NCLEX High Yield Fundamentals Practice Exam

Comprehensive nursing fundamentals flashcards covering wound care, fluid therapy, nutrition, safety, communication, and basic medical-surgical procedures based on the NCLEX High Yield curriculum.

What is dehiscence as it pertains to wound complications?

A complication of wound healing where the edges of the wound separate, also known as incision separation.

Which chronic metabolic condition is listed as a risk factor for poor wound healing?

Diabetes

What are the common interventions to prevent wound dehiscence related to straining?

Stool softeners (Docusate), Antiemetics PRN (Ondansetron, Metoclopramide), and splinting the abdomen with a pillow or folded blanket when coughing.

What should be reported to the healthcare provider regarding a CABG (Coronary Artery Bypass Graft) incision?

Redness, swelling, warmth, or purulent drainage.

What temperature is considered a normal post-operative low-grade fever?

$100.4^{\circ}\text{F}$ ($38^{\circ}\text{C}$)

How long does a CABG leg incision typically take to heal?

$$4-6\,\text{weeks}$$

What hygiene recommendations are given for leg incision care?

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

What should a patient avoid using on their leg incision to prevent infection?

Bath tubs, lotions, and powders.

What is the primary cause of Hospital Acquired Pressure Injuries?

Ischemia/hypoxia of tissue after localized skin injury due to prolonged pressure and friction (immobilization).

What laboratory value decrease is associated with pressure injury risk factors?

Decreased Albumin

How often should a patient be repositioned to prevent pressure injuries?

Every $2\,\text{hours}$ ($Q2hrs$).

What is the function of Negative Pressure Wound Therapy (NPWT)?

It draws out fluid and infection from the wound and promotes faster, proper wound healing and closure.

What is the standard vacuum pressure setting for Negative Pressure Wound Therapy?

$$120\,\text{mmHg}$$

What is the definition of neutropenia?

A very low neutrophil count of less than $1,000$.

Which medication used for trigeminal neuralgia can cause neutropenia?

Carbamazepine

What medications besides Carbamazepine are linked to low neutrophil counts in the transcript?

Chemotherapy, Clozapine, and Steroids/immunosuppressants.

What dietary restrictions apply to a patient on Neutropenic precautions?

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

Which environmental activity should a neutropenic patient avoid?

Gardening

What are the signs of infection a neutropenic patient should report immediately to prevent sepsis?

Sore throat, fever, and GI distress.

What is the goal of End of Life Care?

Comfort and quality of life.

Which medication is used to treat excessive respiratory secretions (the 'death rattle') in end-of-life care?

Atropine (Anticholinergics)

What nursing interventions help with 'death rattle' noises in a dying patient?

Repositioning, suctioning, and administering anticholinergics like Atropine.

What are the common causes of anorexia in terminal patients?

Medications, anxiety, and underlying medical conditions.

What is the difference between Palliative Care and Hospice?

Palliative Care is for serious long-term illness regardless of stage (allows curative treatment); Hospice is for terminal illness with less than $6\,\text{months}$ to live and requires stopping curative treatment.

When is postmortem care performed?

Immediately following the pronouncement of death.

In what circumstances may postmortem care be delayed?

When cultural or religious beliefs require time, or if the death involved trauma, was non-natural, or involved criminal activity.

What are the specific steps of body preparation in postmortem care?

Close the patient's eyes, remove tubes and dressings (unless trauma), wash the body, place a pad under the perineum, and place a pillow under the head.

Why is Vaseline contraindicated for patients using portable oxygen?

It is oil-based, which makes it highly flammable when used with oxygen.

What fabric types should be avoided when using oxygen to prevent fire risk?

Synthetic and wool fabrics.

How far should oxygen be kept from gas stoves and fireplaces?

$$5-10\,\text{ft}$$

What are the priority safety precautions for oxygen use in the home?

No smoking, no nail polish or remover, no hair spray, use water-based lubricants, and test smoke detectors regularly.

What are the initial nursing interventions for IV infiltration?

Stop the infusion immediately, start a new IV, continue to monitor for swelling, and elevate the site.

What is the 'sighted guide technique' for assisting a legally blind patient?

The patient places their hand on the nurse's elbow and walks alongside them.

How should food arrangement be explained to a blind patient?

Using a clock face pattern.

What is 'intravascular' space defined as?

Inside the vessels, specifically the arteries and veins.

What is 'extravascular' space defined as?

Outside the intravascular space, including tissue and interstitial space.

What vital sign change occurs as a compensatory mechanism for huge intravascular fluid loss?

Tachycardia

Why is Lactated Ringers avoided in patients who are metabolically acidotic or have liver issues?

The lactate will turn into lactic acid.

What is 'Locked-in Syndrome' (pontine myelinosis) caused by in the context of fluid therapy?

Correcting Sodium ($Na^+$) levels too fast with $3\%\,\text{NaCl}$.

What are examples of Isotonic solutions?

$0.9\%\,\text{NaCl}$, Lactated Ringers (LR), D5W/5% Dextrose in water , and D5LRS/5% dextrose in LS

What is a major risk for patients receiving Isotonic solutions?

Fluid Volume Excess (FVE), increased blood pressure, and increased sodium.

What happens to cells in a Hypotonic solution?

Fluid shifts from the extracellular space into the intracellular space, causing cells to swell and possibly rupture (lyse).

What are examples of Hypotonic solutions?

$2.5\%\,\text{dextrose and water}$ and $0.45\%\,\text{NaCl}$.

When are Hypotonic solutions contraindicated?

Increased ICP (Intracranial Pressure), burns, and trauma.

What happens to cells in a Hypertonic solution?

Fluids move out of the cells into the extracellular space, causing cells to shrink (crenation).

What are examples of Hypertonic solutions?

$3\%\,\text{NaCl}$, Dextrose $5\%\,\text{in } 0.9\%\,\text{NaCl}$, TPN, Albumin, and Dextran.

Why is Albumin used as a volume expander?

It is a colloid that draws excess extravascular fluid back into the intravascular space.

How should a nurse communicate with low literacy patients?

Use pictures, simple text, involve family members/caretakers, and use approved professional websites.

What is the exception to the therapeutic technique of asking 'Tell me more'?

Suicidal Ideation (SI) or Homicidal Ideation (HI).

What are effective communication strategies for patients with hearing loss?

Face the patient directly, approach from the front, use gestures/facial expressions, keep lights on, and speak toward the least affected ear in a normal volume.

What are the rules for hearing aid care and usage?

Turn volume off before inserting, gradually increase wear time, remove batteries at night, clean with a soft cloth, and keep in a safe, dry place.

What are the requirements for using an interpreter?

Talk in first person, use short sentences, ask one question at a time, avoid medical jargon, and do not use family members (especially children) to interpret.

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

Facts, Assurance, Support, Education

How should body weight be supported when using crutches?

On the hands and arms, not the axilla (underarms).

What are the home safety rules for using crutches?

Environment free of clutter/scatter rugs, look forward while walking, use a small backpack for items, and wear non-skid-soled shoes.

How is a sling properly fitted?

Elbow flexed at $90\,\text{degrees}$, hand held slightly above elbow level, and thumb facing upward or inward.

On which side should a patient hold a cane?

On the stronger side.

What is the sequence for ascending stairs with a cane?

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

What is the sequence for descending stairs with a cane?

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

How should a nurse assist a patient with unilateral weakness during dressing?

Dress the affected side first.

From which side should a nurse approach a patient with unilateral weakness?

The unaffected side.

What must be done before starting enteral feeds via a tube?

Aspirate gastric content.

What gastric residual volume (GRV) indicates the content should not be returned?

Greater than $500\,\text{ml}$.

What is the standard flush volume for enteral feeding tubes after every feed?

$30\,\text{ml}$ of Normal Saline (NS).

What is the proper elevation of the Head of Bed (HOB) for a patient receiving enteral feeds to prevent aspiration?

$$30-45\,\text{degrees}$$

What things can cause inaccurate pulse oximetry readings?

Nail polish, hypoperfusion, hypotension, PVD/PAD, heart failure, edema, shock, vasopressors, smoking, hemorrhage, and burns.

What are the common alternate sensor sites for pulse oximetry in pediatrics?

Toes or earlobes.

What are common signs and symptoms of heat exhaustion?

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

What is recommended for a patient with dysphagia during mealtime?

Modify food consistency (soft), sit upright ($90\,\text{degrees}$), use thickened liquids, put food on the stronger side, and tilt the neck slightly.

At what age does the risk for falls start to increase significantly?

Age $60\,\text{years}$, with a significant increase at age $80\,\text{years}$.

What are the standard precautions for a patient at risk for falls?

Orient patient to the room, call light within reach, bed in lowest position, well-lit room, non-slip socks, and belongings within reach.

What extra precautions are taken for 'High Risk' fall patients?

Bed alarm, colored socks/wristband for identification, sign on the door, and placing the patient near the nurse station.

What medications increase a patient's fall risk?

Benzodiazepines (sedatives), Diuretics, and Vasodilators.

What position should a patient be in during a Paracentesis?

Semi to High Fowler's.

What position is used for a Lumbar Puncture?

Side-lying fetal position or hunched (sitting up and bent forward over a bedside table).

What is the required position for a patient after a Liver Biopsy?

Right side-lying for $3\,\text{hours}$ or more.

How should a patient be positioned after Cardiac Catheterization?

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

What position is indicated for the insertion of a Chest Tube?

Arm raised above the head on the affected side with HOB at $30-60\,\text{degrees}$.

What are the dietary laws of Orthodox Judaism (Kosher)?

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

How long must an Orthodox Jewish patient wait after consuming meat before consuming dairy?

$$3-6\,\text{hours}$$

When is circumcision performed in the Jewish faith?

When the baby is $8\,\text{days}$ old.

What is the absolute restriction for Jehovah's Witnesses regarding medical treatment?

No transfusions containing blood (whole blood, plasma, RBCs, etc.).

What non-blood products are generally accepted by Jehovah's Witnesses to stimulate RBC production?

Epoetin alfa and IV iron.

Which religion prefers a mechanical cardiac valve replacement over a biological one to avoid porcine products?

Hinduism (Lacto Ovo Vegetarian avoids meat).

What are the dietary restrictions for Islam?

No pork, no alcohol, and no gelatin.

How is an otoscope used for an adult during an ear exam?

Pull the pinna up and back.

How is an otoscope used for a child aged 3 and younger?

Pull the pinna down and back.

Why is warm water used for ear irrigation instead of cold water?

Cold water can cause vasoconstriction and disequilibrium, leading to fainting.

What are common sites for head lice (Pediculosis capitis)?

Occipital area, behind the ears, eyebrows, and eyelashes.

How long should non-essential bedding and toys be kept in plastic bags to treat lice?

Two weeks.

What are the safety rules for internal radiation therapy?

Limit time with the patient, maintain distance, use lead shields, private room, no children, and no pregnant staff/visitors.

Where should a nurse stay when dealing with a potentially violent patient?

Stay close to the doorway to allow for an exit.

What should be written on a bottle of glucometer test strips once opened?

The date it was opened.

What should a nurse do with lancets immediately after use?

Discard them.

How should a nurse assist a falling patient?

Step behind the patient, arms under armpits or around waist, feet wide with knees bent; place one foot behind the other, extend the leg, and let the patient slide down the extended leg to the floor.

What are the first priority actions when child abuse is suspected due to fractures?

Report it, perform a complete physical, and document findings.

Where should an EpiPen be administered?

In the mid-outer thigh (can be through clothing).

What food allergies are commonly linked as a cross-allergy to latex?

Bananas, kiwis, avocados, tomatoes, peaches, and grapes.

What are the standard client identifiers used in healthcare?

First and last name, and date of birth.

What are the contraindications for an MRI?

Permanent pacemakers, aneurysm clips, and metallic implants.