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NURS2 UWorld Nclex General Critical Thinking And Rationales

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John Marsh
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Orange County Community College

Nursing- Med Surg (NURS2)

UWorld Nclex General Critical Thinking and Rationales

Injury Patterns in Nonaccidental Trauma Signs of Abuse:
– long bone fractures in humerus or femur – Shaken baby syndrome
– linear type immersion burns – Burns in the shape of household items
– frenulum tears & gingival lesions – Repeated injuries in varied stages of healing
– subdural & epidural hematomas – lapsed time between injury and time when care is sought
– retinal hemorrhage on funduscopic exam – Inconsistency between injury & caregiver’s explanation
Room Assignments
When preparing room assignments, the nurse should not place a client who has a fresh surgical wound or is
immunocompromised in a room with a client who has an active or suspected infection.
Suicide
Clients who articulate long-term personal goals and family milestones are less likely to commit suicide.
Bone Healing
Bone healing depends on multiple factors, including nutrition, adequate circulation, and age. A client with
peripheral arterial disease has decreased perfusion to the extremities due to atherosclerotic changes in the
arteries. Without adequate perfusion, the bone is not supplied with the oxygen and nutrients required for
healing.
Pressure Injuries
 Stage 1: Intact skin with nonblanchable redness
 Stage 2: Partial-thickness skin loss (abrasion, blister, or shallow crater) involving the dermis or
epidermis; the wound bed is red or pink and may be shiny or dry
 Stage 3: Full-thickness skin loss; subcutaneous fat is visible but not tendon, muscle, or bone; tunneling
may be present
 Stage 4: Full-thickness skin loss with visible tendon, muscle, or bone; slough or eschar (scabbing, dead
tissue) may be present; undermining and tunneling may be present
 Pressure injuries are described as “unstageable” if the base is covered by necrotic tissue or eschar
Drawing Insulin
NPH insulin and regular insulin may be safely mixed and administered as a single injection. Regular insulin
should be drawn into the syringe before intermediate-acting insulin to avoid cross-contaminating multidose
vials (mnemonic – RN: Regular before NPH)
1. Inject 25 units of air into the NPH insulin vial without inverting the vial or passing the needle into the
solution.
2. Inject 12 units of air into the regular insulin vial and withdraw the dose, leaving no air bubbles.
3. Draw 25 units of NPH insulin, totaling 37 units in one syringe. Any overdraw of NPH into the syringe
will necessitate wasting the entire quantity.
Transplant
During a heart transplant, the donor heart is cut off from the autonomic nervous system (denervated), which
alters the heart rate during rest and exercise after the transplant. The transplanted heart is expected to be
tachycardic (eg, 90-110/min).
Cardiac
Percutaneous coronary intervention via the femoral approach places the client at increased risk for
retroperitoneal hemorrhage, which is exacerbated by anticoagulants. Back pain, hypotension, flank ecchymosis
(Grey-Turner sign), hematoma formation, and diminished distal pulses can be early signs of bleeding into the
retroperitoneal space and require immediate intervention.
lOMoARcPSD|6170641
MI:
The nurse should rapidly assess (eg, vital signs, heart and lung sounds, pain) and intervene (eg, 2 large-bore IV
lines, oxygen, aspirin, nitroglycerin, morphine) for the client with acute chest pain. Upright positioning
improves ventilation and reduces pressure on the heart. The nurse should obtain a 12-lead ECG, chest x-ray,
and blood work (eg, cardiac markers), and place the client on continuous cardiac monitoring.
Sickle Cell Amemia
The priority intervention is the administration of IV fluids to reduce blood viscosity and restore perfusion to
the areas previously affected by vasoocclusion. Only after IV rehydration reverses vasoocclusion can
nonsickled RBCs effectively carry supplemental oxygen to the tissues.
Organ Donation
A deceased client who is registered as an organ donor does not need familial consent for organ procurement to
proceed. Organ donation does not delay or interfere with funeral arrangements or leave obvious evidence on
the body; deceased clients can still be displayed according to their wishes, including open casket funeral
services.
Pediatrics
A client with signs of basilar skull fracture (eg, periorbital hematomas, bruising behind the ear, leakage of
cerebrospinal fluid) requires immediate cervical spine immobilization, neurologic assessment, and airway,
breathing, and circulation support. Because of their close proximity to the brainstem, basilar skull fractures
pose a risk of serious intracranial injury, which is the most common cause of traumatic death in children.
TPN
– Total parenteral nutrition (intravenous nutrition) is high in glucose, which places the client at risk for
hyperglycemia. Signs and symptoms of hyperglycemia include polydipsia, polyuria, headaches, and blurred
vision.
– The steps for administering an intermittent enteral feeding include identifying the client, elevating the head of
the bed 30-45 degrees, validating tube placement, assessing bowel function, returning aspirated residual
contents to the stomach, flushing before and after feeding with 30 mL of water, and slowly administering
prescribed feedings at room temperature (too fast or too cold will cause cramping).
Disaster Triage
 Immediate (red tag): Life-threatening injuries with good prognoses once treated (eg, airway
obstruction, open fractures, second- or third-degree burns covering 15%-40% body surface area)
 Delayed (yellow tag): Injuries requiring treatment within hours (eg, stable abdominal wounds, soft
tissue injuries)
 Minimal (green tag): Injuries requiring treatment within a few days (eg, minor burns or fractures, small
lacerations)
 Expectant (black tag): Extensive injuries, poor prognosis regardless of treatment
– Disaster triage ranks the likelihood of survival with treatment, not necessarily the severity of injury. Clients
with significant alteration in airway, breathing, and circulation who are likely to survive with timely
intervention are the first priority.
Fall Risk
– Keeping the lights dim increases the risk for falls, particularly when the client is in an unfamiliar
environment. A well-lit room promotes orientation and helps the client avoid obstacles during ambulation.
– Keep bedside commode next to bed to help prevent falls.
lOMoARcPSD|6170641

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NURS2 UWorld Nclex General Critical Thinking And Rationales

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