NCLEX UWorld 2024–2025 Questions and Answers
– Verified 100% Correct | A+ Graded Exam Prep
Appropriate order of actions when client found on floor - CORRECT ANSWERS 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 ANSWERS 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 ANSWERS 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 ANSWERS 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
,NCLEX UWorld 2024–2025 Questions and Answers
– Verified 100% Correct | A+ Graded Exam Prep
When do *advanced directives* go into effect? - CORRECT ANSWERS 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 ANSWERS 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
what medications interact with grapefruit? - CORRECT ANSWERS 1. *calcium channel blockers*
(diltiazem, nifedipine, verapamil, etc)
2. *statins*
3. *SSRIs*
Risk associated with *stent placement* using the *femoral approach* - CORRECT ANSWERS
*retroperitoneal hemorrhage*
what are early signs of bleeding into the retroperitoneal space? - CORRECT ANSWERS 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 ANSWERS bruising of the flanks and
retroperitoneal hemorrhage and is a bluish color
what are some physical signs of peripheral arterial disease? - CORRECT ANSWERS 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)
,NCLEX UWorld 2024–2025 Questions and Answers
– Verified 100% Correct | A+ Graded Exam Prep
transplanted hearts are expected to be - CORRECT ANSWERS tachycardic like 90-110
what is the priority intervention for pain with sickle cell crisis and why? - CORRECT ANSWERS
administer IV fluids to reduce blood viscosity and restore perfusion to areas affected by
vasoocclusion
what is the purpose of continuous bladder irrigation? - CORRECT ANSWERS 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? - CORRECT ANSWERS monitor quality of drainage, titrate
the inflow rate, and manurally irrigating as needed
characteristics of a basilar skull fracture - CORRECT ANSWERS periorbital hematomas (raccoon eyes),
csf fluid rhinorrhea, and battle sign (behind the ear bruising)
immediate client care for basilar skull fracture - CORRECT ANSWERS cervical spime immobilization,
close neurologic monitoring, and support of ABCs
vomiting with intake may mean - CORRECT ANSWERS viral or bacterial infection
tympanosomty tubes are placed for - CORRECT ANSWERS recurrent otis medias
nurse actions during a seizure - CORRECT ANSWERS 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 musclec ontractions can occur during a seizure
what are some early symptoms of ICP? - CORRECT ANSWERS altered LOC, headache, abnormal
reathing, rise in bp, slow pulse, vomiting
client who has a TIA is often placed on - CORRECT ANSWERS prophylactic antithrombotic treatment
like aspirin or clopidogrel
, NCLEX UWorld 2024–2025 Questions and Answers
– Verified 100% Correct | A+ Graded Exam Prep
glascow coma scale ranges from - CORRECT ANSWERS 3-15; 3 being worst 15 being best condition (8
or below in a coma)
what are the 3 components? - CORRECT ANSWERS eye opening
motor response
verbal response
what is a primary component in TPN? - CORRECT ANSWERS *glucose,* so the nurse should be
monitoring blood glucose and be assessing for signs of hyperglycemia
when a client is on TPN, the nurse must assess for hyperglycemia why? - CORRECT ANSWERS bc a
primary component is glucose. therefore the nurse must be assessing to see if the client is getting
too much glucose (hoerglycemia). and with a large urinary output like 4800, this could indicate
symptoms of hyperglycemia
signs of hyperglycemia - CORRECT ANSWERS - polydipsia,
- polyuria,
- restless,
- confused,
- bg over 200,
- fatigue,
- headache
- blurred vision
- kussmaul resp
Interventions to resolve TPN-associated hyperglycemia - CORRECT ANSWERS - reduce amount of
carbohydrate in TPN solution
- slow down infusion rate
- administer subcutaneous insulin
what is the goal for mass casualty events? - CORRECT ANSWERS do the greatest good for the greatest
number of people
– Verified 100% Correct | A+ Graded Exam Prep
Appropriate order of actions when client found on floor - CORRECT ANSWERS 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 ANSWERS 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 ANSWERS 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 ANSWERS 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
,NCLEX UWorld 2024–2025 Questions and Answers
– Verified 100% Correct | A+ Graded Exam Prep
When do *advanced directives* go into effect? - CORRECT ANSWERS 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 ANSWERS 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
what medications interact with grapefruit? - CORRECT ANSWERS 1. *calcium channel blockers*
(diltiazem, nifedipine, verapamil, etc)
2. *statins*
3. *SSRIs*
Risk associated with *stent placement* using the *femoral approach* - CORRECT ANSWERS
*retroperitoneal hemorrhage*
what are early signs of bleeding into the retroperitoneal space? - CORRECT ANSWERS 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 ANSWERS bruising of the flanks and
retroperitoneal hemorrhage and is a bluish color
what are some physical signs of peripheral arterial disease? - CORRECT ANSWERS 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)
,NCLEX UWorld 2024–2025 Questions and Answers
– Verified 100% Correct | A+ Graded Exam Prep
transplanted hearts are expected to be - CORRECT ANSWERS tachycardic like 90-110
what is the priority intervention for pain with sickle cell crisis and why? - CORRECT ANSWERS
administer IV fluids to reduce blood viscosity and restore perfusion to areas affected by
vasoocclusion
what is the purpose of continuous bladder irrigation? - CORRECT ANSWERS 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? - CORRECT ANSWERS monitor quality of drainage, titrate
the inflow rate, and manurally irrigating as needed
characteristics of a basilar skull fracture - CORRECT ANSWERS periorbital hematomas (raccoon eyes),
csf fluid rhinorrhea, and battle sign (behind the ear bruising)
immediate client care for basilar skull fracture - CORRECT ANSWERS cervical spime immobilization,
close neurologic monitoring, and support of ABCs
vomiting with intake may mean - CORRECT ANSWERS viral or bacterial infection
tympanosomty tubes are placed for - CORRECT ANSWERS recurrent otis medias
nurse actions during a seizure - CORRECT ANSWERS 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 musclec ontractions can occur during a seizure
what are some early symptoms of ICP? - CORRECT ANSWERS altered LOC, headache, abnormal
reathing, rise in bp, slow pulse, vomiting
client who has a TIA is often placed on - CORRECT ANSWERS prophylactic antithrombotic treatment
like aspirin or clopidogrel
, NCLEX UWorld 2024–2025 Questions and Answers
– Verified 100% Correct | A+ Graded Exam Prep
glascow coma scale ranges from - CORRECT ANSWERS 3-15; 3 being worst 15 being best condition (8
or below in a coma)
what are the 3 components? - CORRECT ANSWERS eye opening
motor response
verbal response
what is a primary component in TPN? - CORRECT ANSWERS *glucose,* so the nurse should be
monitoring blood glucose and be assessing for signs of hyperglycemia
when a client is on TPN, the nurse must assess for hyperglycemia why? - CORRECT ANSWERS bc a
primary component is glucose. therefore the nurse must be assessing to see if the client is getting
too much glucose (hoerglycemia). and with a large urinary output like 4800, this could indicate
symptoms of hyperglycemia
signs of hyperglycemia - CORRECT ANSWERS - polydipsia,
- polyuria,
- restless,
- confused,
- bg over 200,
- fatigue,
- headache
- blurred vision
- kussmaul resp
Interventions to resolve TPN-associated hyperglycemia - CORRECT ANSWERS - reduce amount of
carbohydrate in TPN solution
- slow down infusion rate
- administer subcutaneous insulin
what is the goal for mass casualty events? - CORRECT ANSWERS do the greatest good for the greatest
number of people
