UWorld – NCLEX Questions and Answers Graded A+

UWorld – NCLEX Questions and Answers Graded A+ Hemophilia A hereditary disease where blood does not coagulate to stop bleeding Primarily seen in males and is due to clotting factors Symptoms include spontaneous bleeding (HEMARTHROSIS) into the joints, especially the knees, ankle, or elbow. Treatment: replace missing clotting factor VIII - Desmopressin (DDAVP) stimulates its release. Sickle Cell Disease A group of disorders that cause red blood cells to become misshapen and break down. Ischemic strokes are more common in children with sickle cell disease Most common presentation of ischemic stroke is the sudden onset of numbness or weakness of an arm or leg intussusception the slipping of one part of bowel inside another to cause obstruction It is the frequent cause of intestinal obstruction during infancy Onset is abrupt, initially with pain and brown stool - then progresses to bilious emesis, palpable abdominal mass, and stools with a red "currant jelly appearance" due to blood and mucus Meningitis inflammation of the meninges Can cause fever, headache, and meningeal signs (neck stiffness) Acute pyelonephritis A severe bacterial infection of the kidney that causes it to swell It can lead to permanent scarring of the kidney and can be life-threatening Initial treatment includes vigorous par Enteral IV fluids & IV antibiotics A patent IV line is a priority Chewy ne-Stokes respiration A cyclic tachypnea to blow off carbon dioxide that decreases into apnea until the carbon dioxide builds up enough to stimulate the respiration increase again S.T.A.R.T. Simple Triage and Rapid Transport It makes a rapid assessment (<1 minute) looking at circulation, respirations, and mental status to determine category for a client in a mass casualty incident (or disaster) Clinical sign of hip fracture Leg abducted Externally rotated Shortened due to muscles pull Hypovolemia decreased blood volume S/S: thready tachycardia New Nurse Should be competent in performing the basic skills needed to care for a client with a musculoskeletal injury (eg, pain and neurovascular assessments) Peak expiratory flow rate Having less than 50% of personal best on peak flow meter requires emergency intervention Antibiotic-related Allergic Reaction S/S: dyspnea and a maculopapular drug rash (rash all over body) Reaction can range from mild to life-threatening anaphylaxis Spleen Part of the immune system and functions as a filter to purify the blood and remove specific microorganisms that cause infections (eg, pneumococcal pneumonia, meningococcal meningitis) Overwhelming postsplenectomy bacterial infection or rapid-onset sepsis are major life long complications in a client w/o a functioning spleen A minor infection can quickly become life-threatening, and so any indicator of infection such as: low grade fever, chills, or headache needs immediate intervention Immune thrombocytopenic purpura (ITP) Autoimmune condition in which clients have abnormal platelet destruction with a count <150,000 Is associated with an increased risk of bleeding Common manifestations: petechiae - pinpoint flat, red or brown microhemorrhages under the skin caused by leakage of red blood cells Anemia A condition in which the red blood cells do not contain enough hemoglobin Clients can develop exertion all dyspnea due to body's inability to meet metabolic demands (oxygen supply) for the activity polycythemia vera Bone marrow overproduced RBCs, WBCs, and platelets This leads to increased hematocrit (>53%) and blood volume, enhanced blood viscosity, and abnormal clotting UAP Tasks Assign UAPs specific tasks that doesn't require specialized knowledge or skills The UAP should not be asked to assess/analyze/evaluate or measure Appropriate uses for Indwelling Urinary Catheters Clients with urinary obstruction or retention, or a need for strict intake and output in critically ill clients Perioperative use for surgical procedures such as urologic surgery or prolonged surgeries, or when large doses of fluid or diuretics are given during surgery During prolonged immobilization when bed rest is essential To improve end-of-life comfort To facilitate healing of an open perineal or sacral would in incontinent clients Inappropriate uses for Indwelling Urinary Catheters Convenience or replacement for nursing care when the client is elderly, confused, incontinent, or voids frequently For obtaining a urine culture when the client can follow directions and void voluntarily Postoperatively for prolonged periods when other appropriate indications are not present vaginal candidiasis (yeast infection) VC often causes itching and painful urination due to urine stinking inflamed areas of the vulva Assessment shows a thick, white, curd-like vaginal discharge and reddened vulvar lesions Miconazole (Monistat) - antifungal cream commonly prescribed to treat VC Best applied at bedtime so that it will remain in vagina longer Clients being treated for VC should wear loose-fitting cotton underwear and refrain from sex for duration of treatment Evaluation of partner is not needed Refrain from douching, which can introduce organisms higher up into the vaginal canal and cervix PTSD (Post Traumatic Stress Disorder) There are 3 categories of PTSD symptoms: 1) Reexperiencing the traumatic event Flashbacks, recurring nightmares, and feelings of intense distress/loss of control or strong physical reactions to event reminders (eg rapid, pounding heart; gastrointestinal distress; diaphoresis) 2) Avoiding reminders of the trauma Avoiding activities, places, thoughts, or other triggers that could serve as reminders Feeling detached and emotionally numb; loss of interest in life; in ability to set goals; amnesia about important details of event 3) Increased anxiety and emotional arousal Insomnia, irritability, outbursts of rage, persistent anger and/or fear, hyper vigilance, exaggerated startle response hypertensive encephalopathy When blood pressure is markedly increased, blood vessels are injured, resulting in increased capillary permeability and intracranial hypertension Neurological manifestations of HE: visual disturbances, seizures, nausea, vomiting, headache, and altered LOC Prompt recognition and pharmacological treatment to lower the BP are critical to prevent irreversible neurological deficits Untreated HE carries high mortality due to risk of acute MI, stroke, and kidney injury Meniere's disease Clients have episodes of vertigo associated with nausea/vomiting and hearing loss. Client should be placed on bed rest to avoid a fall and needs supportive care OB Vaginal Hematoma Is formed when trauma to the tissues of the perineum occurs during delivery Are more likely to occur following a forceps- or vacuum- assisted birth or episiotomy The client reports severe pain or a persistent feeling of fullness in the region Assessment shows a firm, midline uterine fund us with minimal or unchanged vaginal bleeding Bladder exstrophy A congenital disorder in which the bladder was not developed in the abdominal cavity during fusion in the embryo and is exposed externally The priority before surgical repaid is to prevent injury Placing a protective film of plastic (Saran wrap) over the exposed bladder will keep the tissue moist and help prevent infection Newborn Vomiting Bile made by the liver is green and is released into the duodenum on eating to aid in digestion When there is obstruction in intestines and stool cannot pass, it may come back up as green vomit A bowel obstruction is an emergency that can lead to bowel rupture, peritonitis, and sepsis Newborn Vomiting 2 It is common for newborns to vomit frequently as they learn to eat and digest Hydration status and weight gain should be monitored Green vomit represents bile from the intestine, which could indicate bowel obstruction (emergency!) Tiny blood streaks in the vomit may be due to rupture of pressured esophageal veins from frequent vomiting. Not a cause for concern unless vomit contains large amount of blood or blood-streaked vomiting persists. Baby's first dental visit Recommended that baby have first visit within 6 months of first tooth eruption or by their first birthday Purpose of first visit: Assessing risk for dental disease Providing dental care and treatment of dental caries Providing anticipatory guidance about dental hygiene, fluoride, diet and dietary habits, and non-nutritive sucking Establishing care with a license dentist and scheduling future visits Air Leak In Chest Tube Drainage System Is indicated by bubbling of fluid in the base of the water seal chamber of a chest tube drainage unit. The client with a known pneumothorax is expected to have an intermittent air leak, with bubbling in the water seal chamber. Continuous bubbling indicates an air leak somewhere in the chest tube system Central Venous Pressure (CVP) Normal value 2-8 mm Hg Elevated CVP indicates increased systemic circulation volume and increased right ventricular preload. Pulmonary artery wedge pressure (PAWP) Normal value 6-12 mm Hg PAWP elevated indicates increased left ventricular preload In the presence of elevated PAWP & CVP, coarse crackles indicate left-sided failure. Treatment goal is to decrease fluid volume and preload. Furosemide is a loop diuretic that will decrease both left- and right-sided preload Loop diuretics furosemide, bumetanide, torsemide Are effective in decreasing both right and left ventricular preload Prioritization Deciding which needs or problems require immediate action and which ones could be delayed until a later time because they are not urgent Planning Priorities Knowing the patients: 1) Purpose for care 2) Current clinical picture 3) Picture of the outcome or result Assignment Designating nursing activities to be performed by another nurse or assistive personnel that are consistent with his/her scope of practice (licensed person) or role description (unlicensed person) Newer definition: Describes the distribution of work that each staff member is responsible for during a given shift or work period Delegation Transferring to a competent individual the authority to perform a selected nursing task in a selected situation Newer definition: Transferring to a competent individual the authority to perform a selected nursing task in a selected situation. The nurse retains the accountability for the delegation Supervision The provision of guidance and direction, oversight, evaluation, and follow up by the licensed nurse for accomplishment of a nursing task delegated to nursing assistive personnel Four P's The patient's Four Ps (purpose, picture, plan, and part), the right task is a task that, in the nurse's best judgement, is one that can safely be delegated for this patient, given the patient's current condition (Picture) and future preferred outcomes (Purpose, picture), if the nurse has a competent individual to perform it. Right Task Assistive personnel are not to be allocated the duties of "ongoing assessment, interpretation, or decision making that cannot be logically separated from the procedures" Four Cs The Four Cs of initial direction: Instructions and ongoing direction must be 1) Clear 2) Concise 3) Correct 4) Complete