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






2. 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






3. Analgesics - antipyretic - small anticoagulation






4. Acts of both omission and commission. 2. Failure to provide care that a reasonably prudent heath care professional would provide in the given circumstances. 3. Failure to provide care that meets the accepted standards of care - or giving care that re






5. Weight bearing is necessary to keep calcium in the bones 2. Calcium leaving bones may increase risk of kidney stone






6. Caused by a decrease in peripheral resistance - vasoconstriction






7. 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






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






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






10. 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






11. Rescue Alarm Contain Evacuate






12. Lasts more than 6 months B. Appears to serve no useful purpose C. May persist after injury heals D. No autonomic nervous system symptoms






13. Extracellular volume excess 1. Causes a. Too many I.V. fluids too quickly b. Decreased kidney or heart function 2. Manifestations a. Cough - dyspnea - rales - tachypnea b. Increased blood pressure c. Increased CVP d. Neck vein distention e. Tachycard






14. 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






15. Same osmotic pressure as in the cell Normal saline (0.9% NaCl) b. Dextrose 5% in water c. Lactated Ringer's






16. 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






17. PH 7.32 2. pCO2 58 3. HCO3 32 4. pO2 60 5. Respiratory Acidosis - hypoxia 5. Causes: COPD - lung cancer






18. Less osmotic pressure than blood serum - hydrates cells a. Tap water b. Sodium chloride less than 0.9%






19. 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






20. PH 7.32 2. pCO2 30 3. HCO3 18 4. Causes: a. Diabetes b. Renal failure c. Diarrhea






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






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






23. 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






24. Manifestations 1) Headache - flushed skin - tachycardia 2) Venous distention 3) Increased venous pressure 4) Coughing - dyspnea - cyanosis 5) Pulmonary edema b. Prevention 1) Check for preexisting heart condition 2) Monitor flow rate of solution 3) P






25. A generalized reaction to contaminated equipment or solutions a. Manifestations 1) Chills and fever 30-60 minutes after start of infusion 2) Flushing - sudden pulse increase 3) Backache - headache 4) Nausea - vomiting 5) Hypotension - vascular collap






26. Apply cold to prevent swelling - bleeding and relive pain






27. 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






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






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






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






31. Act by altering perception of and response to pain 2. Act on the central nervous system 3. Adverse reactions a. Depress respirations b. Decrease alertness c. Decrease coughing d. Decrease blood pressure and pulse e. Slow peristalsis f. Constrict pupi






32. Caused by poor heart action.- drugs that make heart beat more effectively






33. 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






34. 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






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






36. Head and trunk flat with legs elevated 2. Preferred for shock 3. Increases venous return without putting pressure on the diaphragm






37. Needle does not puncture dura. Spinal headache unlikely. 2. Once sensation and motion return patient may be in any position that is satisfactory for the procedure.






38. 135 - 145 mEq/l






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






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






41. Physiologic needs b. Safety and security c. Love and belonging d. Self esteem e. Self actualization 2. Keep them breathing; keep them safe






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






43. 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






44. 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






45. 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:






46. Manifestations 1) Hypotension - cyanosis - tachycardia 2) Increased venous pressure - loss of consciousness b. Prevention 1) Run fluid through tubing and needle or catheter to force air out before starting infusion 2) When using glass bottle - change






47. Sheet between patient and cooling blanket b. Prevent skin damage c. Change position frequently d. No shivering: Muscle relaxant may be given if patient shivering






48. Full thickness skin loss involving subcutaneous damage or necrosis






49. Legs up in stirrups 2. Uses a. Gyn exams b. Perineal surgery 3. Increases risk of venous stasis and deep vein thrombophlebitis






50. 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