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NCLEX Essential Concepts

Instructions:
  • Answer 50 questions in 15 minutes.
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  • Match each statement with the correct term.
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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. VS - LOC - Skin color - IV infusions - Drainage Tubes - Dressings - DB & C-h






2. 135 - 145 mEq/l






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






5. Analgesic - antipyretic - anticoagulant - anti - inflammatory






6. 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






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






8. 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






9. 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)






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






11. Professional negligence - misconduct - or unreasonable lack of skill resulting in injury or loss to the recipient of the professional services.






12. 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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13. 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






14. 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






15. 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






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






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






18. Caused by a decrease in peripheral resistance - vasoconstriction






19. 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






20. Anticoagulants predispose to hemorrhage; discontinue 1-2 weeks before surgery 2. Aminoglycosides (streptomycin - gentamicin) can cause neuromuscular blockade. Anesthesiologist must know. 3. Diuretics may cause electrolyte imbalances and respiratory d






21. 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






22. 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






23. 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






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






25. 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






26. 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






27. 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






28. Rescue Alarm Contain Evacuate






29. 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






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






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






32. 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






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






34. Immobilized patient at risk for orthostatic hypotension 2. After prolonged period of immobility - gradually sit patient up






35. Analgesics - antipyretic - anticoagulant - anti - inflammatory






36. 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






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






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






39. Short duration B. Serves as a warning C. Subsides as healing occurs D. Autonomic nervous system symptoms frequently present






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






41. Full thickness skin loss involving subcutaneous damage or necrosis






42. 22 - 29 mEq/l






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






44. 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






45. 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






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






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






48. Apply heat to improve circulation and healing






49. Routine tasks b. Routine vital signs






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







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