NCLEX UWorld QUESTIONS AND ANSWERS ALL CORRECT
When do *advanced directives* go into effect? Correct Answer: when person is *unable to speak for
him/herself* due to either:
1. *Mental Incapacity* - *coma *(GCS score ≤ 7)
2. *Aphasia*
(≠as soon as signed; directives can always be changed later by person)
SBAR Communication Framekwork Components Correct Answer: 1. *S* = Situation - what *prompted*
the communication (eg *what* changes occurred)
2. *B* = Background - *pertinent information, relevant history, vital signs*
3. *A* = Assessment - nurse's assessment of the situation (*when* & *what changes* occurred)
4. *R* = Recommendation - *request* for *prescription* or *action* from HCP
Appropriate order of actions when client found on floor Correct Answer: 1. *Assessment* of
*physiological stability* ABCs
2. *Assessment* of *injuries*
3. *Moving client*
4. *Notifications*
5. *Documentation*
Conditions of being *ineligible to leave AMA* Correct Answer: 1 *danger to self or others*
2. *lack of consciousness*
3. *Altered consciousness*
4. *Mental illness*
5. Being under *chemical influence*
6. *Court decision*
Effective handoff communication components Correct Answer: Nurse should:
1. Provide *identifying information* (eg client's name and room number)
2. Note *care priorities* and upcoming or outstanding tasks (eg time to replace medication infusion bag,
need to perform delayed wound care and cause of delay)
3. Provide *exact, pertinent information* (eg medication dose, time, measurable outcomes)
4. Include *multidisciplinary plans* (eg radiology examinations, family meetings, physical therapy)
5. Relay significant client changes in a clear manner
*Risk factors* for *cervical cancer* Correct Answer: 1. Infection with high-risk HPV strains
2. History of sexually transmitted diseases
3. Early onset of sexual activity
4. Multiple or high-risk sexual partners
5. Immunosuppression
6. Oral contraceptive use
7. Low SES
8. Tobacco use
,what medications interact with grapefruit? Correct Answer: 1. *calcium channel blockers* (diltiazem,
nifedipine, verapamil, etc)
2. *statins*
3. *SSRIs*
Risk associated with *stent placement* using the *femoral approach* Correct Answer: *retroperitoneal
hemorrhage*
what are early signs of bleeding into the retroperitoneal space? Correct Answer: hypotension, back
pain, flank ecchymosis (grey turner sign), hematoma formation, diminshed distal pulses
what is the grey-turner sign and what is it a sign of? Correct Answer: bruising of the flanks and
retroperitoneal hemorrhage and is a bluish color
what are some physical signs of peripheral arterial disease? Correct Answer: intermittent calf muscle
pain?, rest pain, hair loss, decreased peripheral pulses, cool, dry, shiny skin, thick brittle nails, gangrene,
ulcers (all of these are in the extremities)
transplanted hearts are expected to be Correct Answer: tachycardic like 90-110
what is the priority intervention for pain with sickle cell crisis and why? Correct Answer: administer IV
fluids to reduce blood viscosity and restore perfusion to areas affected by vasoocclusion
what is the purpose of continuous bladder irrigation? Correct Answer: it is prescribed after TURP to
prevent obstruction of urine outflow by removing clotted blood from the bladder
characteristics of a basilar skull fracture Correct Answer: periorbital hematomas (raccoon eyes), csf fluid
rhinorrhea, and battle sign (behind the ear bruising)
immediate client care for basilar skull fracture Correct Answer: cervical spine immobilization, close
neurologic monitoring, and support of ABCs
nurse actions during a seizure Correct Answer: assist them to lie down is standing/sitting, put them on
side for patent airway, loosen tight clothing, give oxygen as needed, remove objects from immediate
area, document time and duration of seizure (for tests are done later to see which type of seizure and
maybe what exacerates it)
never put anything in mouth or restrain them since muscle contractions can occur during a seizure
what are some early symptoms of Increased Cranial Pressure? Correct Answer: altered LOC, headache,
abnormal breathing, rise in bp, slow pulse, vomiting
glasgow coma scale ranges from Correct Answer: 3-15; 3 being worst 15 being best condition (8 or
below in a coma)
what is a primary component in TPN? Correct Answer: *glucose,* so the nurse should be monitoring
blood glucose and be assessing for signs of hyperglycemia
,what are the 4 categories for triaging? Correct Answer: immediate (red tag)- life threatening injuries
with good prognosis once treated
delayed (yellow)- injuries requiring treatment within hours
minimal (green tag)- injuries requiring treatment within a few days
expectant (black tag)- extensive injuries, poor prognosis regardless of treatment
rule of nines Correct Answer: head: 4.5 front 4.5 back
torso: 18 front 18 back
each arm: 4.5 front 4.5 back (each arm is 9 total)
each leg: 9 front 8 back (each is 18 total)
genitals: 1
parkland formula for burns Correct Answer: % BSA x weight (kg) x 4
give 1/2 fluids in first 8 hours.
remaining 1/2 in last 16 hours.
airborne precautions Correct Answer: tuberculosis, varicella, and rubeola (measles)
wear N95 respirator (and other as needed like for splashes)
ALSO (neg pressure room and HEPA)
clients suspected are to wear a surgical mask after triage
droplet precautions Correct Answer: spiderman! sepsis, scarlet fever, streptococcal pharyngitis,
parvovirus, pneumonia, pertussis,
influenza,
diptheria,
epiglottitis,
rubella,
mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus
(Private room and mask)
contact precautions Correct Answer: Methods of infection control that must be used for patients known
or suspected to be infected with epidemiological microorganisms that can be transmitted by either
direct or indirect contact.
UAP soft wrist restraints can: Correct Answer: do ROM exercises
reapply wrist restraints
report changes in skin to nurse
turn/reposition client in bed
no lasix to what kind of patient Correct Answer: a pneumonia patient with fine crackles bc they dont
result from heart failure or edema
decerebrate posturing (toes point down and amrs/legs straight out) is a sign of Correct Answer: severe
brain damage
near drowning hypothermia Correct Answer: warm iv fluids, blankets, and oxygen
also will find weak and thready pulse
, intussusception
causes intestinal obstruction Correct Answer: ileum telescopes into cecum, pain obstruction, edema,
bowel ischemia, rectal bleeding (CURRANT JELLY stools)
signs of intussusception Correct Answer: initial periodic pain with legs drawn up to abdomen, pain is
severe and progressive though, inconsolable crying, blood/mucousy stools "currant jelly"
guaifenesin (Mucinex) Correct Answer: expectorant med that thins secretions to facilitate expectoration
erythropoeitin Epogen Correct Answer: stimulates bone marrow to make RBCs and combats the effects
of chemo and used for kidney disease
tetraology of fallot Correct Answer: exacerbation can happen when infant or child cries, becomes upset,
or is feeding
you immediately place them in KNEE CHEST position
hemolytic uremic syndrome Correct Answer: life threatening complication of e. coli diarrhea
what are the signs? Correct Answer: anemia (pallor), low platelets (petechiae and purpura, and acute
kidney injury (low UO)
cognitive behavioral therapy (CBT) 5 basic components Correct Answer: education about pts disorder
self observing and monitoring
relaxation techniques
cognitive restructuring
behavioral strategies
Written consents - Nurse's Role Correct Answer: 1. *Witness* that consent was signed *voluntarily*
2. That patient was *competent* at time of signing
3. *Documenting in medical records* after signature obtained with *date/time* of signature
how to stop epistaxis Correct Answer: tilt the head forward and apply direct continuous pressure on the
alaes (sides) for about 5-20 mins
can also hold a cold washcloth to the bridge of nose for vasoconstriction
keep child calm and quiet
IV iodinated contrast used for ct scan can cause Correct Answer: kidney injury; metformin is
discontinued on the day of IV iodine contrast exposure
Gabapentin (Neurontin) Correct Answer: used for neuropathic pain
Phenytoin (Dilantin) Correct Answer: antiseizure
Levofloxacin (Levaquin) Correct Answer: antibiotic
testicular self examination Correct Answer: perform monthly and on same day
When do *advanced directives* go into effect? Correct Answer: when person is *unable to speak for
him/herself* due to either:
1. *Mental Incapacity* - *coma *(GCS score ≤ 7)
2. *Aphasia*
(≠as soon as signed; directives can always be changed later by person)
SBAR Communication Framekwork Components Correct Answer: 1. *S* = Situation - what *prompted*
the communication (eg *what* changes occurred)
2. *B* = Background - *pertinent information, relevant history, vital signs*
3. *A* = Assessment - nurse's assessment of the situation (*when* & *what changes* occurred)
4. *R* = Recommendation - *request* for *prescription* or *action* from HCP
Appropriate order of actions when client found on floor Correct Answer: 1. *Assessment* of
*physiological stability* ABCs
2. *Assessment* of *injuries*
3. *Moving client*
4. *Notifications*
5. *Documentation*
Conditions of being *ineligible to leave AMA* Correct Answer: 1 *danger to self or others*
2. *lack of consciousness*
3. *Altered consciousness*
4. *Mental illness*
5. Being under *chemical influence*
6. *Court decision*
Effective handoff communication components Correct Answer: Nurse should:
1. Provide *identifying information* (eg client's name and room number)
2. Note *care priorities* and upcoming or outstanding tasks (eg time to replace medication infusion bag,
need to perform delayed wound care and cause of delay)
3. Provide *exact, pertinent information* (eg medication dose, time, measurable outcomes)
4. Include *multidisciplinary plans* (eg radiology examinations, family meetings, physical therapy)
5. Relay significant client changes in a clear manner
*Risk factors* for *cervical cancer* Correct Answer: 1. Infection with high-risk HPV strains
2. History of sexually transmitted diseases
3. Early onset of sexual activity
4. Multiple or high-risk sexual partners
5. Immunosuppression
6. Oral contraceptive use
7. Low SES
8. Tobacco use
,what medications interact with grapefruit? Correct Answer: 1. *calcium channel blockers* (diltiazem,
nifedipine, verapamil, etc)
2. *statins*
3. *SSRIs*
Risk associated with *stent placement* using the *femoral approach* Correct Answer: *retroperitoneal
hemorrhage*
what are early signs of bleeding into the retroperitoneal space? Correct Answer: hypotension, back
pain, flank ecchymosis (grey turner sign), hematoma formation, diminshed distal pulses
what is the grey-turner sign and what is it a sign of? Correct Answer: bruising of the flanks and
retroperitoneal hemorrhage and is a bluish color
what are some physical signs of peripheral arterial disease? Correct Answer: intermittent calf muscle
pain?, rest pain, hair loss, decreased peripheral pulses, cool, dry, shiny skin, thick brittle nails, gangrene,
ulcers (all of these are in the extremities)
transplanted hearts are expected to be Correct Answer: tachycardic like 90-110
what is the priority intervention for pain with sickle cell crisis and why? Correct Answer: administer IV
fluids to reduce blood viscosity and restore perfusion to areas affected by vasoocclusion
what is the purpose of continuous bladder irrigation? Correct Answer: it is prescribed after TURP to
prevent obstruction of urine outflow by removing clotted blood from the bladder
characteristics of a basilar skull fracture Correct Answer: periorbital hematomas (raccoon eyes), csf fluid
rhinorrhea, and battle sign (behind the ear bruising)
immediate client care for basilar skull fracture Correct Answer: cervical spine immobilization, close
neurologic monitoring, and support of ABCs
nurse actions during a seizure Correct Answer: assist them to lie down is standing/sitting, put them on
side for patent airway, loosen tight clothing, give oxygen as needed, remove objects from immediate
area, document time and duration of seizure (for tests are done later to see which type of seizure and
maybe what exacerates it)
never put anything in mouth or restrain them since muscle contractions can occur during a seizure
what are some early symptoms of Increased Cranial Pressure? Correct Answer: altered LOC, headache,
abnormal breathing, rise in bp, slow pulse, vomiting
glasgow coma scale ranges from Correct Answer: 3-15; 3 being worst 15 being best condition (8 or
below in a coma)
what is a primary component in TPN? Correct Answer: *glucose,* so the nurse should be monitoring
blood glucose and be assessing for signs of hyperglycemia
,what are the 4 categories for triaging? Correct Answer: immediate (red tag)- life threatening injuries
with good prognosis once treated
delayed (yellow)- injuries requiring treatment within hours
minimal (green tag)- injuries requiring treatment within a few days
expectant (black tag)- extensive injuries, poor prognosis regardless of treatment
rule of nines Correct Answer: head: 4.5 front 4.5 back
torso: 18 front 18 back
each arm: 4.5 front 4.5 back (each arm is 9 total)
each leg: 9 front 8 back (each is 18 total)
genitals: 1
parkland formula for burns Correct Answer: % BSA x weight (kg) x 4
give 1/2 fluids in first 8 hours.
remaining 1/2 in last 16 hours.
airborne precautions Correct Answer: tuberculosis, varicella, and rubeola (measles)
wear N95 respirator (and other as needed like for splashes)
ALSO (neg pressure room and HEPA)
clients suspected are to wear a surgical mask after triage
droplet precautions Correct Answer: spiderman! sepsis, scarlet fever, streptococcal pharyngitis,
parvovirus, pneumonia, pertussis,
influenza,
diptheria,
epiglottitis,
rubella,
mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus
(Private room and mask)
contact precautions Correct Answer: Methods of infection control that must be used for patients known
or suspected to be infected with epidemiological microorganisms that can be transmitted by either
direct or indirect contact.
UAP soft wrist restraints can: Correct Answer: do ROM exercises
reapply wrist restraints
report changes in skin to nurse
turn/reposition client in bed
no lasix to what kind of patient Correct Answer: a pneumonia patient with fine crackles bc they dont
result from heart failure or edema
decerebrate posturing (toes point down and amrs/legs straight out) is a sign of Correct Answer: severe
brain damage
near drowning hypothermia Correct Answer: warm iv fluids, blankets, and oxygen
also will find weak and thready pulse
, intussusception
causes intestinal obstruction Correct Answer: ileum telescopes into cecum, pain obstruction, edema,
bowel ischemia, rectal bleeding (CURRANT JELLY stools)
signs of intussusception Correct Answer: initial periodic pain with legs drawn up to abdomen, pain is
severe and progressive though, inconsolable crying, blood/mucousy stools "currant jelly"
guaifenesin (Mucinex) Correct Answer: expectorant med that thins secretions to facilitate expectoration
erythropoeitin Epogen Correct Answer: stimulates bone marrow to make RBCs and combats the effects
of chemo and used for kidney disease
tetraology of fallot Correct Answer: exacerbation can happen when infant or child cries, becomes upset,
or is feeding
you immediately place them in KNEE CHEST position
hemolytic uremic syndrome Correct Answer: life threatening complication of e. coli diarrhea
what are the signs? Correct Answer: anemia (pallor), low platelets (petechiae and purpura, and acute
kidney injury (low UO)
cognitive behavioral therapy (CBT) 5 basic components Correct Answer: education about pts disorder
self observing and monitoring
relaxation techniques
cognitive restructuring
behavioral strategies
Written consents - Nurse's Role Correct Answer: 1. *Witness* that consent was signed *voluntarily*
2. That patient was *competent* at time of signing
3. *Documenting in medical records* after signature obtained with *date/time* of signature
how to stop epistaxis Correct Answer: tilt the head forward and apply direct continuous pressure on the
alaes (sides) for about 5-20 mins
can also hold a cold washcloth to the bridge of nose for vasoconstriction
keep child calm and quiet
IV iodinated contrast used for ct scan can cause Correct Answer: kidney injury; metformin is
discontinued on the day of IV iodine contrast exposure
Gabapentin (Neurontin) Correct Answer: used for neuropathic pain
Phenytoin (Dilantin) Correct Answer: antiseizure
Levofloxacin (Levaquin) Correct Answer: antibiotic
testicular self examination Correct Answer: perform monthly and on same day
