UWORLD NCLEX-RN TEST 2
QUESTIONS AND ANSWERS. VERIFIED
1. A nurse is triaging victims at the scene of a multi-vehicle accident. Which client should be
assigned a ‘black tag’?
A. A client with a compound fracture of the femur and a pulse of 110/min
B. A client with a closed head injury who is confused but follows commands
C. A client with a sucking chest wound and a respiratory rate of 26/min
D. A client with full-thickness burns over 80% of the body who is unresponsive and apneic
Answer: D
Conceptual Explanation: In disaster triage, the ‘black tag’ (expectant) is assigned to
victims who are deceased or have injuries so severe they are not expected to survive even
with care, such as apnea or massive burns.
2. A client with bipolar disorder is taking lithium. The nurse notes a serum lithium level of 1.8
mEq/L. Which action is the priority?
A. Hold the dose and notify the healthcare provider immediately
B. Continue to monitor the client for therapeutic effects
,C. Administer the next scheduled dose
D. Increase fluid intake to 3 liters per day
Answer: A
Conceptual Explanation: The therapeutic range for lithium is 0.6-1.2 mEq/L. A level of 1.8
mEq/L indicates toxicity. The nurse must hold the medication and notify the provider.
3. Following a thyroidectomy, a client reports tingling in the fingers and around the mouth.
Which medication should the nurse have available?
A. Potassium chloride
B. Sodium bicarbonate
C. Magnesium sulfate
D. Calcium gluconate
Answer: D
Conceptual Explanation: Tingling (paresthesia) is a sign of hypocalcemia, which can occur
if the parathyroid glands are accidentally removed or damaged during a thyroidectomy.
Calcium gluconate is the treatment.
4. Which clinical finding is classic for a child diagnosed with intussusception?
A. Stools mixed with blood and mucus (currant jelly)
B. Projectile vomiting immediately after feeding
C. Ribbon-like, foul-smelling stools
, D. Pain in the lower right quadrant with rebound tenderness
Answer: A
Conceptual Explanation: Intussusception causes intestinal obstruction where one
segment of the bowel slides into another. The classic symptom is ‘currant jelly’ stools due
to blood and mucus.
5. A client on warfarin therapy has an International Normalized Ratio (INR) of 5.0. What
should the nurse anticipate administering?
A. Protamine sulfate
B. Heparin sodium
C. Enoxaparin
D. Vitamin K
Answer: D
Conceptual Explanation: Vitamin K is the antidote for warfarin. An INR of 5.0 is above the
therapeutic range (usually 2.0-3.0), increasing the risk of bleeding.
6. A client with preeclampsia is receiving magnesium sulfate. Which assessment finding
indicates magnesium toxicity?
A. Respiratory rate of 10 breaths/min
B. Urinary output of 50 mL/hr
C. Hyperactive deep tendon reflexes
QUESTIONS AND ANSWERS. VERIFIED
1. A nurse is triaging victims at the scene of a multi-vehicle accident. Which client should be
assigned a ‘black tag’?
A. A client with a compound fracture of the femur and a pulse of 110/min
B. A client with a closed head injury who is confused but follows commands
C. A client with a sucking chest wound and a respiratory rate of 26/min
D. A client with full-thickness burns over 80% of the body who is unresponsive and apneic
Answer: D
Conceptual Explanation: In disaster triage, the ‘black tag’ (expectant) is assigned to
victims who are deceased or have injuries so severe they are not expected to survive even
with care, such as apnea or massive burns.
2. A client with bipolar disorder is taking lithium. The nurse notes a serum lithium level of 1.8
mEq/L. Which action is the priority?
A. Hold the dose and notify the healthcare provider immediately
B. Continue to monitor the client for therapeutic effects
,C. Administer the next scheduled dose
D. Increase fluid intake to 3 liters per day
Answer: A
Conceptual Explanation: The therapeutic range for lithium is 0.6-1.2 mEq/L. A level of 1.8
mEq/L indicates toxicity. The nurse must hold the medication and notify the provider.
3. Following a thyroidectomy, a client reports tingling in the fingers and around the mouth.
Which medication should the nurse have available?
A. Potassium chloride
B. Sodium bicarbonate
C. Magnesium sulfate
D. Calcium gluconate
Answer: D
Conceptual Explanation: Tingling (paresthesia) is a sign of hypocalcemia, which can occur
if the parathyroid glands are accidentally removed or damaged during a thyroidectomy.
Calcium gluconate is the treatment.
4. Which clinical finding is classic for a child diagnosed with intussusception?
A. Stools mixed with blood and mucus (currant jelly)
B. Projectile vomiting immediately after feeding
C. Ribbon-like, foul-smelling stools
, D. Pain in the lower right quadrant with rebound tenderness
Answer: A
Conceptual Explanation: Intussusception causes intestinal obstruction where one
segment of the bowel slides into another. The classic symptom is ‘currant jelly’ stools due
to blood and mucus.
5. A client on warfarin therapy has an International Normalized Ratio (INR) of 5.0. What
should the nurse anticipate administering?
A. Protamine sulfate
B. Heparin sodium
C. Enoxaparin
D. Vitamin K
Answer: D
Conceptual Explanation: Vitamin K is the antidote for warfarin. An INR of 5.0 is above the
therapeutic range (usually 2.0-3.0), increasing the risk of bleeding.
6. A client with preeclampsia is receiving magnesium sulfate. Which assessment finding
indicates magnesium toxicity?
A. Respiratory rate of 10 breaths/min
B. Urinary output of 50 mL/hr
C. Hyperactive deep tendon reflexes
