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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. 135 - 145 mEq/l






2. Head at 90 degrees 2. Used for persons with COPD

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3. 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






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






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






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






7. 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






8. 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






9. Apply heat to improve circulation and healing






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






11. Caused by a decrease in peripheral resistance - vasoconstriction






12. 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






13. Analgesics - antipyretic - small anticoagulation






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






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






16. 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:






17. 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






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






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






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. 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






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






23. Patient pushes button and receives IV analgesia 2. Device has preset dose and frequency limits 3. Nurse must instruct patient in use of device 4. Nurse must continue to assess patient for a. Pain b. Pain relief c. Side effects (vital signs) 5. Studie






24. Rescue Alarm Contain Evacuate






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






26. 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






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






28. 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






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






31. 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






32. 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






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






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






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






36. 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






37. 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)






38. 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






39. 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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40. 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






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






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






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






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






45. 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






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






47. Analgesics - antipyretic - anticoagulant - anti - inflammatory






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






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






50. 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






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