UWORLD: ASSESSMENT #2 QUESTIONS AND ANSWERS

UWORLD NCLEX-RN TEST 2
QUESTIONS AND ANSWERS




A0nurse0coworker0is0called0into0work0from0home0to0help0care0for0an0influx0of0clients0b
eing0admitted0after0a0bus0accident.0While0assisting0the0coworker0prepare0for0incoming
0clients,0the0nurse0becomes0concerned0that0the0coworker0may0be0under0the0influence
0of0an0impairing0substance.0Which0action0by0the0nurse0is0best?
1.
Ask0another0coworker0to0observe0the0individual0to0confirm0the0suspicion
2.
Confront0the0coworker0about0the0concern0and0offer0emotional0support
3.
Speak0with0the0nursing0supervisor0about0the0concern
4.
Telephone0the0appropriate0regulatory0agency0and0make0a0report0-0ans✔3.

A0nurse0is0administering0a0rituximab0infusion0to0a0client0with0lymphoma0in0an0oncolog
y0clinic.0Which0client0symptom0would0be0a0priority0to0report0to0the0health0care0provider
?
1.
Dizziness0and0sudden0diarrhea
2.
Nausea0and0onset0of0vomiting
3.
New-onset0tachypnea0and0dyspnea
4.
Temperature0of01010F0(38.30C)0-0ans✔3.

The0student0nurse0plans0postmortem0care0for0an0Orthodox0Jewish0client0hospitalized0f
or0the0last0week0with0heart0failure0who0did0not0sign0consents0for0any0postmortem0acti
ons.0Which0statement0by0the0student0would0require0further0education0by0the0supervisi
ng0nurse?
1.
"I0will0allow0the0family0to0remain0with0the0client0at0all0times."
2.
"I0will0call0the0next0of0kin0before0providing0any0postmortem0care."

,3.
"I0will0prepare0the0client0for0transfer0to0the0morgue0for0autopsy."
4.
"I0will0provide0a0sheet0to0be0placed0over0the0client's0face."0-0ans✔3.

The0nurse0is0caring0for0a0client0with0chronic0pancreatitis.0Which0meal0should0the0nurs
e0recommend0when0assisting0the0client0in0selecting0food0items0from0a0menu?
1.
Baked0tilapia0with0lemon0wedge,0sweet0potatoes,0and0green0peas
2.
Cream0of0potato0soup0and0roast0beef0sandwich0on0a0croissant
3.
Sautéed0salmon,0macaroni0and0cheese,0string0beans,0and0a0biscuit
4.
Shrimp0enchiladas0with0tomato0salsa,0rice,0cornbread,0and0refried0beans0-0ans✔1.

The0nurse0is0preparing0to0change0the0dressing0of0a0client's0subclavian0central0venous
0catheter0using0a0chlorhexidine0gluconate0(CHG)-
impregnated0patch0and0transparent0adhesive0dressing.0Place0the0procedural0steps0in0t
he0correct0order.0All0options0must0be0used.

Apply0CHG0patch0over0catheter0insertion0site0and0cover0with0a0sterile0transparent0dre
ssing

Cleanse0the0site0with0CHG0for0at0least0300seconds0using0friction;0allow0to0air0dry0com
pletely

Discard0the0clean0gloves,0perform0hand0hygiene,0and0apply0sterile0gloves

Perform0hand0hygiene,0don0face0mask,0place0a0mask0on0the0client,0and0apply0clean0g
loves

Remove0old0dressing0and0CHG-impregnated0patch;0assess0insertion0site0-
0ans✔Perform0hand0hygiene,0don0face0mask,0place0a0mask0on0the0client,0and0apply0c
lean0gloves

Remove0old0dressing0and0CHG-impregnated0patch;0assess0insertion0site

Discard0the0clean0gloves,0perform0hand0hygiene,0and0apply0sterile0gloves

Cleanse0the0site0with0CHG0for0at0least0300seconds0using0friction;0allow0to0air0dry0com
pletely

Apply0CHG0patch0over0catheter0insertion0site0and0cover0with0a0sterile0transparent0dre
ssing

,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.
Refer0the0UAP0to0the0occupational0health0department0for0postexposure0prophylaxis
4.
Send0the0UAP0to0the0facility's0emergency0department0for0medical0evaluation0-0ans✔1.

The0nurse0prepares0to0administer0a0client's0scheduled0prandial0regular0insulin0plus0a0c
orrectional0dose0based0on0a0sliding0scale0as0the0client's0breakfast0tray0arrives.0The0cli
ent's0fasting0blood0glucose0level0is02100mg/dL0(11.70mmol/
L).0How0many0total0units0of0regular0insulin0should0the0nurse0administer?
0Click0the0exhibit0button0for0additional0information.0Record0your0answer0using0a0whole
0number.


EXHIBIT:
Medication0administration0record:
Allergies:0NKA

Medications:
-Regular0insulin:040units0subcutaneously0with0each0meal0(0800,01200,01700)

-Regular0insulin:0per0sliding0scale,0subcutaneously0with0each0meal0and0before0bed0
(0800,01200,01700,02100)0

Sliding-Scale0Blood0Glucose0Levels:
<1500mg/dL0-000units
150-1990mg/dL0-030units
200-2490mg/dL0-060units
250-2990mg/dL0-090units

, 300-3490mg/dL0-0120units
≥3500mg/dL0-0150units;0notify0HCP0-0ans✔Answer:0100(units)

The0nurse0is0caring0for0a0client0taking0escitalopram0who0reports0no0improvement0of0d
epressive0feelings0since0starting0the0medication020months0ago.0What0is0the0best0resp
onse0by0the0nurse?
1.
"Have0you0had0any0recent0changes0or0added0stresses0in0your0life?"
2.
"It0is0too0early0to0notice0any0difference.0Please0continue0to0take0the0medicine0as0pres
cribed."
3.
"Let's0talk0more0about0how0you0have0been0taking0this0medication."
4.
"We0will0talk0with0your0health0care0provider0about0changing0the0prescription."0-
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't0have0to0talk0about0this0right0now."0-0ans✔3.

The0nurse0is0assisting0with0a0presentation0on0protecting0clients'0privacy0and0confidenti
ality.0Which0of0the0following0incidents0does0the0nurse0recognize0as0a0violation0of0client
0confidentiality?0Select0all0that0apply.
1.