NCLEX FUNDAMENTALS (UWORLD) EXAM
QUESTIONS WITH
CORRECT ANSWERS | ALREADY GRADED A+
STUDY GUIDE
Neonatal heel stick - CORRECT 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
Page 1 of 37
,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 - CORRECT 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 - CORRECT 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
Page 2 of 37
,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 - CORRECT 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 - CORRECT 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
Page 3 of 37
, 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.
Ascending Stairs with Crutches - CORRECT 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.
Page 4 of 37
QUESTIONS WITH
CORRECT ANSWERS | ALREADY GRADED A+
STUDY GUIDE
Neonatal heel stick - CORRECT 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
Page 1 of 37
,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 - CORRECT 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 - CORRECT 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
Page 2 of 37
,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 - CORRECT 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 - CORRECT 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
Page 3 of 37
, 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.
Ascending Stairs with Crutches - CORRECT 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.
Page 4 of 37
