NCLEX UWorld - Fundamentals (UWorld) Questions with 100% Correct Answers | Verified | Latest Update

NCLEX UWorld - Fundamentals (UWorld) Questions with 100% Correct Answers | Verified | Latest Update Ascending Stairs with Crutches - answerAssume the tripod position (ie, crutch stance) and place body weight on the crutches while preparing to move the unaffected leg. Place the unaffected leg (ie, good leg) onto the step. Transfer body weight from the crutches to the unaffected leg and then use the unaffected leg (ie, good leg) to raise the body up onto the step. Advance the affected leg and the crutches together up the step. Realign the crutches with the unaffected leg on the step before repeating the process. IV Solutions - answerThe nurse should question the administration of a hypotonic IV solution (ie, 0.45% sodium chloride) to replace gastrointestinal tract fluid losses as this would create a concentration gradient and shift fluid out of the intravascular compartment into the interstitial tissue and cells, worsening the client's fluid volume deficit. Isotonic IV solutions (eg, 0.9% sodium chloride, lactated Ringer's) have the same osmolality as plasma and are administered to expand intravascular fluid volume. These solutions replace fluid losses commonly associated with vomiting and diarrhea, burns, and traumatic injury. Bathing Clients with MRSA - answerCurrent evidence supports the recommendation for clients with methicillin-resistant Staphylococcus aureus (MRSA) or other drug-resistant organisms to be bathed with pre-moistened cloths or warm water containing chlorhexidine solution. Bathing clients in this way can significantly reduce MRSA infection. Neonatal heel stick - answerThe neonatal heel stick (heel lancing) is used to collect a blood sample to assess capillary glucose and perform newborn screening for inherited disorders (eg, congenital hypothyroidism, phenylketonuria). Proper technique is essential for minimizing discomfort and preventing complications and includes: Select a location on the medial or lateral side of the outer aspect of the heel. Avoid the center of the heel to prevent accidental insult to the calcaneus. Puncture should not occur over edematous or infected skin. Warm the heel for several minutes with a warm towel compress or approved single-use instant heat pack to promote vasodilation. Cleanse the intended puncture site with alcohol. Sucrose and nonnutritive sucking on a pacifier may reduce procedural pain. Use an automatic lancet, which controls the depth of puncture. Lancing the heel too deeply can result in penetration of the calcaneus bone, leading to osteochondritis or osteomyelitis. An acceptable alternate method of blood collection in the neonate is venipuncture (ie, drawing blood from a vein). Venipuncture is considered less painful and often requires fewer punctures to obtain a sample, especially if a larger volume is needed. Measuring Nasogastric Tube - answerBecause distance from the nares to the stomach varies with each client, it is important to measure and mark the NG tube prior to insertion to ensure its correct placement in the stomach. The Traditional Method is most commonly used for large-bore NG tube placement. Traditional Method: Using the end of the tube that will eventually rest in the stomach, measure from the tip of the nose, extend the tube to the earlobe and then down to the xiphoid process. Mark the distance with a small piece of tape that can be easily removed. Pseudohyperkalemia - answerWith the exception of clients with end-stage renal disease, a serum potassium value >6.5 mEq/L (6.5 mmol/L) in a client who is walking and talking should raise suspicion for an erroneously elevated serum potassium (pseudohyperkalemia) level due to poor hematology technique. A serum potassium level of 7.0 mEq/L (7.0 mmol/L) constitutes a life-threatening electrolyte imbalance that would cause severe weakness or paralysis, unstable arrhythmias, and eventual cardiac arrest. Assessment focuses on evaluating cardiac symptoms