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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. 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






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






3. Analgesics - antipyretic - anticoagulant - anti - inflammatory






4. 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






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






6. 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






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






8. 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






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






10. 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






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






13. 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






14. 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






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






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






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






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

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19. 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






20. 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






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






22. 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






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






24. 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:






25. Rescue Alarm Contain Evacuate






26. 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






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






28. 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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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. 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






31. 22 - 29 mEq/l






32. Movement of particles from higher to lower concentration






33. A generalized reaction to contaminated equipment or solutions a. Manifestations 1) Chills and fever 30-60 minutes after start of infusion 2) Flushing - sudden pulse increase 3) Backache - headache 4) Nausea - vomiting 5) Hypotension - vascular collap






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






35. A decrease in total blood volume such as hemorrhage - transfusions






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






37. Analgesics - antipyretic - small anticoagulation






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






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






40. 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






41. Routine tasks b. Routine vital signs






42. 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






43. 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






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






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






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






47. 85 - 115 mEq/l






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






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






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







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