1
NCLEX UWORLD EXAM LATEST EXAM
QUESTIONS AND CORRECT DETAILED
ANSWERS
When do *advanced directives* go into effect? - (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 - (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 - (ANSWER)1.
*Assessment* of *physiological stability* (ABCs)
2. *Assessment* of *injuries*
3. *Moving client*
4. *Notifications*
5. *Documentation*
, 2
Conditions of being *ineligible to leave AMA* - (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 - (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* - (ANSWER)1. Infection with high-risk HPV
strains
2. History of sexually transmitted diseases
3. Early onset of sexual activity
, 3
4. Multiple or high-risk sexual partners
5. Immunosuppression
6. Oral contraceptive use
7. Low SES
8. Tobacco use
what medications interact with grapefruit? - (ANSWER)1. *calcium channel
blockers* (diltiazem, nifedipine, verapamil, etc)
2. *statins*
3. *SSRIs*
Risk associated with *stent placement* using the *femoral approach* -
(ANSWER)*retroperitoneal hemorrhage*
what are early signs of bleeding into the retroperitoneal space? -
(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? - (ANSWER)bruising of the
flanks and retroperitoneal hemorrhage and is a bluish color
what are some physical signs of peripheral arterial disease? -
(ANSWER)intermittent calf muscle pain?, rest pain, hair loss, decreased peripheral
, 4
pulses, cool, dry, shiny skin, thick brittle nails, gangrene, ulcers (all of these are in
the extremities)
transplanted hearts are expected to be - (ANSWER)tachycardic like 90-110
what is the priority intervention for pain with sickle cell crisis and why? -
(ANSWER)administer IV fluids to reduce blood viscosity and restore perfusion to
areas affected by vasoocclusion
what is the purpose of continuous bladder irrigation? - (ANSWER)it is perscribed
after TURP to prevent obstruction of urine outflow by removing clotted blood
from the bladder
what is the nurses care of monitoring CBI? - (ANSWER)monitor quality of
drainage, titrate the inflow rate, and manurally irrigating as needed
characteristics of a basilar skull fracture - (ANSWER)periorbital hematomas
(raccoon eyes), csf fluid rhinorrhea, and battle sign (behind the ear bruising)
immediate client care for basilar skull fracture - (ANSWER)cervical spime
immobilization, close neurologic monitoring, and support of ABCs
vomiting with intake may mean - (ANSWER)viral or bacterial infection
NCLEX UWORLD EXAM LATEST EXAM
QUESTIONS AND CORRECT DETAILED
ANSWERS
When do *advanced directives* go into effect? - (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 - (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 - (ANSWER)1.
*Assessment* of *physiological stability* (ABCs)
2. *Assessment* of *injuries*
3. *Moving client*
4. *Notifications*
5. *Documentation*
, 2
Conditions of being *ineligible to leave AMA* - (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 - (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* - (ANSWER)1. Infection with high-risk HPV
strains
2. History of sexually transmitted diseases
3. Early onset of sexual activity
, 3
4. Multiple or high-risk sexual partners
5. Immunosuppression
6. Oral contraceptive use
7. Low SES
8. Tobacco use
what medications interact with grapefruit? - (ANSWER)1. *calcium channel
blockers* (diltiazem, nifedipine, verapamil, etc)
2. *statins*
3. *SSRIs*
Risk associated with *stent placement* using the *femoral approach* -
(ANSWER)*retroperitoneal hemorrhage*
what are early signs of bleeding into the retroperitoneal space? -
(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? - (ANSWER)bruising of the
flanks and retroperitoneal hemorrhage and is a bluish color
what are some physical signs of peripheral arterial disease? -
(ANSWER)intermittent calf muscle pain?, rest pain, hair loss, decreased peripheral
, 4
pulses, cool, dry, shiny skin, thick brittle nails, gangrene, ulcers (all of these are in
the extremities)
transplanted hearts are expected to be - (ANSWER)tachycardic like 90-110
what is the priority intervention for pain with sickle cell crisis and why? -
(ANSWER)administer IV fluids to reduce blood viscosity and restore perfusion to
areas affected by vasoocclusion
what is the purpose of continuous bladder irrigation? - (ANSWER)it is perscribed
after TURP to prevent obstruction of urine outflow by removing clotted blood
from the bladder
what is the nurses care of monitoring CBI? - (ANSWER)monitor quality of
drainage, titrate the inflow rate, and manurally irrigating as needed
characteristics of a basilar skull fracture - (ANSWER)periorbital hematomas
(raccoon eyes), csf fluid rhinorrhea, and battle sign (behind the ear bruising)
immediate client care for basilar skull fracture - (ANSWER)cervical spime
immobilization, close neurologic monitoring, and support of ABCs
vomiting with intake may mean - (ANSWER)viral or bacterial infection
