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NCLEX Essential Concepts

Instructions:
  • Answer 50 questions in 15 minutes.
  • If you are not ready to take this test, you can study here.
  • Match each statement with the correct term.
  • Don't refresh. All questions and answers are randomly picked and ordered every time you load a test.

This is a study tool. The 3 wrong answers for each question are randomly chosen from answers to other questions. So, you might find at times the answers obvious, but you will see it re-enforces your understanding as you take the test each time.
1. Obesity B. Aging - plus recovery C. Concomitant diseases 1. Cardiovascular a. Danger of congestive failure - avoid fluid overload b. Avoid prolonged immobilization as it may cause venous stasis c. Encourage change of position; avoid sudden exertion 2






2. Place the wheel chair on the patient's strong side B. Position the open part of the chair toward the foot of the bed. C. Have patient stand on strong foot and pivot - then sit in chair






3. Glaucoma and cataracts (lens becomes opaque) occur frequently 2. Presbyopia (farsightedness of aging) occurs in almost all persons as they age Difficulty seeing in dim light due to loss of light responsiveness Presbycussis: progressive hearing loss a






4. Extracellular fluid volume deficit 1. Causes: Loosing more fluid than is taken in a. Vomiting b. Diarrhea c. Diuretics d. Increased respirations e. Insufficient I.V. fluid replacement or PO 2. Manifestations a. Weight loss b. Poor skin turgor c. Dry






5. Caused by a decrease in peripheral resistance - vasoconstriction






6. On left side with lower arm behind the back 2. Good position for administering enema

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7. A decrease in total blood volume such as hemorrhage - transfusions






8. Manifestations 1) Muscle weakness 2) ECG changes b. Causes 1) Renal failure 2) Acidosis c. Management 1) Kayexalate by mouth or retention enema - reduces serum potassium 2) Insulin and glucose IV






9. PH 7.35-7.45 2. pCO2 = 35 - 45 3. pO2 = 80 - 100 4. HCO3 = 22 - 26






10. The pressure demonstrated when a solvent moves through the semipermeable membrane from weaker to stronger concentrations






11. Head up 20 to 30 degrees 2. Reduces intracranial pressure; good for head injuries and craniotomies 3. Good for cervical neck surgery

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12. 3.5 - 5.5 mEq/l






13. Causes 1) Decreased water intake 2) Increased sodium intake 3) Impaired renal function b. Manifestations 1) Edema 2) Dry - sticky mucous membranes 3) Thirst 4) Elevated temp. 5) Flushed skin c. Management: Give water






14. 135 - 145 mEq/l






15. Partial thickness loss of skin involving epidermis and/or part of dermis






16. Apply heat to improve circulation and healing






17. Head at 90 degrees 2. Used for persons with COPD

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18. Analgesics - antipyretic - small anticoagulation






19. Movement of fluid from lower to higher concentration. Across semipermeable membrane; high concentration of glucose






20. Full thickness skin loss involving subcutaneous damage or necrosis






21. VS - LOC - Skin color - IV infusions - Drainage Tubes - Dressings - DB & C-h






22. 85 - 115 mEq/l






23. PH 7.52 2. pCO2 52 3. HCO3 34 4. Cause: Vomiting; excessive diuresis






24. Dispose of sharps in puncture - resistant containers B. Do not recap used needles C. Wear protective barriers (gloves - gowns - masks - eyewear) when at risk for exposure to body fluids D. Clean blood spills with soap and water or household bleach 1:






25. Purposes 1. Relaxes muscle spasm 2. Softens exudate for removal 3. Vasodilates; hastens healing 4. Localizes infection 5. Reduces congestion 6. Relaxes - comforts






26. Movement of particles from higher to lower concentration






27. Causative agent --> reservoir -->portal of exit --> Mode of transmission -->portal of entry-->susceptible host






28. Patient is moved all at once so there is no twisting of spine B. One person moves the head and shoulders C. Second person moves the feet and legs at the same time D. Turning sheet may be helpful E. Place the bed in a high position to promote good bod






29. When opening a sterile package open the first flap away from you B. Never turn your back on a sterile field C. Avoid talking D. Keep all objects within vies; below the waist is not a sterile field. E. Moisture carries organisms through a barrier F. O






30. Lukewarm or tepid water b. Compresses on wrists - ankles - armpits - or groin to speed cooling c. Prevent shivering






31. Emergency care can be given to stabilize patient who is not able to give consent. 2. Age of majority is eighteen 3. Unconscious adults need permission for care by parents or spouse if married. 4. Persons who are not alert or have been given mind alte






32. Made in the adrenal cortex b. Causes kidney to retain sodium and water and get rid of potassium






33. Patient pushes button and receives IV analgesia 2. Device has preset dose and frequency limits 3. Nurse must instruct patient in use of device 4. Nurse must continue to assess patient for a. Pain b. Pain relief c. Side effects (vital signs) 5. Studie






34. PH 7.52 2. pCO2 30 3. HCO3 20 4. Cause: hyperventilation; rebreathe CO2






35. Head lower than trunk and feet 2. Uses a. Shock - sometimes b. Prolapsed cord when mother not in hospital; Increases venous return






36. Patient on side 2. Prevents aspiration when patient is not fully alert






37. Needle punctures dura and cerebral spinal fluid lost. 2. Patient at risk for spinal headache.






38. Head up 45-60 degrees 2. Reduces venous return and reduces cardiac workload 3. Promotes thoracic expansion 4. Reduces tension on the suture line for persons who have had abdominal surgery 5. Promotes drainage

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39. Changes in color:( red - blue - purple) - temperature changes - and skin stiffness






40. Flush daily with saline or heparin to prevent clots from forming B. Change dressing three times per week C. Check for infection D. Discard 5-10 ml when drawing blood E. In multilumen catheters use ports for designated purpose F. Valsalva's maneuver w






41. Manifestations 1) Tenderness and pain in vein 2) Edema and redness at site 3) Warmth b. Management 1) Cold compresses immediately to relieve pain and inflammation 2) Follow with moist warm compresses to stimulate circulation and promote absorption






42. Can do sterile procedures b. Can give medications except IV meds






43. Manifestations 1) Muscle weakness 2) Weak pulse and ECG changes b. Causes 1) Potassium depleting diuretics 2) Burns 3) Diarrhea - colitis 4) Vomiting c. Management: Potassium replacement -- DO Not give Digoxin






44. Follow physician's orders B. Do not apply without order except in emergency C. Use least restraint possible D. Each unit should have a written protocol E. Check patient frequently for safety F. Loosen restraints every 2 hours G. Do not use as punishm






45. Higher osmotic pressure than blood serum; causes cells to shrink; pulls fluid out of cells into blood stream a. Dextrose 5% or higher in saline b. Dextrose stronger than 5% in water c. Albumin






46. Made in the hypothalamus and stored and secreted by the posterior pituitary b. Causes kidney to retain sodium and water






47. On the person's abdomen 2. Prevents hip flexion contractures






48. Full thickness skin loss with severe destruction - necrosis - or damage to muscles - bone - or supporting structures






49. Fluid balance - acid - base - nerve conduction a. Causes 1) Increased perspiration 2) Drinking only tap water 3) GI losses: diarrhea - vomiting - suction 4) Diuretics b - Manifestations 1) Confusion 2) Hypotension 3) Oliguria 4) Muscle weakness 5) Co






50. Assess for signs of circulatory overload 2. Assess urinary output to determine renal function 3. Assess needle site 4. Assess infusion site for signs of infiltration 5. Assess flow rate 6. Assess IV container 7. Assess IV tubing