UWorld NCLEX-RN TEST 2 Spring 2023 with complete
solution
A nurse coworker is called into work from home to help care for an influx of
clients being admitted after a bus accident. While assisting the coworker prepare
for incoming clients, the nurse becomes concerned that the coworker may be
under the influence of an impairing substance. Which action by the nurse is best?
1.
Ask another coworker to observe the individual to confirm the suspicion
2.
Confront the coworker about the concern and offer emotional support
3.
Speak with the nursing supervisor about the concern
4.
Telephone the appropriate regulatory agency and make a report
3.
A nurse is administering a rituximab infusion to a client with lymphoma in an
oncology clinic. Which client symptom would be a priority to report to the health
care provider?
1.
Dizziness and sudden diarrhea
2.
Nausea and onset of vomiting
3.
New-onset tachypnea and dyspnea
4.
Temperature of 101 F (38.3 C)
3.
The student nurse plans postmortem care for an Orthodox Jewish client
hospitalized for the last week with heart failure who did not sign consents for any
postmortem actions. Which statement by the student would require further
education by the supervising nurse?
1.
"I will allow the family to remain with the client at all times."
2.
"I will call the next of kin before providing any postmortem care."
3.
"I will prepare the client for transfer to the morgue for autopsy."
4.
"I will provide a sheet to be placed over the client's face."
3.
The nurse is caring for a client with chronic pancreatitis. Which meal should the
nurse recommend when assisting the client in selecting food items from a menu?
1.
Baked tilapia with lemon wedge, sweet potatoes, and green peas
,2.
Cream of potato soup and roast beef sandwich on a croissant
3.
Sautéed salmon, macaroni and cheese, string beans, and a biscuit
4.
Shrimp enchiladas with tomato salsa, rice, cornbread, and refried beans
1.
The nurse is preparing to change the dressing of a client's subclavian central
venous catheter using a chlorhexidine gluconate (CHG)-impregnated patch and
transparent adhesive dressing. Place the procedural steps in the correct order.
All options must be used.
Apply CHG patch over catheter insertion site and cover with a sterile transparent
dressing
Cleanse the site with CHG for at least 30 seconds using friction; allow to air dry
completely
Discard the clean gloves, perform hand hygiene, and apply sterile gloves
Perform hand hygiene, don face mask, place a mask on the client, and apply
clean gloves
Remove old dressing and CHG-impregnated patch; assess insertion site
Perform hand hygiene, don face mask, place a mask on the client, and apply clean
gloves
Remove old dressing and CHG-impregnated patch; assess insertion site
Discard the clean gloves, perform hand hygiene, and apply sterile gloves
Cleanse the site with CHG for at least 30 seconds using friction; allow to air dry
completely
Apply CHG patch over catheter insertion site and cover with a sterile transparent
dressing
Four clients enter the pediatric emergency department at the same time. Which
client should the nurse see first?
1.
2-week-old with tricuspid atresia who has dusky lips and nailbeds
2.
5-week-old with forceful vomiting after every feeding who is crying
3.
12-month-old who was wheezing at home and is now lethargic with no wheezing
4.
3-year-old with fever who had a brief seizure at home and is asleep
,3.
The unlicensed assistive personnel (UAP) reports being splashed in the eye while
emptying urine from the catheter bag of a client with AIDS. The UAP is afraid of
becoming infected with HIV and requests immediate testing. What is the nurse's
priority action?
1.
Direct the UAP to immediately flush the eye with water at the unit's eyewash
station
2.
Reassure the UAP that the risk for HIV is low as urine does not transmit the virus
3.
Refer the UAP to the occupational health department for postexposure
prophylaxis
4.
Send the UAP to the facility's emergency department for medical evaluation
1.
The nurse prepares to administer a client's scheduled prandial regular insulin
plus a correctional dose based on a sliding scale as the client's breakfast tray
arrives. The client's fasting blood glucose level is 210 mg/dL (11.7 mmol/L). How
many total units of regular insulin should the nurse administer? Click the exhibit
button for additional information. Record your answer using a whole number.
EXHIBIT:
Medication administration record:
Allergies: NKA
Medications:
-Regular insulin: 4 units subcutaneously with each meal (0800, 1200, 1700)
-Regular insulin: per sliding scale, subcutaneously with each meal and before
bed
(0800, 1200, 1700, 2100)
Sliding-Scale Blood Glucose Levels:
<150 mg/dL - 0 units
150-199 mg/dL - 3 units
200-249 mg/dL - 6 units
250-299 mg/dL - 9 units
300-349 mg/dL - 12 units
≥350 mg/dL - 15 units; notify HCP
Answer: 10 (units)
The nurse is caring for a client taking escitalopram who reports no improvement
of depressive feelings since starting the medication 2 months ago. What is the
best response by the nurse?
1.
"Have you had any recent changes or added stresses in your life?"
, 2.
"It is too early to notice any difference. Please continue to take the medicine as
prescribed."
3.
"Let's talk more about how you have been taking this medication."
4.
"We will talk with your health care provider about changing the prescription."
3.
The nurse reinforces teaching to the parents of a 12-month-old who has begun
weaning from breastfeeding. Which statement by the parents indicates that
teaching has been effective?
1.
"I can allow my child to sleep with a bottle for comfort while weaning."
2.
"I can start substituting breastfeeding sessions with whole cow's milk."
3.
"I should discourage my child from drinking milk to increase solid food intake."
4.
"I will stop breastfeeding completely to expedite the weaning process."
2.
The home health nurse is discussing the care needs of a client in the last stage of
Huntington disease with the family. When the nurse recommends a hospital bed,
the client's spouse becomes visibly upset and says, "No hospital bed. I'm just not
ready for it yet." What is the best response by the nurse?
1.
"A hospital bed will make your spouse's care easier."
2.
"Are you not ready for this particular change?"
3.
"What upsets you about having a hospital bed?"
4.
"You seem upset. We don't have to talk about this right now."
3.
The nurse is assisting with a presentation on protecting clients' privacy and
confidentiality. Which of the following incidents does the nurse recognize as a
violation of client confidentiality? Select all that apply.
1.
A family member informs the registered nurse that the client has not been taking
the prescribed metformin at home
2.
An oncology nurse reviews the electronic health record of a client in the
emergency department who was the victim of a recent mass shooting event
3.
The licensed practical nurse (LPN) leaves the client's report sheet in the cafeteria
after lunch
4.
solution
A nurse coworker is called into work from home to help care for an influx of
clients being admitted after a bus accident. While assisting the coworker prepare
for incoming clients, the nurse becomes concerned that the coworker may be
under the influence of an impairing substance. Which action by the nurse is best?
1.
Ask another coworker to observe the individual to confirm the suspicion
2.
Confront the coworker about the concern and offer emotional support
3.
Speak with the nursing supervisor about the concern
4.
Telephone the appropriate regulatory agency and make a report
3.
A nurse is administering a rituximab infusion to a client with lymphoma in an
oncology clinic. Which client symptom would be a priority to report to the health
care provider?
1.
Dizziness and sudden diarrhea
2.
Nausea and onset of vomiting
3.
New-onset tachypnea and dyspnea
4.
Temperature of 101 F (38.3 C)
3.
The student nurse plans postmortem care for an Orthodox Jewish client
hospitalized for the last week with heart failure who did not sign consents for any
postmortem actions. Which statement by the student would require further
education by the supervising nurse?
1.
"I will allow the family to remain with the client at all times."
2.
"I will call the next of kin before providing any postmortem care."
3.
"I will prepare the client for transfer to the morgue for autopsy."
4.
"I will provide a sheet to be placed over the client's face."
3.
The nurse is caring for a client with chronic pancreatitis. Which meal should the
nurse recommend when assisting the client in selecting food items from a menu?
1.
Baked tilapia with lemon wedge, sweet potatoes, and green peas
,2.
Cream of potato soup and roast beef sandwich on a croissant
3.
Sautéed salmon, macaroni and cheese, string beans, and a biscuit
4.
Shrimp enchiladas with tomato salsa, rice, cornbread, and refried beans
1.
The nurse is preparing to change the dressing of a client's subclavian central
venous catheter using a chlorhexidine gluconate (CHG)-impregnated patch and
transparent adhesive dressing. Place the procedural steps in the correct order.
All options must be used.
Apply CHG patch over catheter insertion site and cover with a sterile transparent
dressing
Cleanse the site with CHG for at least 30 seconds using friction; allow to air dry
completely
Discard the clean gloves, perform hand hygiene, and apply sterile gloves
Perform hand hygiene, don face mask, place a mask on the client, and apply
clean gloves
Remove old dressing and CHG-impregnated patch; assess insertion site
Perform hand hygiene, don face mask, place a mask on the client, and apply clean
gloves
Remove old dressing and CHG-impregnated patch; assess insertion site
Discard the clean gloves, perform hand hygiene, and apply sterile gloves
Cleanse the site with CHG for at least 30 seconds using friction; allow to air dry
completely
Apply CHG patch over catheter insertion site and cover with a sterile transparent
dressing
Four clients enter the pediatric emergency department at the same time. Which
client should the nurse see first?
1.
2-week-old with tricuspid atresia who has dusky lips and nailbeds
2.
5-week-old with forceful vomiting after every feeding who is crying
3.
12-month-old who was wheezing at home and is now lethargic with no wheezing
4.
3-year-old with fever who had a brief seizure at home and is asleep
,3.
The unlicensed assistive personnel (UAP) reports being splashed in the eye while
emptying urine from the catheter bag of a client with AIDS. The UAP is afraid of
becoming infected with HIV and requests immediate testing. What is the nurse's
priority action?
1.
Direct the UAP to immediately flush the eye with water at the unit's eyewash
station
2.
Reassure the UAP that the risk for HIV is low as urine does not transmit the virus
3.
Refer the UAP to the occupational health department for postexposure
prophylaxis
4.
Send the UAP to the facility's emergency department for medical evaluation
1.
The nurse prepares to administer a client's scheduled prandial regular insulin
plus a correctional dose based on a sliding scale as the client's breakfast tray
arrives. The client's fasting blood glucose level is 210 mg/dL (11.7 mmol/L). How
many total units of regular insulin should the nurse administer? Click the exhibit
button for additional information. Record your answer using a whole number.
EXHIBIT:
Medication administration record:
Allergies: NKA
Medications:
-Regular insulin: 4 units subcutaneously with each meal (0800, 1200, 1700)
-Regular insulin: per sliding scale, subcutaneously with each meal and before
bed
(0800, 1200, 1700, 2100)
Sliding-Scale Blood Glucose Levels:
<150 mg/dL - 0 units
150-199 mg/dL - 3 units
200-249 mg/dL - 6 units
250-299 mg/dL - 9 units
300-349 mg/dL - 12 units
≥350 mg/dL - 15 units; notify HCP
Answer: 10 (units)
The nurse is caring for a client taking escitalopram who reports no improvement
of depressive feelings since starting the medication 2 months ago. What is the
best response by the nurse?
1.
"Have you had any recent changes or added stresses in your life?"
, 2.
"It is too early to notice any difference. Please continue to take the medicine as
prescribed."
3.
"Let's talk more about how you have been taking this medication."
4.
"We will talk with your health care provider about changing the prescription."
3.
The nurse reinforces teaching to the parents of a 12-month-old who has begun
weaning from breastfeeding. Which statement by the parents indicates that
teaching has been effective?
1.
"I can allow my child to sleep with a bottle for comfort while weaning."
2.
"I can start substituting breastfeeding sessions with whole cow's milk."
3.
"I should discourage my child from drinking milk to increase solid food intake."
4.
"I will stop breastfeeding completely to expedite the weaning process."
2.
The home health nurse is discussing the care needs of a client in the last stage of
Huntington disease with the family. When the nurse recommends a hospital bed,
the client's spouse becomes visibly upset and says, "No hospital bed. I'm just not
ready for it yet." What is the best response by the nurse?
1.
"A hospital bed will make your spouse's care easier."
2.
"Are you not ready for this particular change?"
3.
"What upsets you about having a hospital bed?"
4.
"You seem upset. We don't have to talk about this right now."
3.
The nurse is assisting with a presentation on protecting clients' privacy and
confidentiality. Which of the following incidents does the nurse recognize as a
violation of client confidentiality? Select all that apply.
1.
A family member informs the registered nurse that the client has not been taking
the prescribed metformin at home
2.
An oncology nurse reviews the electronic health record of a client in the
emergency department who was the victim of a recent mass shooting event
3.
The licensed practical nurse (LPN) leaves the client's report sheet in the cafeteria
after lunch
4.
