NCLEX EXAM zm
Exam Solution zm
NCLEX UWorld 2026 A+ GRADE ASSURED COMPLETE S
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OLUTIONS AND VERIFIED ANSWERS (BDE90) zm zm zm zm
QUESTION 1 zm
When do *advanced directives* go into effect?
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ANSWER
when person is *unable to speak for him/herself* due to either: 1. *Mental Incapacity* -
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*coma *(GCS score ≤ 7) 2. *Aphasia* (≠as soon as signed; directives can always be changed later b
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y person)
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QUESTION 2 zm
SBAR Communication Framekwork Components
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ANSWER
1. *S* = Situation -
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what *prompted* the communication (eg *what* changes occurred) 2. *B* = Background -
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*pertinent information, relevant history, vital signs* 3. *A* = Assessment -
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nurse's assessment of the situation (*when* & *what changes* occurred) 4. *R* = Recommendation
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- *request* for *prescription* or *action* from HCP
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QUESTION 3 zm
Appropriate order of actions when client found on floor
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ANSWER
1. *Assessment* of *physiological stability* (ABCs) 2. *Assessment* of *injuries* 3. *Moving client* 4.
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*Notifications* 5. *Documentation*
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QUESTION 4 zm
Conditions of being *ineligible to leave AMA*
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,ANSWER
1 *danger to self or others* 2. *lack of consciousness* 3. *Altered consciousness* 4. *Mental illness*
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5. Being under *chemical influence* 6. *Court decision*
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QUESTION 5 zm
Effective handoff communication components
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ANSWER
Nurse should: 1. Provide *identifying information* (eg client's name and room number) 2. Note *car
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e priorities* and upcoming or outstanding tasks (eg time to replace medication infusion bag, need to
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perform delayed wound care and cause of delay) 3. Provide *exact, pertinent information* (eg medi
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cation dose, time, measurable outcomes) 4. Include *multidisciplinary plans* (eg radiology examinati
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ons, family meetings, physical therapy) 5. Relay significant client changes in a clear manner
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QUESTION 6 zm
*Risk factors* for *cervical cancer*
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ANSWER
1. Infection with high-
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risk HPV strains 2. History of sexually transmitted diseases 3. Early onset of sexual activity 4. Multip
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le or high-
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risk sexual partners 5. Immunosuppression 6. Oral contraceptive use 7. Low SES 8. Tobacco use
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QUESTION 7 zm
what medications interact with grapefruit?
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ANSWER
1. *calcium channel blockers* (diltiazem, nifedipine, verapamil, etc) 2. *statins* 3. *SSRIs*
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QUESTION 8 zm
Risk associated with *stent placement* using the *femoral approach*
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ANSWER
*retroperitoneal hemorrhage* zm
QUESTION 9 zm
what are early signs of bleeding into the retroperitoneal space?
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ANSWER
,hypotension, back pain, flank ecchymosis (grey turner sign), hematoma formation, diminshed distal p
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ulses
QUESTION 10 zm
what is the grey-turner sign and what is it a sign of?
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ANSWER
bruising of the flanks and retroperitoneal hemorrhage and is a bluish color
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QUESTION 11 zm
what are some physical signs of peripheral arterial disease?
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ANSWER
intermittent calf muscle pain?, rest pain, hair loss, decreased peripheral pulses, cool, dry, shiny skin,
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thick brittle nails, gangrene, ulcers (all of these are in the extremities)
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QUESTION 12 zm
transplanted hearts are expected to be zm zm zm zm zm
ANSWER
tachycardic like 90-110 zm zm
QUESTION 13 zm
what is the priority intervention for pain with sickle cell crisis and why?
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ANSWER
administer IV fluids to reduce blood viscosity and restore perfusion to areas affected by vasoocclusi
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on
QUESTION 14 zm
what is the purpose of continuous bladder irrigation?
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ANSWER
it is perscribed after TURP to prevent obstruction of urine outflow by removing clotted blood from t
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he bladder
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QUESTION 15 zm
, what is the nurses care of monitoring CBI?
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ANSWER
monitor quality of drainage, titrate the inflow rate, and manurally irrigating as needed
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QUESTION 16 zm
characteristics of a basilar skull fracture zm zm zm zm zm
ANSWER
periorbital hematomas (raccoon eyes), csf fluid rhinorrhea, and battle sign (behind the ear bruising)
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QUESTION 17 zm
immediate client care for basilar skull fracture
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ANSWER
cervical spime immobilization, close neurologic monitoring, and support of ABCs
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QUESTION 18 zm
vomiting with intake may mean zm zm zm zm
ANSWER
viral or bacterial infection
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QUESTION 19 zm
tympanosomty tubes are placed for zm zm zm zm
ANSWER
recurrent otis medias zm zm
QUESTION 20 zm
nurse actions during a seizure
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ANSWER
assist them to lie down is standing/sitting, put them on side for patent airway, loosen tight clothing,
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mgive oxygen as needed, remove objects from immediate area, document time and duration of seizur
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e (for tests are done later to see which type of seizure and maybe what exacerates it) never put an
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ything in mouth or restrain them since musclec ontractions can occur during a seizure
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Exam Solution zm
NCLEX UWorld 2026 A+ GRADE ASSURED COMPLETE S
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OLUTIONS AND VERIFIED ANSWERS (BDE90) zm zm zm zm
QUESTION 1 zm
When do *advanced directives* go into effect?
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ANSWER
when person is *unable to speak for him/herself* due to either: 1. *Mental Incapacity* -
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*coma *(GCS score ≤ 7) 2. *Aphasia* (≠as soon as signed; directives can always be changed later b
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y person)
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QUESTION 2 zm
SBAR Communication Framekwork Components
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ANSWER
1. *S* = Situation -
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what *prompted* the communication (eg *what* changes occurred) 2. *B* = Background -
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*pertinent information, relevant history, vital signs* 3. *A* = Assessment -
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nurse's assessment of the situation (*when* & *what changes* occurred) 4. *R* = Recommendation
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- *request* for *prescription* or *action* from HCP
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QUESTION 3 zm
Appropriate order of actions when client found on floor
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ANSWER
1. *Assessment* of *physiological stability* (ABCs) 2. *Assessment* of *injuries* 3. *Moving client* 4.
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*Notifications* 5. *Documentation*
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QUESTION 4 zm
Conditions of being *ineligible to leave AMA*
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,ANSWER
1 *danger to self or others* 2. *lack of consciousness* 3. *Altered consciousness* 4. *Mental illness*
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5. Being under *chemical influence* 6. *Court decision*
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QUESTION 5 zm
Effective handoff communication components
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ANSWER
Nurse should: 1. Provide *identifying information* (eg client's name and room number) 2. Note *car
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e priorities* and upcoming or outstanding tasks (eg time to replace medication infusion bag, need to
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
perform delayed wound care and cause of delay) 3. Provide *exact, pertinent information* (eg medi
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
cation dose, time, measurable outcomes) 4. Include *multidisciplinary plans* (eg radiology examinati
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ons, family meetings, physical therapy) 5. Relay significant client changes in a clear manner
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QUESTION 6 zm
*Risk factors* for *cervical cancer*
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ANSWER
1. Infection with high-
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risk HPV strains 2. History of sexually transmitted diseases 3. Early onset of sexual activity 4. Multip
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le or high-
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risk sexual partners 5. Immunosuppression 6. Oral contraceptive use 7. Low SES 8. Tobacco use
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QUESTION 7 zm
what medications interact with grapefruit?
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ANSWER
1. *calcium channel blockers* (diltiazem, nifedipine, verapamil, etc) 2. *statins* 3. *SSRIs*
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QUESTION 8 zm
Risk associated with *stent placement* using the *femoral approach*
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ANSWER
*retroperitoneal hemorrhage* zm
QUESTION 9 zm
what are early signs of bleeding into the retroperitoneal space?
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ANSWER
,hypotension, back pain, flank ecchymosis (grey turner sign), hematoma formation, diminshed distal p
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ulses
QUESTION 10 zm
what is the grey-turner sign and what is it a sign of?
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ANSWER
bruising of the flanks and retroperitoneal hemorrhage and is a bluish color
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QUESTION 11 zm
what are some physical signs of peripheral arterial disease?
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ANSWER
intermittent calf muscle pain?, rest pain, hair loss, decreased peripheral pulses, cool, dry, shiny skin,
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thick brittle nails, gangrene, ulcers (all of these are in the extremities)
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QUESTION 12 zm
transplanted hearts are expected to be zm zm zm zm zm
ANSWER
tachycardic like 90-110 zm zm
QUESTION 13 zm
what is the priority intervention for pain with sickle cell crisis and why?
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ANSWER
administer IV fluids to reduce blood viscosity and restore perfusion to areas affected by vasoocclusi
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on
QUESTION 14 zm
what is the purpose of continuous bladder irrigation?
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ANSWER
it is perscribed after TURP to prevent obstruction of urine outflow by removing clotted blood from t
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
he bladder
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QUESTION 15 zm
, what is the nurses care of monitoring CBI?
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ANSWER
monitor quality of drainage, titrate the inflow rate, and manurally irrigating as needed
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QUESTION 16 zm
characteristics of a basilar skull fracture zm zm zm zm zm
ANSWER
periorbital hematomas (raccoon eyes), csf fluid rhinorrhea, and battle sign (behind the ear bruising)
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QUESTION 17 zm
immediate client care for basilar skull fracture
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ANSWER
cervical spime immobilization, close neurologic monitoring, and support of ABCs
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QUESTION 18 zm
vomiting with intake may mean zm zm zm zm
ANSWER
viral or bacterial infection
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QUESTION 19 zm
tympanosomty tubes are placed for zm zm zm zm
ANSWER
recurrent otis medias zm zm
QUESTION 20 zm
nurse actions during a seizure
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ANSWER
assist them to lie down is standing/sitting, put them on side for patent airway, loosen tight clothing,
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mgive oxygen as needed, remove objects from immediate area, document time and duration of seizur
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e (for tests are done later to see which type of seizure and maybe what exacerates it) never put an
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ything in mouth or restrain them since musclec ontractions can occur during a seizure
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