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Nclex RN UWORLD STUDY GUIDE 150 QUESTION AND ANSWERS 2024 AGRADE
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Nclex RN UWORLD STUDY GUIDE 150 QUESTION AND ANSWERS 2024 AGRADE
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Nclex RN UWORLD STUDY GUIDE 150QUESTION AND ANSWERS 2024 AGRADE
The ECG of a client with a single-chamber atrial pacemaker should display -
<<ANSWER>>a pacemaker spike before the P wave.
On an electrocardiogram (ECG), - <<ANSWER>>the P wave represents atrial
depolarization and the QRS complex represents ventricular depolarization. The ECG of
a client with a single-chamber atrial pacemaker should display a pacemaker spike
before the P wave.
occurs when a blood clot becomes lodged in a vein. Clinical manifestations include
unilateral edema, localized pain, tenderness to touch, warmth, and erythema. -
<<ANSWER>>Deep venous thrombosis
When caring for clients with overflow incontinence, - <<ANSWER>>the nurse should
implement a fixed voiding schedule, teach the client techniques that assist with bladder
emptying (eg, Valsalva maneuver, Credé maneuver, double voiding), monitor for
perineal skin breakdown, and measure postvoid residual volumes as prescribed.
The FLACC scale (Facial expression, Leg movement, Activity, Cry, Consolability) can
be used to assess pain in nonverbal clients. - <<ANSWER>>Client behaviors or
physical signs of pain include closed eyes and a clenched jaw, flexed positioning (eg,
knees bent up), frequent shifting of positions, and moaning or whimpering.
Unstageable pressure injuries have - <<ANSWER>>slough and/or eschar in the base
that prevents the nurse from fully visualizing the wound depth to determine the stage.
Slough and eschar must be debrided before the wound can be staged.
Urge incontinence (UI) - <<ANSWER>>is characterized by involuntary bladder muscle
spasms that cause a strong, sudden urge to urinate followed by involuntary urine
leakage. UI may be idiopathic or related to conditions that disrupt communication from
the nervous system or impair urination, leading to increased bladder musculature over
time.
Enema administration can be uncomfortable for clients because -
<<ANSWER>>instilling enema solution into the bowel may produce abdominal
cramping and discomfort. If the client experiences discomfort during a cleansing enema,
,the instillation should be stopped temporarily (eg, 15-30 sec) and then resumed at a
slower rate.
Pain control is the priority assessment for clients with rheumatoid arthritis. -
<<ANSWER>>Without adequate pain control, clients will have decreased ability to self-
manage activities of daily living, maintain mobility and activity tolerance, and maintain
self-esteem and a positive body image.
Positional plagiocephaly, or flattening of the skull, can develop when infants spend a lot
of time in the same position. - <<ANSWER>>Positioning techniques (eg, "tummy time,"
alternating the head position) can prevent or correct plagiocephaly. Infants should
always be placed in the supine position to sleep.
Postmortem care may be delayed or not performed if - <<ANSWER>>the family has
certain cultural or religious beliefs or if the death is considered nonnatural, traumatic, or
associated with criminal activity. Nurses should provide opportunities to support the
families of clients and involve them in postmortem care as much as is desired and
possible.
Treatment with hypertonic enteral formulas can cause - <<ANSWER>>nausea,
vomiting, and diarrhea. These symptoms can be alleviated by slowing the infusion rate
and then gradually increasing the rate to the established goal.
Urge incontinence is characterized by involuntary bladder muscle spasms that cause a
strong, sudden urge to urinate followed by involuntary urine leakage. -
<<ANSWER>>Frequent nocturia is common and can cause significant sleep disruption.
Clients with iron deficiency anemia should be taught to eat - <<ANSWER>>iron-rich
foods such as meats, shellfish, eggs, green leafy vegetables, broccoli, dried fruits, dried
beans, brown rice, and oatmeal. Iron absorption can be enhanced by consuming iron-
rich food with sources of vitamin C.
The low-residue diet of a client with a new ileostomy helps prevent obstruction of the
narrow lumen of the stoma. - <<ANSWER>>During the immediate postoperative period,
the client should avoid foods that are high in fiber; stringy vegetables; and fruits and
vegetables with pits, seeds, or edible peels.
The nurse should ensure a client's foreskin is fully reduced before applying a condom
catheter because prolonged retraction - <<ANSWER>>can cause paraphimosis,
progressive swelling of the foreskin, vascular compromise, and permanent damage to
the glans penis.
When a client with celiac disease does not experience symptom relief after starting a
gluten-free diet, it is most important for the nurse to - <<ANSWER>>assess the
underlying cause. The most common reason for persistent symptoms is that gluten has
not been fully eliminated from the diet.
, For clients receiving peritoneal dialysis, strict intake and output monitoring is required,
and dialysate is included when calculating net fluid balance. - <<ANSWER>>Net fluid
balance is calculated by subtracting total output from total intake.
Cystic fibrosis (CF) is a multisystem condition that causes the exocrine glands to be
thicker and stickier than normal, damaging the gastrointestinal tract and impairing the
absorption of nutrients. - <<ANSWER>>Clients with CF should consume a diet high in
calories and protein to ensure adequate nutrients for growth and development.
To prevent falls when descending the stairs using a cane, - <<ANSWER>>the client
should lead with the cane, follow with the affected leg, and then step down with the
unaffected leg.
Stress incontinence occurs during certain physical activities and is usually caused by
weak pelvic floor muscles. - <<ANSWER>>Clients should limit caffeine and alcohol
intake, void every 2 hours while awake, use incontinence pads as needed, and perform
pelvic floor muscle exercises.
is an opioid used for the treatment of opioid use disorder. Clients should notify the
health care provider if experiencing symptoms of cardiac dysrhythmias (eg, dizziness,
palpitations) because methadone can cause QT-interval prolongation and lethal cardiac
dysrhythmias (eg, torsades de pointes). - <<ANSWER>>Methadone
is a life-threatening complication of pericarditis that develops when fluid accumulates
within the layers of the pericardium. Clinical manifestations include tachycardia, muffled
heart tones, jugular venous distension, and pulsus paradoxus. -
<<ANSWER>>Explanation
Cardiac tamponade
Clients with pericardial effusion should be - <<ANSWER>>monitored and assessed
closely for the development of cardiac tamponade. Signs and symptoms of tamponade
include muffled or distant heart tones, hypotension, narrowed pulse pressure, jugular
venous distension, and pulsus
indicate turbulent blood flow across diseased or malformed cardiac valves. They are
often described as musical, blowing, or swooshing sounds that occur between normal
heart sounds. They may be auscultated at the aortic, pulmonic, tricuspid, or mitral
areas. - <<ANSWER>>Murmurs
Clients taking estrogen therapy are at an increased risk for -
<<ANSWER>>hypercoagulability and thromboembolic complications. Signs or
symptoms of deep venous thrombosis (eg, leg swelling, redness, pain) should be
reported to the health care provider immediately.
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