NCLEX UWorld 2025 Complete
Questions And Answers | Verified
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
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
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)
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
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
keep in mind that disaster triage ranks the likelihood of survival with treatment, not
necessarily the severity of the injury CORRECT ANSWERS
what are the 4 categories for triaging? CORRECT ANSWERS immediate (red tag)- life
threatening injuries with good prognosis once treated
delayed (yellow)- injuries requiring treatment within hours
minimal (green tag)- injuries requiring treatment within a few days
expectant (black tag)- extensive injuries, poor prognosis regardless of treatment
rule of nines CORRECT ANSWERS head: 4.5 front 4.5 back
torso: 18 front 18 back
each arm: 4.5 front 4.5 back (each arm is 9 total)
each leg: 9 front 8 back (each is 18 total)
genitals: 1
extrapyramidal side effects CORRECT ANSWERS ACUTE DYSTONIC REACTION:
sudden onset sustained muscle contractions
AKATHISIA: restlessness with inability to sit still
drug induce PARKINSONISM: tremor, rigidity, bradykinies, masked like faces
AKINISIA: loss of involuntary movement
TARDIVE DYSKININIA
NEUROLEPTIC MALIGNANT SYNDROME
dont give morphine if RR under 12 bc it can cause CORRECT ANSWERS respiratory
depression
airborne precautions CORRECT ANSWERS tuberculosis, varicella, and rubeola
(measles)
wear N95 respirator (and other as needed like for splashes)
ALSO (neg pressure room and HEPA)
clients suspected are to wear a surgical mask after triage
UAP soft wrist restraints can: CORRECT ANSWERS do ROM exercises
reapply wrist restraints
report changes in skin to nurse
turn/reposition client in bed
a client with major depression and severe weight loss needs what type of diet?
CORRECT ANSWERS high in calories and protein, also foods that are easy to chew
and dont require a lot of energy bc they may have a low energy level
examples: while milk/dairy, granola muffins, pottoes, meat fish eggs, pasta
also small frequent meals
Questions And Answers | Verified
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
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
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)
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
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
keep in mind that disaster triage ranks the likelihood of survival with treatment, not
necessarily the severity of the injury CORRECT ANSWERS
what are the 4 categories for triaging? CORRECT ANSWERS immediate (red tag)- life
threatening injuries with good prognosis once treated
delayed (yellow)- injuries requiring treatment within hours
minimal (green tag)- injuries requiring treatment within a few days
expectant (black tag)- extensive injuries, poor prognosis regardless of treatment
rule of nines CORRECT ANSWERS head: 4.5 front 4.5 back
torso: 18 front 18 back
each arm: 4.5 front 4.5 back (each arm is 9 total)
each leg: 9 front 8 back (each is 18 total)
genitals: 1
extrapyramidal side effects CORRECT ANSWERS ACUTE DYSTONIC REACTION:
sudden onset sustained muscle contractions
AKATHISIA: restlessness with inability to sit still
drug induce PARKINSONISM: tremor, rigidity, bradykinies, masked like faces
AKINISIA: loss of involuntary movement
TARDIVE DYSKININIA
NEUROLEPTIC MALIGNANT SYNDROME
dont give morphine if RR under 12 bc it can cause CORRECT ANSWERS respiratory
depression
airborne precautions CORRECT ANSWERS tuberculosis, varicella, and rubeola
(measles)
wear N95 respirator (and other as needed like for splashes)
ALSO (neg pressure room and HEPA)
clients suspected are to wear a surgical mask after triage
UAP soft wrist restraints can: CORRECT ANSWERS do ROM exercises
reapply wrist restraints
report changes in skin to nurse
turn/reposition client in bed
a client with major depression and severe weight loss needs what type of diet?
CORRECT ANSWERS high in calories and protein, also foods that are easy to chew
and dont require a lot of energy bc they may have a low energy level
examples: while milk/dairy, granola muffins, pottoes, meat fish eggs, pasta
also small frequent meals
