UWorld NCLEX-RN
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
the nurse clients,
becomes concerned that the coworker may be under the
impairing
influence of an 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
Correct answers
3.Speak with the nursing supervisor about the
concern
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) Correct
answers 3. tachypnea and
New-onset
dyspnea
The student nurse plans postmortem care for an Orthodox Jewish client
hospitalized
the last weekfor with heart failure who did not sign consents for any
postmortem
Which actions.
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." Correct
answers
"I 3.
will prepare the client for transfer to the morgue for
autopsy."
,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 Correct
answers
1.
Baked tilapia with lemon wedge, sweet potatoes, and
green peas
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
used must be
.
Apply CHG patch over catheter insertion site and cover with a sterile
transparent
dressin
g
Cleanse the site with CHG for at least 30 seconds using friction; allow
to air dry
completel
y
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
glove clean
s
Remove old dressing and CHG-impregnated patch; assess insertion
site Correct
answers 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
completel
y
Apply CHG patch over catheter insertion site and cover with a sterile
transparent
dressin
g
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 Correct
answers 3.
12-month-old who was wheezing at home and is now lethargic with no
wheezing
Educational objective:A client who suddenly stops wheezing may be
experiencing
impending respiratory failure and should be assessed
immediately.
The unlicensed assistive personnel (UAP) reports being splashed in the
eye while urine from the catheter bag of a client with AIDS. The UAP
emptying
is afraid ofinfected with HIV and requests immediate testing. What is the
becoming
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 Correct
answers
1.
Direct the UAP to immediately flush the eye with water at the unit's
eyewash station
The nurse prepares to administer a client's scheduled prandial regular
insulin plus adose based on a sliding scale as the client's breakfast tray
correctional
arrives. fasting
client's The blood glucose level is 210 mg/dL (11.7 mmol/L). How many
total units
regular insulin
of should the nurse administer? Click the exhibit button for
additional
information. Record your answer using a whole
number.
EXHIBIT:
Medication administration
record:
Allergies:
NKA
Medication
s:
-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 Correct answers Answer:
10 (units)
The nurse is caring for a client taking escitalopram who reports no
improvement
depressive of
feelings since starting the medication 2 months ago. What
is the bestby the
response
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." Correct
answers
3.
"Let's talk more about how you have been taking this
medication."
The nurse reinforces teaching to the parents of a 12-month-old who has
begun
from weaning
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
3 milk."
."I should discourage my child from drinking milk to increase solid
food intake."
4
."I will stop breastfeeding completely to expedite the weaning process."
Correct answers
2
."I can start substituting breastfeeding sessions with whole
cow's milk."
The home health nurse is discussing the care needs of a client in the
last stage ofdisease with the family. When the nurse recommends a
Huntington
hospitalspouse
client's bed, thebecomes visibly upset and says, "No hospital bed. I'm just
not
it ready
yet." for is the best response by the
What
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
4
bed?"
."You seem upset. We don't have to talk about this right now." Correct
answers 3.
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
the nurse clients,
becomes concerned that the coworker may be under the
impairing
influence of an 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
Correct answers
3.Speak with the nursing supervisor about the
concern
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) Correct
answers 3. tachypnea and
New-onset
dyspnea
The student nurse plans postmortem care for an Orthodox Jewish client
hospitalized
the last weekfor with heart failure who did not sign consents for any
postmortem
Which actions.
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." Correct
answers
"I 3.
will prepare the client for transfer to the morgue for
autopsy."
,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 Correct
answers
1.
Baked tilapia with lemon wedge, sweet potatoes, and
green peas
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
used must be
.
Apply CHG patch over catheter insertion site and cover with a sterile
transparent
dressin
g
Cleanse the site with CHG for at least 30 seconds using friction; allow
to air dry
completel
y
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
glove clean
s
Remove old dressing and CHG-impregnated patch; assess insertion
site Correct
answers 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
completel
y
Apply CHG patch over catheter insertion site and cover with a sterile
transparent
dressin
g
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 Correct
answers 3.
12-month-old who was wheezing at home and is now lethargic with no
wheezing
Educational objective:A client who suddenly stops wheezing may be
experiencing
impending respiratory failure and should be assessed
immediately.
The unlicensed assistive personnel (UAP) reports being splashed in the
eye while urine from the catheter bag of a client with AIDS. The UAP
emptying
is afraid ofinfected with HIV and requests immediate testing. What is the
becoming
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 Correct
answers
1.
Direct the UAP to immediately flush the eye with water at the unit's
eyewash station
The nurse prepares to administer a client's scheduled prandial regular
insulin plus adose based on a sliding scale as the client's breakfast tray
correctional
arrives. fasting
client's The blood glucose level is 210 mg/dL (11.7 mmol/L). How many
total units
regular insulin
of should the nurse administer? Click the exhibit button for
additional
information. Record your answer using a whole
number.
EXHIBIT:
Medication administration
record:
Allergies:
NKA
Medication
s:
-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 Correct answers Answer:
10 (units)
The nurse is caring for a client taking escitalopram who reports no
improvement
depressive of
feelings since starting the medication 2 months ago. What
is the bestby the
response
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." Correct
answers
3.
"Let's talk more about how you have been taking this
medication."
The nurse reinforces teaching to the parents of a 12-month-old who has
begun
from weaning
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
3 milk."
."I should discourage my child from drinking milk to increase solid
food intake."
4
."I will stop breastfeeding completely to expedite the weaning process."
Correct answers
2
."I can start substituting breastfeeding sessions with whole
cow's milk."
The home health nurse is discussing the care needs of a client in the
last stage ofdisease with the family. When the nurse recommends a
Huntington
hospitalspouse
client's bed, thebecomes visibly upset and says, "No hospital bed. I'm just
not
it ready
yet." for is the best response by the
What
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
4
bed?"
."You seem upset. We don't have to talk about this right now." Correct
answers 3.
