NCLEX UWorld Exam(Questions Set)| 1823
Questions with Complete Solutions
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*
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
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 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
tympanosomty tubes are placed for - ANSWER recurrent otis medias
, nurse actions during a seizure - 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 musclec ontractions can occur during a
seizure
what are some early symptoms of ICP? - ANSWER altered LOC, headache, abnormal reathing,
rise in bp, slow pulse, vomiting
client who has a TIA is often placed on - ANSWER prophylactic antithrombotic treatment like
aspirin or clopidogrel
glascow coma scale ranges from - ANSWER 3-15; 3 being worst 15 being best condition (8 or
below in a coma)
what are the 3 components? - ANSWER eye opening
motor response
verbal response
what is a primary component in TPN? - ANSWER *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? - ANSWER 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 - ANSWER - polydipsia,
- polyuria,
Questions with Complete Solutions
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*
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
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 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
tympanosomty tubes are placed for - ANSWER recurrent otis medias
, nurse actions during a seizure - 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 musclec ontractions can occur during a
seizure
what are some early symptoms of ICP? - ANSWER altered LOC, headache, abnormal reathing,
rise in bp, slow pulse, vomiting
client who has a TIA is often placed on - ANSWER prophylactic antithrombotic treatment like
aspirin or clopidogrel
glascow coma scale ranges from - ANSWER 3-15; 3 being worst 15 being best condition (8 or
below in a coma)
what are the 3 components? - ANSWER eye opening
motor response
verbal response
what is a primary component in TPN? - ANSWER *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? - ANSWER 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 - ANSWER - polydipsia,
- polyuria,
