UWORLD NCLEX-RN TEST 2
QUESTIONS AND ANSWERS
Four0clients0enter0the0pediatric0emergency0department0at0the0same0time.0Which0client
0should0the0nurse0see0first?
1.
2-week-old0with0tricuspid0atresia0who0has0dusky0lips0and0nailbeds
2.
5-week-old0with0forceful0vomiting0after0every0feeding0who0is0crying
3.
12-month-old0who0was0wheezing0at0home0and0is0now0lethargic0with0no0wheezing
4.
3-year-old0with0fever0who0had0a0brief0seizure0at0home0and0is0asleep0-0ans✔3.
The0unlicensed0assistive0personnel0(UAP)0reports0being0splashed0in0the0eye0while0em
ptying0urine0from0the0catheter0bag0of0a0client0with0AIDS.0The0UAP0is0afraid0of0becomi
ng0infected0with0HIV0and0requests0immediate0testing.0What0is0the0nurse's0priority0actio
n?
1.
Direct0the0UAP0to0immediately0flush0the0eye0with0water0at0the0unit's0eyewash0station
2.
Reassure0the0UAP0that0the0risk0for0HIV0is0low0as0urine0does0not0transmit0the0virus
3.
Refer0the0UAP0to0the0occupational0health0department0for0postexpos0-0ans✔1.
The0nurse0prepares0to0administer0a0client's0scheduled0prandial0regular0insulin0plus0a0c
orrectional0dose0based0on0a0sliding0scale0as0the0client's0breakfast0tray0arrives.0The0cli
ent's0fasting0blood0glucose0level0is02100mg/dL0(11.70mmol/
L).0How0many0total0units0of0regular0insulin0should0the0nurse0administer?
0Click0the0exhibit0button0for0additional0information.0Record0your0answer0using0a0whole
0number.
EXHIBIT:
Medication0administration0record:
Allergies:0NKA
Medications:
,-Regular0insulin:040units0-0ans✔Answer:0100(units)
The0nurse0is0caring0for0a0client0taking0escitalopram0who0reports0no0improvement0of0d
epressive0feelings0since0starting0the0medication020months0ago.0What0is0the0best0resp
onse0by0the0nurse?
1.
"Have0you0had0any0recent0changes0or0added0stresses0in0your0life?"
2.
"It0is0too0early0to0notice0any0difference.0Please0continue0to0take0the0medicine0as0pres
cribed."
3.
"Let's0talk0more0about0how0you0have0been0taking0this0medication."
4.
"We0will0talk0with0your0health0care0provider0about0changing0the0prescript0-0ans✔3.
The0nurse0reinforces0teaching0to0the0parents0of0a012-month-
old0who0has0begun0weaning0from0breastfeeding.0Which0statement0by0the0parents0indi
cates0that0teaching0has0been0effective?
1.
"I0can0allow0my0child0to0sleep0with0a0bottle0for0comfort0while0weaning."
2.
"I0can0start0substituting0breastfeeding0sessions0with0whole0cow's0milk."
3.
"I0should0discourage0my0child0from0drinking0milk0to0increase0solid0food0intake."
4.
"I0will0stop0breastfeeding0completely0to0expedite0the0weaning0process."0-0ans✔2.
The0home0health0nurse0is0discussing0the0care0needs0of0a0client0in0the0last0stage0of0H
untington0disease0with0the0family.0When0the0nurse0recommends0a0hospital0bed,0the0cl
ient's0spouse0becomes0visibly0upset0and0says,0"No0hospital0bed.0I'm0just0not0ready0for
0it0yet."0What0is0the0best0response0by0the0nurse?
1.
"A0hospital0bed0will0make0your0spouse's0care0easier."
2.
"Are0you0not0ready0for0this0particular0change?"
3.
"What0upsets0you0about0having0a0hospital0bed?"
4.
"You0seem0upset.0We0don't0have0to0t0-0ans✔3.
The0nurse0is0assisting0with0a0presentation0on0protecting0clients'0privacy0and0confidenti
ality.0Which0of0the0following0incidents0does0the0nurse0recognize0as0a0violation0of0client
0confidentiality?0Select0all0that0apply.
1.
A0family0member0informs0the0registered0nurse0that0the0client0has0not0been0taking0the0
prescribed0metformin0at0home
, 2.
An0oncology0nurse0reviews0the0electronic0health0record0of0a0client0in0the0emergency0d
epartment0who0was0the0victim0of0a0recent0mass0shooting0event
3.
The0licensed0-0ans✔2,03,05
A0nurse0is0screening0clients0for0skin0cancer.0Which0assessment0would0be0most0conce
rning?
1.
Client0with0a0blue0and0black,0irregular0papule0on0the0hand
2.
Client0with0a0pearly,0pink0papule0with0ulceration0on0the0ear
3.
Client0with0a0pink0patch0with0silvery0scales0on0the0neck
4.
Client0with0a0red,0scaly0patch0with0rough0edges0on0the0forehead0-0ans✔1
The0nurse0determines0that0a0client0with0incontinence0and0limited0mobility0is0at0increas
ed0risk0for0skin0breakdown0and0pressure0injury.0While0caring0for0this0client,0which0of0t
he0following0nursing0interventions0are0appropriate?0Select0all0that0apply.
1.
Applying0moisture0barrier0cream0to0the0skin0after0performing0perineal0care
2.
Providing0a0diet0that0is0high0in0protein0and0contains0adequate0calories
3.
Repositioning0the0client0using0a0turn0sheet0every020hours
4.
Restricting0fluid0intake0to0≤20-0ans✔1,02,03,05
The0client0admitted0to0the0psychiatric0unit0with0severe0anxiety0is0pacing0rapidly0in0the0
room,0crying,0and0hyperventilating.0The0client0yells,0"I0can't0believe0you0took0my0belon
gings!0Where0are0you0keeping0them?
0This0is0so0frustrating!"0What0is0the0appropriate0response0by0the0nurse?
1.
"I0understand0that0you0are0frustrated.0I0will0give0you0some0time0to0yourself0to0decompr
ess."
2.
"This0is0frustrating0for0me0too.0I0wish0I0could0give0you0your0belongings0right0now,0but0I
0can't."
3.
"Would0you0like0-0ans✔4
The0nurse0is0caring0for0a0client0who0is020days0postoperative0craniotomy0with0bone0fla
p0removal.0The0nurse0notes0clear0wound0drainage0saturating0the0dressing0over0the0in
cision.0Which0action0by0the0nurse0is0most0appropriate0at0this0time?
1.
QUESTIONS AND ANSWERS
Four0clients0enter0the0pediatric0emergency0department0at0the0same0time.0Which0client
0should0the0nurse0see0first?
1.
2-week-old0with0tricuspid0atresia0who0has0dusky0lips0and0nailbeds
2.
5-week-old0with0forceful0vomiting0after0every0feeding0who0is0crying
3.
12-month-old0who0was0wheezing0at0home0and0is0now0lethargic0with0no0wheezing
4.
3-year-old0with0fever0who0had0a0brief0seizure0at0home0and0is0asleep0-0ans✔3.
The0unlicensed0assistive0personnel0(UAP)0reports0being0splashed0in0the0eye0while0em
ptying0urine0from0the0catheter0bag0of0a0client0with0AIDS.0The0UAP0is0afraid0of0becomi
ng0infected0with0HIV0and0requests0immediate0testing.0What0is0the0nurse's0priority0actio
n?
1.
Direct0the0UAP0to0immediately0flush0the0eye0with0water0at0the0unit's0eyewash0station
2.
Reassure0the0UAP0that0the0risk0for0HIV0is0low0as0urine0does0not0transmit0the0virus
3.
Refer0the0UAP0to0the0occupational0health0department0for0postexpos0-0ans✔1.
The0nurse0prepares0to0administer0a0client's0scheduled0prandial0regular0insulin0plus0a0c
orrectional0dose0based0on0a0sliding0scale0as0the0client's0breakfast0tray0arrives.0The0cli
ent's0fasting0blood0glucose0level0is02100mg/dL0(11.70mmol/
L).0How0many0total0units0of0regular0insulin0should0the0nurse0administer?
0Click0the0exhibit0button0for0additional0information.0Record0your0answer0using0a0whole
0number.
EXHIBIT:
Medication0administration0record:
Allergies:0NKA
Medications:
,-Regular0insulin:040units0-0ans✔Answer:0100(units)
The0nurse0is0caring0for0a0client0taking0escitalopram0who0reports0no0improvement0of0d
epressive0feelings0since0starting0the0medication020months0ago.0What0is0the0best0resp
onse0by0the0nurse?
1.
"Have0you0had0any0recent0changes0or0added0stresses0in0your0life?"
2.
"It0is0too0early0to0notice0any0difference.0Please0continue0to0take0the0medicine0as0pres
cribed."
3.
"Let's0talk0more0about0how0you0have0been0taking0this0medication."
4.
"We0will0talk0with0your0health0care0provider0about0changing0the0prescript0-0ans✔3.
The0nurse0reinforces0teaching0to0the0parents0of0a012-month-
old0who0has0begun0weaning0from0breastfeeding.0Which0statement0by0the0parents0indi
cates0that0teaching0has0been0effective?
1.
"I0can0allow0my0child0to0sleep0with0a0bottle0for0comfort0while0weaning."
2.
"I0can0start0substituting0breastfeeding0sessions0with0whole0cow's0milk."
3.
"I0should0discourage0my0child0from0drinking0milk0to0increase0solid0food0intake."
4.
"I0will0stop0breastfeeding0completely0to0expedite0the0weaning0process."0-0ans✔2.
The0home0health0nurse0is0discussing0the0care0needs0of0a0client0in0the0last0stage0of0H
untington0disease0with0the0family.0When0the0nurse0recommends0a0hospital0bed,0the0cl
ient's0spouse0becomes0visibly0upset0and0says,0"No0hospital0bed.0I'm0just0not0ready0for
0it0yet."0What0is0the0best0response0by0the0nurse?
1.
"A0hospital0bed0will0make0your0spouse's0care0easier."
2.
"Are0you0not0ready0for0this0particular0change?"
3.
"What0upsets0you0about0having0a0hospital0bed?"
4.
"You0seem0upset.0We0don't0have0to0t0-0ans✔3.
The0nurse0is0assisting0with0a0presentation0on0protecting0clients'0privacy0and0confidenti
ality.0Which0of0the0following0incidents0does0the0nurse0recognize0as0a0violation0of0client
0confidentiality?0Select0all0that0apply.
1.
A0family0member0informs0the0registered0nurse0that0the0client0has0not0been0taking0the0
prescribed0metformin0at0home
, 2.
An0oncology0nurse0reviews0the0electronic0health0record0of0a0client0in0the0emergency0d
epartment0who0was0the0victim0of0a0recent0mass0shooting0event
3.
The0licensed0-0ans✔2,03,05
A0nurse0is0screening0clients0for0skin0cancer.0Which0assessment0would0be0most0conce
rning?
1.
Client0with0a0blue0and0black,0irregular0papule0on0the0hand
2.
Client0with0a0pearly,0pink0papule0with0ulceration0on0the0ear
3.
Client0with0a0pink0patch0with0silvery0scales0on0the0neck
4.
Client0with0a0red,0scaly0patch0with0rough0edges0on0the0forehead0-0ans✔1
The0nurse0determines0that0a0client0with0incontinence0and0limited0mobility0is0at0increas
ed0risk0for0skin0breakdown0and0pressure0injury.0While0caring0for0this0client,0which0of0t
he0following0nursing0interventions0are0appropriate?0Select0all0that0apply.
1.
Applying0moisture0barrier0cream0to0the0skin0after0performing0perineal0care
2.
Providing0a0diet0that0is0high0in0protein0and0contains0adequate0calories
3.
Repositioning0the0client0using0a0turn0sheet0every020hours
4.
Restricting0fluid0intake0to0≤20-0ans✔1,02,03,05
The0client0admitted0to0the0psychiatric0unit0with0severe0anxiety0is0pacing0rapidly0in0the0
room,0crying,0and0hyperventilating.0The0client0yells,0"I0can't0believe0you0took0my0belon
gings!0Where0are0you0keeping0them?
0This0is0so0frustrating!"0What0is0the0appropriate0response0by0the0nurse?
1.
"I0understand0that0you0are0frustrated.0I0will0give0you0some0time0to0yourself0to0decompr
ess."
2.
"This0is0frustrating0for0me0too.0I0wish0I0could0give0you0your0belongings0right0now,0but0I
0can't."
3.
"Would0you0like0-0ans✔4
The0nurse0is0caring0for0a0client0who0is020days0postoperative0craniotomy0with0bone0fla
p0removal.0The0nurse0notes0clear0wound0drainage0saturating0the0dressing0over0the0in
cision.0Which0action0by0the0nurse0is0most0appropriate0at0this0time?
1.
