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Passpoint Flashcards

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NCLEX-PN® flashcards NCLEX-RN® flashcards
1
Q

Caused by loss of calcium and phosphate from the bones, causing easy fractures

A

Osteoporosis

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2
Q

Insufficient bone mineralization result of lack Vitamin D, calcium, phosphorous

Softening Bones

A

Osteomalacia

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3
Q

Phebitis is….

A

Inflammation of a vein, often related to IV therapy

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4
Q

“______” is a female who has never been pregnant.

A “______” is a female who is pregnant for the first time or has been pregnant once.

A “______” or “______” is a female who has been pregnant more than once.

A

nulligravida

primigravida

multigravida / secundigravida

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5
Q

mature female reproductive cell,

Can divide to give rise to an embryo usually only after fertilization by a male cell.

How long do they live

A

Ovum

24 hrs

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6
Q

When does ovulation occur in a 28 day cycle

A

Day 14, plus or minus 2 days

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7
Q

Why is

Providing wound care for a client’s venous ulcer at an ambulatory clinic near the client’s home

More Community Based Nursing

Than

Organization of blood pressure screening clinic at a shopping mall

A

Community based care is

Providing care for acute and chronic illnesses In the Geographic Region near client’s home

BP screening and health maintenance education are

Population-based and Community Health Initiatives

Distinct from COMMUNITY BASED CARE

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8
Q

What is the difference between

Developmental Stage & Functional Age

A

Developmental Stage: Understanding cognitive, emotional, social Development

Functional Age: Refers to ability to preform daily tasks

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9
Q

A potentially dangerous pregnancy complication characterized by high blood pressure.

usually begins after 20 weeks of pregnancy in a woman whose blood pressure had been normal. It can lead to serious, even fatal, complications for both mother and baby.

Name 4 Symptoms

A

Pre-eclampsia

High BP
EpiGastric Pain
Swelling of Hands & Feet
Protein in Urine

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10
Q

_____ A portable device that continuously monitors patient ECG, respiratory rate and/or oxygen saturations while automatically transmitting information to a central monitor.

A

Telemetry

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11
Q

The ______ method is a combination of methods. The two most commonly used are the Basal body temperature method and the cervical mucus method. The Marquette method combines BBT and cervical mucus tracking with use of an electronic hormonal fertility monitor. The monitor detects hormones in urine to confirm fertile days.

A

symptothermal

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12
Q

Laminectomy is….

A

surgery Removing bone spurs and tissues associated with arthritis of the spine.

Removing a small piece of the back part (lamina) of the small bones of the spine (vertebrae).

Laminectomy enlarges the spinal canal to relieve pressure on the spinal cord or nerves.

Laminectomy is often done as part of a decompression surgery

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13
Q

Hot-cold concept of humoral medicine (Hispanic Folklore)

Health is believed to be a balance between hot and cold elements in the body.

When the body’s equilibrium is upset by being too “hot” or too “cold,” illness can occur.

Balance can be restored by treatment with foods, remedies, or medicines of the opposite valence.

True or False

A

True

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14
Q

Access skin tugor in an elderly

What should nurse keep in mind

Over hydration causes skin tenting

Dehydration causes skin to appear edematous and spongy

Inelastic skin turgor is normal aging

Normal is moist and boggy

A

Inelastic skin tugor is normal part of aging

Dehydration- not over hydration- causes Inelastic skin with tenting.

Normal skin turgor is dry and firm

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15
Q

Match the following

Rapid, deep breathing without pauses.

Shallow breathing with an increased resipatory rate

Breaths gradually become faster and deeper than normal and then slower with periods of apnea

Deep breathing at normal rate.

A. Hyperpnea
B. Cheyne-Strokes
C. Kussmaul
D. Tachypnea

A

C. Kussmaul
D. Tachypnea
B. Cheyne- Strokes
A. Hyperpnea

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16
Q

Weighing the diaper of an infant after micturition revelas an increase in weight of 40 g

How much urine is this

A

40 mL

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17
Q

Best way for nurse to assess for bladder distention in Male & Female clients

A

Palpate for rounded swelling above the pubis

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18
Q

Client with possible concussion should be positioned with HOB @ ….

A

30 degrees

Promoting Venus return from the head

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19
Q

In hemorrhagic stroke

Monitor ______ to avoid aspiration

A

Gag reflex

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20
Q

Correct placement to palpate the Maxillary and frontal sinuses

A

Maxillary: either side of nose; below the cheekbone (zygomatic bone)

Frontal: just above eye; under the bony ridge of the orbit

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21
Q

______ increased pressure in an enclosed space that can compromise muscle,vascular, and nerve function, can be caused by a Cast that is too tight.

Name 5 symptoms

A

Compartment Syndrome

Inability to feel light touch
Pain
Paresthesia
Coolness
Pallor distal to cast

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22
Q

In compartment syndrome associated with a Tight Cast

To reduce swelling and pressure under the cast and promote venous return the nurse should

A

Elevate leg

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23
Q

Bivalve a cast ….

Define

A

To cut a cast to relieve pressure

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24
Q

A fat embolism can occur how?

Name 5 manifestaciones

A

Long bone fracture

Hypotension, tachycardia, hypoxemia, dyspnea, petechiae, change in LOC level of consciousness

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25
Q

Fasciotomy is…

A

Surgery to improve Compartment Syndrome

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26
Q

Assess Dark Skinned client for cyanosis.

Which is the best spots

A

Conjunctiva

Lips

Oral mucos membranes

Nail beds are NOT APPROPRIATE ASSESSMENT FOR CYANOSIS IN ANYONE

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27
Q

Is a medical scale used to measure the agitation or sedation level of a person

A

Richmond Agitation-Sedation Scale (RASS)

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28
Q

_______ scale is a measurement used to assess pain for children between the ages of 2 months and 7 years or individuals that are unable to communicate their pain.

The scale is scored in a range of 0–10 with 0 representing no pain

A

The FLACC scale or Face, Legs, Activity, Cry, Consolability

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29
Q

Rates critically ill patients’ pain based on clinical observation.

A

Critical Care Pain Observation Tool
(CPOT)

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30
Q

________ is an easy-to-use and easy-to-evaluate tool designed to help cancer patients and professionals communicate accurately about the prevention and control of nausea and vomiting that may occur with chemotherapy.

A

The MASCC Antiemesis Tool (MAT)

Serotonin receptor antagonists: The cornerstone for preventing nausea and vomiting caused by radiotherapy
EXP.
5-HT3 Ondansetron (Zofran)

Four-drug regimen: For preventing acute nausea and vomiting after non-AC ChT with a high emetic risk, the guidelines recommend a regimen of:
A single dose of a 5-HT-RA
Dexamethasone
An NK-RA (aprepitant, fosaprepitant, netupitant, fosnetupitant, or rolapitant)
Olanzapine

31
Q

Which task is most appropriate for an LPN

Assessing Clients oxygen status
Assisting client ambulate
Administración of tube feeding
Reminding client to use the bathroom

A

Tube food

32
Q

A child with the following symptoms maybe suffering from which disease

High fever
Muffled speech
Inspiratory stridor
Drooling

A

Epiglottitis

33
Q

Client admitted to hospital for Aspiration Pneumonia secondary to progression of Parkinson’s disease

Which findings should the nurse expect

Cough while drinking fluid
Muscle flaccid of lower extremities
Bilateral upper muscle weakness
Tremors in fingers, increased with movement

A

Cough while drinking fluids

34
Q

Oliguria is a medical term for low urine output (how much you pee).

In the case of an adult, this means less than ________ of urine per 24 hour

A

400 milliliters (mL) to 500 mL (around two cups

35
Q

Which nursing assessment finding in an elderly client with sepsis requires immediate intervention

Temp. 97.9
Confusion when listening to instructions
Polydipsia
<90 mL urine output over past 6 hrs

A

<90 mL urine in 6 hrs.

Decreased urine output
Tachypnea
Tachycardia
Hypotension

Associated with deterioration due to sepsis

36
Q

Which is the priority for a client showing symptoms of MI

Assess pain level, administration of prescribed Analgesics
Assess level of anxiety, provide emotional support
Prepare client for pulmonary artery catheterization
Ensure family is kept informed

A

Pain & analgesics

Prepare to admin Nitroglycerin or Morphine

Priority to stabilize medically

Pulmonary Artery Catheterization is used to diagnose: Pulmonary hypertension, Shock, Heart Function

37
Q

Doctors use _______ to diagnose and evaluate common heart and blood vessel problems

Chest pain or an abnormal stress test due to coronary artery disease

Heart valve conditions like a leaky or narrowed valve, a high blood pressure condition in the lungs

Blood clots in the lungs from an embolism

Enlarged heart

A

cardiac catheterization

38
Q

Soft to firm, circular, moveable, unlikely to cause nipple retractions

Fibrocystic disease or Cancer

A

Fibrocyctic Disease

39
Q

Irregular in shape, firm, non moveable, nipple retractions.

Fibrocystic Disease or Cancer

A

Cancer

40
Q

The ear canal slants ____ in children and ____ in adults.

To best visualize tympanic membrane in an infant (describe maneuver)

To best visualize tympanic membrane in an adult (describe maneuver)

A

Children Down & Adult Up

Grasp auricle with nondominant hand pull Down and Back from 6 - 9 posistion (Child)

Grasp auricle with nondominant hand pull Up and Back toward 10 posistion (Adult)

41
Q

Normal intraocular pressure is _____ mm Hg

Greater than this range is associated with

Type of eye drops and side effect associated with them

A

10 - 21

Glaucoma

Prostaglandin (Change color of iris)

42
Q

In ______ glaucoma, the increase in pressure is often small and slow.In _______ glaucoma, the increase is often high and sudden. Either type can damage the optic nerve

A

open-angle / closed-angle

43
Q

After suctioning client with trach tube

Which finding indicates no further interventions are needed

Pulse ox changes 85 to 89
Resp rate drops from 24 to 16
Coughing out yellow sputum
Coarse breath sounds in anterior chest diminish

A

Resp rate drops.

Proper suctioning should produce a patent airway as Demonstrated by Resp Rate within norms

44
Q

New onset confusion, headache, Bounding pulse been drinking copious amounts of water and voiding frequently

Which abnormal lab value is associated with these findings

Serum Sodium: 122 mmol/L
Norm (135 - 145 mmol /L)

Urine Specific Gravity: 1.041
Norm (1.003 - 1.035)

Serum Osmolality 325 mmol/kgH²O
Norm (275 -295 mmol/kgH²O)

A

Hyponatremia

Nurse would expect the Serum Osmolality & Specific Gravity to be LOW not HIGH

45
Q

functional nursing, team nursing, primary nursing and total patient care

Are all types of…

A

Nursing care delivery systems

46
Q

A task oriented approach to delivering care

Tasks are delegated to team members

Team members focus on their specific task - Instead of treating the whole patient

A

Functional Nursing

47
Q

Led by RN team leader

Leader assigns patients to members of the team.

Each member is responsible for the individual patient care and outcomes

A

Team

48
Q

Focus on keeping nurse at bedside

Actively involved in patient care

One nurse is responsible in managing care from admission to discharge.

A

Primary/ Relationship Based Practice

49
Q

Nurse take total responsibility of planning and delivering care to patient for an Assigned Time Period

A

Total patient care approach/ Patient Focused Care

50
Q

Urine output should be ____ in 24 hrs

A

20ml /h

51
Q

When accessing a client’s incision one day after surgery a nurse sees redness and warmth around incision site.

Select best action

A. Culture the wound
B. Apply a cool compression
C. Assess for blanching
D. Note the wound edges in the client’s chart

A

D.

Warmth and redness are normal sign of inflammation and don’t require interventions.

Blanching would not demonstrate that there is a wound infection

52
Q

Correct technique when applying an elastic bandage to a leg

A. Increase tension with each turn of the bandage
B. Start at distal end of extremity and move towards the trunk.
C. Secure bandage with clips over the area of the inner thigh
D. Overlap each layer 2 times when wrapping.

A

B.

Tension should be kept even to prevent circulation impairment

Overlapping can impairment circulation

Clips placed on the outer aspect of the leg to Avoid Pressure Point on Other Leg

53
Q

Swelling around the eyes and in the feet and ankles
Foamy urine
Weight gain due to excess fluid retention.

Proteinuria and hypoalbuminemia Results in edema and hyperlipidemia

History of diabetes places client at risk

A kidney disorder that causes the body to excrete too much protein in the urine.

A

Nephrotic Syndrome

54
Q

Urine culture and sensitivity test identifies….

A

Organisms in urine

55
Q

Why apply a warm compress

Vasodilation/ Vasoconstriction

A

Vasodilation

Promotes circulation
Increase tissue metabolism
Leukocyte mobility

56
Q

Why apply cold compress to an area

Vasodilation/ Vasoconstriction

A

Vasoconstriction

Prevent swelling

57
Q

Why is a cather bag placed in a location below the bladder

A

To prevent back flow of urine into the bladder

58
Q

To avoid injury, remember

The center of gravity is located…

A

At the Pelvis

59
Q

Which is the correct way for a client to clean a tracheostomy dressing

A. Clean around the incision site, using gauze squares and full-strength hydrogen peroxide
B. Rinse around the clean incision site, using gauze squares moistened with normal saline.
C. Cleaning around the incision site, the client applies cotton-filled gauze squares as a sterile dressing.

A

B.

Use 50/50 hydro peroxide/ saline if crust are difficult to remove.

Don’t use cotton-filled gauze squares.

Use non-raveling material

60
Q

When changing a sterile surgical dressing, a nurse first must

A. Wash hands
B. Put on sterile gloves
C. Remove old dressing while wearing clean gloves
D.Open sterile packages and moisten the dressing with sterile saline solution

A

A. Always wash hands first

Remove old dressing while wearing clean gloves

Put on sterile gloves

Open packages and moisten dressing with saline

Are all correct but come after

61
Q

Before bronchoscopy (visualization of the trachea and bronchial tree) the Client is instructed what? Why?

After procedure The client is put in semi-Fowlers position

A

Not to eat 6 hours prior

Prevent aspiration

62
Q

What is insensible fluid loss

Give examples

A

Fluid loss that is not easily measured

Respitory system, skin, stool

63
Q

Use of Montgomery straps when changing a dressing is…

A

Prevent skin breakdown

The Montgomery straps work to hold dressing in place instead of Tape (which when removed will break skin down)

64
Q

Proper position for AED pads

A

Right upper sternum

Left 5 / 6 intercoastal space left of anterior axillary line

65
Q

Best way to communicate with client with a trachea tube

Does a trachea plug help?

A

Magic slate to write

No, a plug is used when being weaned off a trachea

66
Q

First action to take when giving the client the wrong meds

A

Assess for potential allergies and vitals

Then, notify practitioner and charge nurse

67
Q

What action can a nurse take to help minimize loss of calcium from clients bones.

A. Provide dairy products at frequent intervals
B. Supplemental feedings between meals
C. Encourage client to walk down hallway

A

C.

Calcium absorption diminishes with reduced physical activity

Due to decreased bone stimulation

Dairy products won’t help because
Additional calcium doesn’t increase bone stimulation or osteoblast activity

68
Q

What should a nurse do to a client who presents to the hospital with anaphylaxis shock?

A. Admin Diphenhydramine
B. Insert IV
C. Admin metoprol
D. Have resp therapy provide Albuterol treatment
E. Monitor International Normalized Ratio IRN Level

A

A, B, D

69
Q

While cleaning around a G-tube placed 1 week ago and changing the gauze dressing

Which type of Precautions are needed.

Sterile procedure, droplets Precautions

Clean procedure, universal Precautions

Clean procedure, contact Precautions

Sterile procedure, airborne Precautions

A

Clean procedure, universal Precautions

70
Q

3 factors for radiation safety

A

Time, Distance, shielding

71
Q

A blister is found on the heel of a patient with compression stockings.

What would be the correct next steps regarding this issue

How often does a nurse check skin in compression stockings

A

Discontinue for Discoloration, markings, or blisters in heel.

Notify provider

Sequential compression devices will be used instead to prevent DVT

72
Q

Does massage increase or decrease blood flow to the area

A

Decrease

73
Q

What is the purpose of a Time Out Procedure in the OR.

A

Review of client safety

Review surgical site markings
ID correct surgical procedure
Confirm clients name band

A NCLEX (44 decks)

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