UWORLD NCLEX-RN UPDATED EXAM SCRIPT QUESTIONS
AND SOLUTIONS RATED A+
✔✔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 - ✔✔3.
✔✔The unlicensed assistive personnel (UAP) reports being splashed in the eye while
emptying urine from the catheter bag of a client with AIDS. The UAP is afraid of
becoming infected with HIV and requests immediate testing. What is the 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 - ✔✔1.
✔✔The nurse prepares to administer a client's scheduled prandial regular insulin plus a
correctional dose based on a sliding scale as the client's breakfast tray arrives. The
client's fasting blood glucose level is 210 mg/dL (11.7 mmol/L). How many total units of
regular insulin should the nurse administer? Click the exhibit button for additional
information. Record your answer using a whole number.
EXHIBIT:
Medication administration record:
Allergies: NKA
Medications:
-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 - ✔✔Answer: 10 (units)
✔✔The nurse is caring for a client taking escitalopram who reports no improvement of
depressive feelings since starting the medication 2 months ago. What is the best
response by the 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." - ✔✔3.
✔✔The nurse reinforces teaching to the parents of a 12-month-old who has begun
weaning from 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 milk."
3.
"I should discourage my child from drinking milk to increase solid food intake."
4.
"I will stop breastfeeding completely to expedite the weaning process." - ✔✔2.
✔✔The home health nurse is discussing the care needs of a client in the last stage of
Huntington disease with the family. When the nurse recommends a hospital bed, the
client's spouse becomes visibly upset and says, "No hospital bed. I'm just not ready for
it yet." What is the best response by the 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 bed?"
4.
"You seem upset. We don't have to talk about this right now." - ✔✔3.
, ✔✔The nurse is assisting with a presentation on protecting clients' privacy and
confidentiality. Which of the following incidents does the nurse recognize as a violation
of client confidentiality? Select all that apply.
1.
A family member informs the registered nurse that the client has not been taking the
prescribed metformin at home
2.
An oncology nurse reviews the electronic health record of a client in the emergency
department who was the victim of a recent mass shooting event
3.
The licensed practical nurse (LPN) leaves the client's report sheet in the cafeteria after
lunch
4.
The LPN tells the unlicensed assistive personnel (UAP) who is pregnant to not enter the
room of a client with toxoplasmosis
5.
The UAP tells a client that the hospital roommate will return to the room after receiving
hemodialysis - ✔✔2, 3, 5
✔✔A nurse is screening clients for skin cancer. Which assessment would be most
concerning?
1.
Client with a blue and black, irregular papule on the hand
2.
Client with a pearly, pink papule with ulceration on the ear
3.
Client with a pink patch with silvery scales on the neck
4.
Client with a red, scaly patch with rough edges on the forehead - ✔✔1
✔✔The nurse determines that a client with incontinence and limited mobility is at
increased risk for skin breakdown and pressure injury. While caring for this client, which
of the following nursing interventions are appropriate? Select all that apply.
1.
Applying moisture barrier cream to the skin after performing perineal care
2.
Providing a diet that is high in protein and contains adequate calories
3.
Repositioning the client using a turn sheet every 2 hours
4.
Restricting fluid intake to ≤2 L/day to reduce number of incontinent episodes
5.
Using foam padding placed under the client's legs to elevate the heels - ✔✔1, 2, 3, 5
AND SOLUTIONS RATED A+
✔✔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 - ✔✔3.
✔✔The unlicensed assistive personnel (UAP) reports being splashed in the eye while
emptying urine from the catheter bag of a client with AIDS. The UAP is afraid of
becoming infected with HIV and requests immediate testing. What is the 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 - ✔✔1.
✔✔The nurse prepares to administer a client's scheduled prandial regular insulin plus a
correctional dose based on a sliding scale as the client's breakfast tray arrives. The
client's fasting blood glucose level is 210 mg/dL (11.7 mmol/L). How many total units of
regular insulin should the nurse administer? Click the exhibit button for additional
information. Record your answer using a whole number.
EXHIBIT:
Medication administration record:
Allergies: NKA
Medications:
-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 - ✔✔Answer: 10 (units)
✔✔The nurse is caring for a client taking escitalopram who reports no improvement of
depressive feelings since starting the medication 2 months ago. What is the best
response by the 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." - ✔✔3.
✔✔The nurse reinforces teaching to the parents of a 12-month-old who has begun
weaning from 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 milk."
3.
"I should discourage my child from drinking milk to increase solid food intake."
4.
"I will stop breastfeeding completely to expedite the weaning process." - ✔✔2.
✔✔The home health nurse is discussing the care needs of a client in the last stage of
Huntington disease with the family. When the nurse recommends a hospital bed, the
client's spouse becomes visibly upset and says, "No hospital bed. I'm just not ready for
it yet." What is the best response by the 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 bed?"
4.
"You seem upset. We don't have to talk about this right now." - ✔✔3.
, ✔✔The nurse is assisting with a presentation on protecting clients' privacy and
confidentiality. Which of the following incidents does the nurse recognize as a violation
of client confidentiality? Select all that apply.
1.
A family member informs the registered nurse that the client has not been taking the
prescribed metformin at home
2.
An oncology nurse reviews the electronic health record of a client in the emergency
department who was the victim of a recent mass shooting event
3.
The licensed practical nurse (LPN) leaves the client's report sheet in the cafeteria after
lunch
4.
The LPN tells the unlicensed assistive personnel (UAP) who is pregnant to not enter the
room of a client with toxoplasmosis
5.
The UAP tells a client that the hospital roommate will return to the room after receiving
hemodialysis - ✔✔2, 3, 5
✔✔A nurse is screening clients for skin cancer. Which assessment would be most
concerning?
1.
Client with a blue and black, irregular papule on the hand
2.
Client with a pearly, pink papule with ulceration on the ear
3.
Client with a pink patch with silvery scales on the neck
4.
Client with a red, scaly patch with rough edges on the forehead - ✔✔1
✔✔The nurse determines that a client with incontinence and limited mobility is at
increased risk for skin breakdown and pressure injury. While caring for this client, which
of the following nursing interventions are appropriate? Select all that apply.
1.
Applying moisture barrier cream to the skin after performing perineal care
2.
Providing a diet that is high in protein and contains adequate calories
3.
Repositioning the client using a turn sheet every 2 hours
4.
Restricting fluid intake to ≤2 L/day to reduce number of incontinent episodes
5.
Using foam padding placed under the client's legs to elevate the heels - ✔✔1, 2, 3, 5
