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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. 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






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






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






4. Caused by a decrease in peripheral resistance - vasoconstriction






5. 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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6. 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






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






8. Dislodging of needle causes fluid to infiltrate tissues a. Manifestations 1) Edema - blanching - puffiness on under surface of arm 2) Discomfort 3) Slow drip rate 4) Cool to the touch 5) Necrosis and sloughing of tissue with certain drugs (Levophed)






9. 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






10. 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






11. 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






12. 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






13. Decision maker b. Can do complex procedures c. Can give medications via all routes that nurses can give meds d. Is best person for teaching e. Coordinates care f. Performs admission assessments






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






15. 135 - 145 mEq/l






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






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






18. Routine tasks b. Routine vital signs






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






20. Apply heat to improve circulation and healing






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






22. 85 - 115 mEq/l






23. 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:






24. 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.






25. On the person's back 2. Maintains alignment






26. 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






27. 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






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






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






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






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






32. 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






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






34. 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






35. 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






36. Acts by blocking opiate receptors in the brain 2. Used to treat: a. Opiate induced respiratory depression b. Opiate overdose 3. Side effects: a. Withdrawal symptoms in addicted persons b. Return of pain 4. Drug is rapid acting; narcotic may last long






37. 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






38. 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






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






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

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






42. Inadequate blood supply to the vital organs: the brain - heart and kidneys; inadequate circulating volume. Manifestations A. Pulse pressure decreases B. Blood pressure deceases C. Urine output decreases (ADH and Aldosterone) D. Pulse increases E. Res






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






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






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

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46. Full thickness skin loss involving subcutaneous damage or necrosis






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






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






49. Adjust to retirement C. Adjust to loss of friends - family D. View own death as appropriate outcome of life






50. 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