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

NCLEX UWorld - Fundamentals () Questions with 100% Pass | Verified | Latest Update /. Ascending Stairs with Crutches - Answer-Assume 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 - Answer-The 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 - Answer-Current 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 - Answer-The 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 - Answer-Because 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 - Answer-With 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 and muscle strength and should be reported to the registered nurse (RN). It is likely that a repeat blood draw would be prescribed. Pseudohyperkalemia can be avoided on the repeat blood draw through minimal use of a tourniquet and fist clenching and use of a larger gauge needle and heparin-impregnated hematology vials to prevent clotting. /.IV Occlusion - Answer-IV infusion pumps display an occlusion alarm when IV solution cannot be infused due to pressure in the line. Common causes of occlusion include clamped or kinked IV tubing, clotting in the IV catheter, and kinking in the IV catheter with extremity movement (eg, elbow, wrist). The nurse should assess the tubing and IV site and flush the IV catheter to check patency. In the absence of identifiable occlusion, an alarming IV pump should be exchanged for a different one (Option 2). Malfunctioning equipment may harm the client and should be removed from the care area. The malfunctioning equipment is labeled as out of service and is sent for maintenance. /.Promoting normal sleep pattern for critically ill - Answer-It is important to maintain the client's normal circadian rhythms in the intensive care unit (ICU). Interventions that help to maintain the normal sleep-wake cycle include dimming the lights at night, allowing quiet and uninterrupted periods of sleep when possible, scheduling interventions and activities during the day, frequently reorienting the client as necessary, and opening the window shades in the morning. Excessive stimuli and lack of sleep can predispose the client to delirium. Unless the client is awake and chooses to have the television turned on, this extra stimulus is disruptive to sleep. Turning the alarms off in the client's room would pose a risk to safety as the nurse may not be alerted to a change in condition or equipment failure. If possible, alarm parameters should be adjusted according to the client's routine to prevent unnecessary awakening. /.NG Tube Insertion - Answer-During NG tube insertion, the tube sometimes slips into the larynx or coils in the throat, which can result in coughing and gagging. The nurse should withdraw the tube slightly and then stop or pause while the client takes a few breaths. After the client stops coughing, the nurse can proceed with advancement, asking the client to take small sips of water to facilitate advancement to the stomach. The client should not be asked to swallow during coughing or aspiration may occur. If resistance or obstruction occurs during tube advancement, the nurse should rotate the tube while trying to advance it. If resistance continues, the tube should be withdrawn and inserted into the other naris if possible. /.Ear irrigation - Answer-may be prescribed to remove impacted or excess cerumen; the following steps describe this procedure: Assess client for contraindications (eg, fever, ear infection). Use an otoscope to inspect the external ear canal. Verify that the tympanic membrane is intact and ensure there are no foreign bodies. Explain the procedure to the client, including possible sensations (eg, vertigo, fullness, warmth). Place the client in a side-lying or sitting position with the head tilted toward the affected ear.Place a towel and an emesis basin under the ear. Verify that the irrigation solution is at body temperature (98.6 F [37 C]) to minimize discomfort. Straighten the ear canal, pulling the pinna up and back for adults or down and back for children age ≤3 years.