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






2. 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






3. 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






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






5. 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






6. 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






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






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






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






10. 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






11. 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






12. Caused by a decrease in peripheral resistance - vasoconstriction






13. 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






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






15. 135 - 145 mEq/l






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






17. 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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18. 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






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






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






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






22. Full thickness skin loss involving subcutaneous damage or necrosis






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






24. 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






25. 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:






26. 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






27. 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.






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






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






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

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31. 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






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






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






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






35. 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






36. 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






37. Movement of particles from higher to lower concentration






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






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






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






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






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






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






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






45. 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






46. 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






47. 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)






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






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






50. 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