NCLEX High Yield Fundamentals Practice Flashcards

Comprehensive practice flashcards created from the NCLEX High Yield Fundamentals lecture notes covering basic care, comfort, procedures, safety, and pharmacology.

Who are the authors of the NCLEX High Yield Fundamentals document?

Dr. Zeeshan Hoodbhoy, M.D. and Nurse Brittany Friedman, BSN, RN.

What is wound dehiscence?

A complication of wound healing where the edges of a surgical incision or wound separate.

What are the risk factors for impaired wound healing and wound dehiscence?

Impaired oxygenation, diabetes, smoking, obesity, advanced age, malnutrition, infection, steroid use, and straining (coughing or vomiting).

What PRN medications can be administered to prevent abdominal straining post-surgery?

Stool softeners (such as Docusate) and antiemetics PRN (such as Ondansetron or Metoclopramide).

What non-pharmacological intervention should a post-op patient perform when coughing to prevent dehiscence?

Splint the abdomen by holding a pillow or folded blanket tightly against the incision site.

How should leg incisions be cleaned post-coronary artery bypass graft (CABG)?

Wash the incision daily with soap and water while showering, and pat dry.

What actions should be avoided during leg incision care to prevent infection post-op?

Avoid bath tubs, lotion, and powders.

What signs and symptoms regarding a leg incision should a patient report to their healthcare provider?

Swelling, increased drainage, redness, warmth, purulent drainage, or numbness, tingling, and itching.

How long does a leg incision typically take to heal post-op?

It takes $4-6$\,weeks to heal.

What elevation in white blood cell (WBC) count or body temperature is expected post-op due to stress?

White blood cells (neutrophils) may be elevated due to stress, and a low-grade fever ($<100.4^\text{o}F$) is an expected post-op finding.

What causes hospital-acquired pressure injuries?

They are localized skin injuries caused by tissue ischemia/hypoxia after prolonged pressure and friction or shear.

What are key risk factors for hospital-acquired pressure injuries?

Immobilization, advanced age, quadriplegia, impaired sensation, nutritional deficits (decreased albumin, weight loss), perfusion/oxygenation deficits, skin moisture/incontinence, edema, fever, altered mental status (AMS), cancer, and appetite-suppressing medications.

How frequently should an immobilized patient be repositioned to prevent pressure injuries?

Consistently move or reposition them every $2$\,hours ($q2hrs$).

How does Negative Pressure Wound Therapy (NPWT) promote wound closure?

It draws out fluid and infection from the wound using a vacuum pump over a special sealed dressing, helping it heal faster and properly.

What standard continuous pressure setting is commonly used for Negative Pressure Wound Therapy (NPWT)?

$120$\,mmHg.

What is the nurse's main responsibility regarding the Negative Pressure Wound Therapy (NPWT) device?

Do not touch or alter the settings; monitor the device and wound.

What absolute neutrophil count defines neutropenia?

A very low neutrophil count of $<1,000$\,cells/$\mu L$.

Which specific drugs are highlighted as causing neutropenia?

Chemotherapy agents, Clozapine, Carbamazepine (used for trigeminal neuralgia), steroids, and immunosuppressants.

What dietary precautions are required for a patient on neutropenic precautions?

No raw or unwashed vegetables, and all meat and seafood must be fully cooked.

What vaccine type is contraindicated for neutropenic patients?

Live vaccines.

What signs or symptoms in a neutropenic patient indicate a potential progression to sepsis?

Sore throat, fever, and gastrointestinal (GI) distress.

What is the overarching goal of end-of-life care?

To maintain comfort and quality of life.

How should a nurse manage excessive respiratory secretions ("death rattle") in an end-of-life patient?

Reposition the patient, perform suctioning, and administer anticholinergic medications such as Atropine to dry up secretions.

What is the order of care transition between palliative care and hospice care?

Palliative care comes first, followed by hospice care when terminal status is established.

How should a nurse disclose information during end-of-life care counseling?

Disclose everything factually without expressing personal opinions or feelings toward the situation.

What interventions can help alleviate anorexia in terminal end-of-life patients?

Provide opportunities to eat with family/friends outside the room, offer oral care, use topical treatments, provide appetite stimulants, involve the patient in meal planning, and consider medical cannabis.

Who is eligible to receive palliative care?

Patients diagnosed with a serious long-term illness (such as cancer, kidney disease, or AIDS) regardless of the stage of disease.

Can a patient receive palliative care alongside curative treatments?

Yes, palliative care can be provided alongside curative and life-prolonging treatments.

What prognosis requirement determines eligibility for hospice care?

Patients with a terminal illness who have $<6$\,months to live.

What treatment adjustment must occur when a patient enters hospice care?

Curative and life-prolonging treatments must be stopped.

When should postmortem care be performed?

Immediately following the official pronouncement of death.

Under what circumstances should postmortem care be delayed or suspended?

When cultural or religious beliefs require time before handling, or when deaths are due to trauma, non-natural causes, or criminal activity requiring investigation.

What routine care steps are included in postmortem care?

Close the patient's eyes, remove tubes and dressings, wash the body, place a pad under the perineum for discharge, place a pillow under the head, and give belongings to the family.

What skin product must be avoided when a patient is using portable oxygen due to fire risk?

Vaseline (or any oil-based products); water-based humidifiers and lotions should be used instead.

How far away must portable oxygen be kept from gas stoves, open flames, or fireplaces?

$5-10$\,feet.

What clothing fabrics should be avoided around portable oxygen to prevent static sparks?

Synthetic and wool fabrics.

What immediate actions should a nurse take if IV infiltration occurs?

Stop the infusion immediately, start a new IV line, monitor for swelling, and elevate the extremity.

What technique should be used to ambulate a legally blind patient?

Use the sighted guide technique: place the patient's hand on the nurse's elbow and walk alongside them.

How should a nurse explain food arrangement on a plate for a visually impaired or legally blind patient?

Use a clock face pattern.

What volume and tone should a nurse use when communicating with a legally blind patient?

Use a normal speaking tone and volume.

Why is Lactated Ringers (LR) contraindicated in patients with liver disease or metabolic acidosis?

The lactate in LR is metabolized by the liver; if the liver is dysfunctional, it cannot process it and it turns into lactic acid.

What severe neurological complication occurs if $3\%$ hypertonic saline is administered too rapidly to correct severe hyponatremia?

Central pontine myelinolysis (resulting in locked-in syndrome, where the patient cannot move or speak but can see and hear).

What standard medical interventions are given to treat Diabetic Ketoacidosis (DKA)?

IV fluids, regular insulin, and potassium ($K^+$).

What happens to a cell placed in a hypotonic solution?

Fluid shifts from the extracellular space into the intracellular space, causing the cell to swell and potentially lyse.

What happens to a cell placed in a hypertonic solution?

Fluid shifts out of the cell into the extracellular space, causing the cell to shrink (crenation).

What are standard examples of isotonic IV fluids?

$0.9\%$ NaCl (Normal Saline), Lactated Ringers (LR), $D_5W$ ($5\%$ Dextrose in Water), and $D_5LRS$.

What are standard examples of hypotonic IV fluids?

$0.45\%$ NaCl ($1/2$ Normal Saline) and $2.5\%$ dextrose in water.

What are standard examples of hypertonic IV solutions?

$3\%$ NaCl, Dextrose $5\%$ in $0.9\%$ NaCl ($D_5NS$), Dextrose $10\%$ in $0.9\%$ NaCl ($D_{10}NS$), TPN, Albumin, and Dextran.

What communication techniques should be used for low literacy patients?

Use pictures, simple text, involve family members or caretakers, and provide professionally approved resource websites.

What therapeutic open-ended phrase should nurses frequently utilize, and what is the exception?

Use "Tell me more…"; the exception is when the patient expresses Suicidal Ideation (SI) or Homicidal Ideation (HI).

What communication guidelines should be followed for a patient with hearing loss?

Post a sign, approach from the front, face the patient directly, keep lights on, use facial expressions/gestures, speak toward the least affected ear in a normal volume, and ensure hearing aids are in place.

What are key teaching instructions for hearing aid care and wear?

Turn volume off before inserting, gradually increase wear time and volume, do not wear with heat lamps or hair dryers, remove batteries at night and turn off when not in use, and clean with a soft dry cloth.

How should a nurse communicate with a patient who has Alzheimer's disease?

Face the patient, turn off distractions (like the TV), close the door, and keep communication simple.

What rules must a nurse follow when working with a language interpreter?

Speak in first person ("I"), use short sentences, ask one question at a time, avoid medical jargon, brief the interpreter before meeting the patient, and ask the patient for gender preference.

What does the acronym FASE stand for in addressing post-op body image concerns?

Facts, Assurance, Support, Education.

How should crutches be properly adjusted to fit a patient?

Ensure proper height measurement so body weight is supported on the hands and arms, not the axillae (wear and tear on axillary pads indicates improper fit and risk of nerve damage).

Where should a patient support their body weight when using crutches?

On their hands and arms.

What home safety instructions apply to walking with crutches?

Keep the environment free of clutter and scatter rugs, look forward (not down), use a small backpack to hold items, wear non-skid slippers/shoes, and keep rubber tips dry.

What indicates a properly fitted arm sling?

Elbow flexed at $90^\text{o}$, hand held slightly above elbow level, bottom end covering the wrist with fingers visible, and thumb facing upward or inward.

On which side should a patient hold a cane?

On the stronger side.

What is the step sequence for descending stairs with a cane?

1. Cane, 2. Weaker leg, 3. Stronger leg.

What is the step sequence for ascending stairs with a cane?

1. Stronger leg, 2. Cane, 3. Weaker leg.

How should a nurse assist a client with unilateral weakness when dressing and ambulating?

Dress the affected side first, instruct the patient to turn head to scan the environment, and approach the patient from the unaffected side.

At what Gastric Residual Volume (GRV) threshold should an enteral feeding be held?

Hold the feed if the residual volume is $>500$\,mL.

How much Normal Saline (NS) or water should be used to flush an enteral feeding tube after feeds?

$30$\,mL.

How long is an opened container or formula bag of enteral nutrition good for?

$24$\,hours.

To prevent aspiration, what elevation should the head of bed (HOB) be maintained at during enteral tube feeding?

$30-45^\text{o}$.

What conditions cause low peripheral perfusion and lead to inaccurate pulse oximetry readings?

Hypotension, shock, sepsis, Peripheral Arterial Disease (PAD), Heart Failure (HF), edema, vasopressors, hypothermia, smoking, hemorrhage, burns, and dark nail polish.

What alternate pulse oximetry sensor placement sites can be used in pediatric patients?

Toes or earlobes.

What are the common signs and symptoms of heat exhaustion?

Elevated body temperature, dizziness, weakness, fatigue, sweating, flushing, nausea, tachycardia, and muscle cramping.

What insertion angle and catheter size should be used for IV insertion in elderly patients with fragile skin?

Use the smallest catheter (e.g., $24$\,gauge) at an insertion angle of $5-15^\text{o}$.

What interventions are implemented for a patient with dysphagia to prevent aspiration?

Modify food consistency (soft foods), give thickened liquids, have patient sit upright at $90^\text{o}$, place food on the stronger side of the mouth, and instruct them to tilt their neck slightly forward.

At what ages does fall risk begin and significantly escalate?

Fall risk starts to increase at age $60$ and increases significantly at age $80$.

Which medication classes elevate fall risk by causing orthostatic hypotension or drowsiness?

Sedatives, opioids/pain meds, benzodiazepines, diuretics, and vasodilators.

What position should a patient be placed in during an abdominal paracentesis?

Semi-Fowler's or High Fowler's position.

What position is used during a Lumbar Puncture, and what position is maintained post-procedure?

During: Side-lying fetal position or sitting hunched forward over a table. After: Supine position.

What position should a patient be placed in following a liver biopsy?

Right side-lying position for $3$\,or more hours (to compress the site and prevent bleeding).

What position and extremity constraint are required after a cardiac catheterization?

Flat or Low Fowler's position with the affected extremity kept straight for $4-6$\,hours.

What position should a patient be placed in if an air embolism is suspected?

Trendelenburg position on the left side.

What are the specific head of bed (HOB) angles for Fowler's positions?

Low Fowler's: $15-30^\text{o}$; Semi-Fowler's: $30-45^\text{o}$; Standard Fowler's: $45-60^\text{o}$; High/Full Fowler's: $90^\text{o}$.

Why is Total Parenteral Nutrition (TPN) indicated over enteral nutrition in conditions like severe pancreatitis or GI obstructions?

To bypass the non-functional or inflamed GI tract and allow it to rest.

What glucose complication must nurses monitor for in patients receiving Total Parenteral Nutrition (TPN)?

Hyperglycemia (look for the 3 Ps: polyuria, polydipsia, polyphagia).

If a TPN bag runs out before the new bag arrives from the pharmacy, what IV fluid should be infused to prevent severe hypoglycemia?

Infuse a Dextrose IV solution ($10\%$ Dextrose in water).

What are key dietary restrictions under Orthodox Jewish Kosher laws?

No pork, no shellfish, no fish without scales, and strict separation of meat/poultry from dairy.

How long must a person keeping Kosher wait after consuming meat/poultry before consuming dairy?

At least $3-6$\,hours.

Why must a nurse check with pharmacy before administering gelatin capsules to an Orthodox Jewish patient?

Gelatin often contains pork products, which are non-Kosher; alternative non-gelatin dosage forms must be requested.

What blood products are prohibited for Jehovah's Witness patients?

Transfusions containing whole blood or any of its 4 main components (RBCs, WBCs, platelets, plasma).

What fluids and medications are acceptable blood-sparing alternatives for a hemorrhaging Jehovah's Witness patient?

Non-blood IV fluids (Normal Saline, Lactated Ringers, Dextran), Epoetin alfa, and IV iron.

If a minor child of a Jehovah's Witness parent is in severe life-threatening emergency, will a blood transfusion be administered?

Yes; life-saving transfusions will be administered to minors despite parental religious refusal.

What dietary choices are standard in Hinduism?

Lacto-Ovo Vegetarian diet (no meat/poultry/fish; dairy and eggs are allowed).

Can a Hindu patient receive a cardiac valve replacement from animal sources?

They can receive a mechanical cardiac valve replacement (avoiding porcine/bovine valves).

What substances are prohibited in Islam?

Pork, alcohol, and gelatin.

What dietary practice occurs during the month of Ramadan for Muslims?

Fasting (refusing food and drink) from sunrise to sunset.

What dietary guidelines are practiced by Seventh-day Adventists?

A plant-based diet avoiding animal products, alcohol, and caffeine.

How is the pinna pulled during ear irrigation for an adult versus a child 3 years or younger?

Adults: pull pinna up and back. Children $\le 3$ years: pull pinna down and back.

What water temperature must be used for ear irrigation, and why?

Use warm/body temperature water; cold water causes severe vasoconstriction, disequilibrium, nausea, and dizziness/fainting.

Under what conditions is ear irrigation contraindicated?

A perforated, non-intact, or inflamed tympanic membrane, or if foreign vegetable matter is present in the ear canal.

What is Scopolamine used for, and what are its contraindications?

It is a transdermal anticholinergic patch used behind the ear for motion sickness/disequilibrium. Contraindicated in glaucoma, urinary retention, and GI obstruction.

How should non-washable bedding and clothing be handled to eliminate head lice (Pediculosis capitis)?

Seal non-essential bedding, clothing, and toys in a plastic bag for $2$\,weeks.

How should a breast pump be handled and maintained after use?

Sanitize after every use (hot water, steam, or soap/water), and turn off the suction before breaking the seal on the breast to prevent tissue trauma.