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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.
  • 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. 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






2. 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






3. Apply heat to improve circulation and healing






4. 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






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

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6. 22 - 29 mEq/l






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






8. 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






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






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. 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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12. 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:






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






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






15. 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






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






17. 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






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






20. Full thickness skin loss involving subcutaneous damage or necrosis






21. 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






22. Analgesics - antipyretic - anticoagulant - anti - inflammatory






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






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






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






26. Caused by a decrease in peripheral resistance - vasoconstriction






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






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






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






30. 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






31. Routine tasks b. Routine vital signs






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






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






34. 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






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






36. 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






37. 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






38. 85 - 115 mEq/l






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






40. 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)






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






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






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






44. 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






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






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






47. Analgesic - antipyretic - anticoagulant - anti - inflammatory






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






49. 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






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