all of the fat soluble vitamins

A

Vitamins A, D, E, K

46
Q

Name two localized symptoms of a surgical site infection

A

Any two of the following:
- Pain
- Erythema
- Induration
- Purulent drainage

47
Q

Following an operation, when should a patient be allowed to drink water?

A

After the patient’s gag reflex returns

48
Q

What is a solution’s tonicity if it causes water to move into a cell?

A

Hypotonic

49
Q

Name three symptoms of fluid volume excess

A

Any three of the following:
- Weight gain
- Edema
- Tachycardia
- Tachypnea
- Hypertension
- Bounding pulse
- Dyspnea
- Crackles in lungs
- Jugular vein distention

50
Q

If the patient’s next TPN bag will not be available on time, what type of fluid should the nurse administer until it arrives?

A

Administer 10-20% dextrose in water until it arrives

51
Q

How often and with how much water should a feeding tube be flushed with during continuous feeding?

A

Flush every four hours with 30 mL of water

52
Q

What kind of transmission precautions are required for a patient with TB?

A

Airborne precautions

53
Q

What PP is required for a patient on airborne precautions?

A

Gown, gloves, N95 mask or respirator

54
Q

True or false: If a patient is having a seizure, the nurse should attempt to insert an artificial airway.

A

False - the nurse should not put anything in a patient’s mouth during a seizure

55
Q

Name two actions that are contraindicated for patients with a DVT

A

Do not place a pillow/knee gatch under the leg and do not massage the limb

56
Q

To ensure an indwelling catheter drains properly, name two things to assess while providing patient care

A

Any two of the following:
- Make sure the bag is hanging below the level of the bladder
- Check tubing for kinks
- Ensure there are no dependent loops

57
Q

Which of the following is NOT a risk factor associated with stress incontinence?
A) Stroke
B) Menopause
C) Prior pregnancy
D)Obesity

A

A) Stroke

58
Q

In which chamber of a chest tube should continuous bubbling be observed?

A

The suction control chamber

59
Q

What is expected or normal to observe in the water seal chamber of a chest tube?

A

Tidaling - Slight movement of the water level corresponding to a patient’s breaths

60
Q

What is the most concerning symptom of a potassium imbalance? (Hyer/hypokalemia)

A

Cardiac dysrythmias

61
Q

Are tachycardia, hypertension, and increased DTRs a sign of hypo or hypermagnesemia?

A

Hypomagnesemia

62
Q

If a patient reports abdominal cramping during an enema, what should the nurse do first?

A

Lower the solution container

63
Q

Name two risk factors for constipation

A

Any two of the following:
- Insufficient fluid intake
- Insufficient fiber intake
- Physical inactivity
- Medication side effects
- Older age

64
Q

List the appropriate order to doff (remove) PPE

A
  1. Gloves
  2. Eye protection
  3. Gown
  4. Mask
65
Q

List the appropriate order to don (put on) PPE

A
  1. Gown
  2. Mask
  3. Eye protection
  4. Gloves
66
Q

Name three late signs of hypoxia

A

Any three of the following:
- Decreased LOC
- Cyanosis
- Increased lactic acid
- Dysrhythmias
- Bradycardia
- Bradypnea
- Hypotension

67
Q

Name three early sign of hypoxia

A

Any three of the following:
- Restlessness
- Irritability
- Use of accessory muscles
- Nasal flaring
- Adventitious lung sounds
- Tachycardia
- Tachypnea
- Hypertension
- Pallor

68
Q

After an x-ray confirms the location of an NG tube, what is the best way to confirm NG tube placement at the bedside?

A

Aspiration of fluid and testing the pH

69
Q

Name two reasons a patient may need an NG tube

A

Two of the following:
- Decompression for bowel obstruction
- Short-term nutrition support
- Administration of medications

70
Q

When reviewing results of a urinalysis, what are four substances that should no be present?

A

Any four of the following:
- Glucose
- Ketones
- Blood
- Protein
- Bilirubin
- Nitrates
- Leukocytes
- Esterase

71
Q

What does a urine specific gravity of 1.040 indicate?

A

Concentrated urine

72
Q

Hypoventilation due to a respiratory disorder can cause which acid-base imbalance?

A

Respiratory acidosis

73
Q

Diabetic ketoacidosis (DKA) causes which type of acid-base imbalance?

A

Metabolic acidosis

74
Q

Which stage of pressure injury is characterized by a deep wound with an exposed tendon or bone?

A

Stage IV (4)

75
Q

Which stage of pressure injury is characterized by red, non-blanchable, intact skin?

A

Stage I

76
Q

Name the five stages of grief defined by Kubler-Ross

A
  1. Denial
  2. Anger
  3. Bargaining
  4. Depression
  5. Acceptance
77
Q

Which stage of general adaptation syndrome is characterized by a “fight or flight” response, increased cortisol levels, and increased BP/HR?

A

Alarm reaction stage

78
Q

Name two situations in which it is important to use soap and water vs hand sanitizer?

A

Any two of the following:
- Hands are visibly dirty
- Before eating
- After using the bathroom
After caring for a patient with infectious diarrhea (C-Diff)

79
Q

What PPE is required when caring for a patient with contact precautions?

A

Gown and gloves

80
Q

Opioid analgesics are appropriate for what level of pain?

A

Moderate to severe

81
Q

How full should the bag of a partial rebreather mask be maintained?

A

2/3 full

82
Q

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

A
  • Pursed lip breathing
  • Diaphragmatic breathing
83
Q

How many calories does 1g of fat provide?

A

9 calories

84
Q

What nutrient is most important to prevent pressure injuries?

A

Protein

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