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NCLEX Essential Concepts

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  • Answer 50 questions in 15 minutes.
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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. 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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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. PH 7.32 2. pCO2 58 3. HCO3 32 4. pO2 60 5. Respiratory Acidosis - hypoxia 5. Causes: COPD - lung cancer






4. 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






5. 22 - 29 mEq/l






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






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






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






9. Cold vasoconstricts and controls bleeding and swelling 2. Local anesthetic effect 3. Intermittently applied 4. Sterile technique for open wound






10. 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.






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






12. 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






13. 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






14. 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






15. 3.5 - 5.5 mEq/l






16. Caused by a decrease in peripheral resistance - vasoconstriction






17. 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






18. 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






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






20. 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






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






22. 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






23. Routine tasks b. Routine vital signs






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






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






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






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






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






29. 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






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






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






32. Rescue Alarm Contain Evacuate






33. 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






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






35. 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






36. Analgesics - antipyretic - anticoagulant - anti - inflammatory






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






38. Analgesic - antipyretic - anticoagulant - anti - inflammatory






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






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






41. 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






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






43. Movement of particles from higher to lower concentration






44. Full thickness skin loss involving subcutaneous damage or necrosis






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






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






47. 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






48. 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






49. 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






50. 85 - 115 mEq/l







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