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NCLEX Essential Concepts

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






3. 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






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

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






6. 135 - 145 mEq/l






7. 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






8. 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






9. 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






10. 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






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






12. Rescue Alarm Contain Evacuate






13. Analgesic - antipyretic - anticoagulant - anti - inflammatory






14. 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






15. 85 - 115 mEq/l






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






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

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






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






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






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






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






23. 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






24. 22 - 29 mEq/l






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






26. 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






27. Routine tasks b. Routine vital signs






28. 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






29. 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






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






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






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






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






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






35. 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






36. 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






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






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






39. 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






40. 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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41. Analgesics - antipyretic - anticoagulant - anti - inflammatory






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






43. Full thickness skin loss involving subcutaneous damage or necrosis






44. 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






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






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






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






48. 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






49. 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.






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







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