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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. 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






2. 3.5 - 5.5 mEq/l






3. Full thickness skin loss involving subcutaneous damage or necrosis






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






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






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






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






8. Analgesics - antipyretic - small anticoagulation






9. 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






10. 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






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






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






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






14. 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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15. 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






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






17. 135 - 145 mEq/l






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






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






20. 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






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






22. Rescue Alarm Contain Evacuate






23. Routine tasks b. Routine vital signs






24. 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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25. 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






26. 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






27. 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






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






29. 85 - 115 mEq/l






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






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






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






33. 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






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






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






36. 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






37. 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






38. Movement of particles from higher to lower concentration






39. 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






40. 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






41. Apply heat to improve circulation and healing






42. 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






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






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






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






46. 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






47. 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






48. 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






49. 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






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

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