Page 1 of 438
UWORLD NCLEX EXAM WITH CORRECT
ANSWERS ,RATIONALES AND WHY THE
OTHERS ARE NOT CORRECT NEWEST 2026
EXAM VERIFIED 100%
The nurse auscultates the lung sounds of a client with shortness of breath.
Then, the nurse notifies the health care provider about the adventitious
sounds heard. Which medication prescription should the nurse anticipate?
Listen to the audio clip.(Headphones are required for best audio quality.)
1) Albuterol
2) Bumetanide
3) Guafenisin
4) Methylprednisolone
Coarse crackles (loud, low-pitched bubbling) are term-102heard primarily during
inspiration and are not cleared by coughing. The sound is similar to that of Velcro
being pulled apart. Coarse crackles may be confused with fine crackles (eg,
atelectasis), which have a high-pitched, popping sound.
Coarse crackles are present when fluid or mucus collects in the lower respiratory
tract (eg, pulmonary edema, pulmonary fibrosis). During heart failure, the left
ventricle fails to eject enough blood, causing increased pressure in the pulmonary
vasculature. As a result, fluid leaks into the alveoli (pulmonary edema). Loop
diuretics (eg, bumetanide, furosemide) treat pulmonary edema by reducing
intravascular fluid volume through significant increase of fluid excretion by the
, Page 2 of 438
kidneys (Option 2).
(Options 1 and 4) Clients with asthma or chronic obstructive pulmonary disease (eg,
emphysema) develop wheezing due to bronchospasm. Bronchodilators (eg,
albuterol, ipratropium) and systemic corticosteroids (eg, methylprednisolone) may be
prescribed to these clients.
(Option 3) Clients with acute upper respiratory infections or chronic bronchitis (ie,
inflammation of the upper airways) may be prescribed guaifenesin to loosen and
improve the expectoration of mucus. Clients with chronic bronchitis typically develop
rhonchi (ie, sonorous wheezes), which are continuous, low-pitched adventitious
breath sounds that resemble moaning or snoring.
Educational objective:Auscultation of coarse crackles indicates the presence of fluid
or mucus in the lower respiratory tract. This may indicate pulmonary edema or
pulmonary fibrosis. Administration of a loop diuretic (eg, bumetanide) is appropriate
for treating pulmonary edema.
A nurse is caring for a client who had a transurethral resection of the prostate
and is receiving continuous bladder irrigation by gravity. Which of the
following tasks can the nurse delegate to unlicensed assistive personnel?
Select all that apply.
1.Calculating the difference between irrigant intake and total drainage output
2.Cleaning around the catheter insertion site daily
3.Immediately notifying the nurse if the client reports pain
4.Increasing the irrigation rate when the urine becomes more red than pink
5.Measuring the total volume of output in the drainage collection bag
Continuous bladder irrigation is prescribed following surgical transurethral resection
of the prostate and prevents obstruction of urine outflow by removing clotted blood
from the bladder. A 3-way catheter is used to continuously infuse the solution into
the bladder by gravity. The catheter drains urine, irrigant solution, and blood into a
collection bag.
The registered nurse (RN) should consider the five rights of delegation when
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delegating to unlicensed assistive personnel (UAP):
Catheter care is a routine, noncomplex task that may be safely delegated to UAP
(Option 2).
Any client reports of pain or bladder spasms to UAP should be immediately
conveyed to the RN because these symptoms may indicate obstruction (Option 3).
Measuring output is routine data measurement. UAP should report the volume to the
RN, who will determine the adequacy of drainage (Option 5).
(Option 1) Clots or kinks may obstruct drainage and cause a smaller volume of
outflow than inflow. The nurse should calculate this difference to determine the need
to reestablish patency using manual irrigation.
(Option 4) The irrigation rate should be titrated to maintain light-pink outflow drainage
with few clots. It is not within the UAP's scope of practice to titrate the inflow rate or
to monitor drainage quality.
Educational objective:To maintain patency of a continuous bladder irrigation system,
the registered nurse (RN) must monitor the quality of drainage, titrate the inflow rate,
and manually irrigate as needed. The RN may delegate routine tasks (eg, catheter
care, measuring output) to unlicensed assistive personnel.
The nurse on the antepartum unit is performing shift assessments of several
clients that are pregnant. Which client assessment is the priority to report to
the health care provider?
1. Client with gestational diabetes mellitus reporting dysuria
2.Client with hyperemesis gravidarum with a blood pressure of 95/58 mm Hg
3.Client with oligohydramnios and a reactive fetal nonstress test
4.Client with preeclampsia with 3+ reflexes and 2 beats of clonus
Clients with preeclampsia are at risk for developing preeclampsia-associated seizure
activity (eg, eclampsia) due to increased central nervous system irritability. The
presence of neurologic manifestations (eg, hyperreflexia, clonus) may indicate
worsening preeclampsia and can precede seizure activity (Option 4). This client is at
the most immediate risk of harm and is the priority to report to the health care
provider.
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To assess for clonus, the nurse firmly dorsiflexes the foot with 1 hand while
supporting the leg and ankle with the other hand. The abnormal finding of positive
clonus is identified when rhythmic, jerking "beats" of the foot are present as the foot
is released and allowed to fall back into plantar flexion.
(Option 1) Clients with gestational diabetes mellitus are more susceptible to infection
(eg, urinary tract infection, vaginal yeast infection). Although the client's report of
dysuria may indicate a urinary tract infection, the assessment findings do not indicate
immediate risk.
(Option 2) Hyperemesis gravidarum usually affects clients in the first trimester and is
characterized by severe nausea and vomiting that can lead to dehydration,
hypotension, electrolyte imbalances, and nutritional deficits. This client should be
assessed for further symptoms of hypotension (eg, dizziness, blurry vision) before
notifying the health care provider.
(Option 3) Oligohydramnios indicates low amniotic fluid, which may lead to umbilical
cord compression and fetal compromise. However, a reactive nonstress test is a
reassuring finding.
Educational objective:Hyperreflexia and clonus are abnormal findings that may
indicate worsening preeclampsia and impending seizure activity.
The nurse prepares to administer potassium chloride to a client through a
peripherally inserted IV line. Which of the following are appropriate nursing
interventions related to administration of this medication? Select all that apply.
1.
Administer as IV bolus2.Assess IV site frequently3.Assess renal function
laboratory results and urine output4.Place client on cardiac monitor5.Verify
that IV pump infusion is not >10 mEq/hr (10 mmol/hr)
Potassium chloride (KCl) is commonly prescribed to correct or prevent hypokalemia.
The normal range for serum potassium is 3.5-5.0 mEq/L (3.5-5.0 mmol/L).
Potassium is commonly lost through diarrhea, vomiting, and diuretic use. Appropriate
nursing interventions when administering KCl IV should include:
Frequent monitoring of the IV insertion site for extravasation to prevent tissue
necrosis because Potassium is a vesicant (Option 2).
Frequent monitoring of renal function laboratory results (eg, blood urea nitrogen,
creatinine) and urine output as clients with impaired renal function are unable to
excrete potassium and other electrolytes effectively, potentially leading to toxicity
UWORLD NCLEX EXAM WITH CORRECT
ANSWERS ,RATIONALES AND WHY THE
OTHERS ARE NOT CORRECT NEWEST 2026
EXAM VERIFIED 100%
The nurse auscultates the lung sounds of a client with shortness of breath.
Then, the nurse notifies the health care provider about the adventitious
sounds heard. Which medication prescription should the nurse anticipate?
Listen to the audio clip.(Headphones are required for best audio quality.)
1) Albuterol
2) Bumetanide
3) Guafenisin
4) Methylprednisolone
Coarse crackles (loud, low-pitched bubbling) are term-102heard primarily during
inspiration and are not cleared by coughing. The sound is similar to that of Velcro
being pulled apart. Coarse crackles may be confused with fine crackles (eg,
atelectasis), which have a high-pitched, popping sound.
Coarse crackles are present when fluid or mucus collects in the lower respiratory
tract (eg, pulmonary edema, pulmonary fibrosis). During heart failure, the left
ventricle fails to eject enough blood, causing increased pressure in the pulmonary
vasculature. As a result, fluid leaks into the alveoli (pulmonary edema). Loop
diuretics (eg, bumetanide, furosemide) treat pulmonary edema by reducing
intravascular fluid volume through significant increase of fluid excretion by the
, Page 2 of 438
kidneys (Option 2).
(Options 1 and 4) Clients with asthma or chronic obstructive pulmonary disease (eg,
emphysema) develop wheezing due to bronchospasm. Bronchodilators (eg,
albuterol, ipratropium) and systemic corticosteroids (eg, methylprednisolone) may be
prescribed to these clients.
(Option 3) Clients with acute upper respiratory infections or chronic bronchitis (ie,
inflammation of the upper airways) may be prescribed guaifenesin to loosen and
improve the expectoration of mucus. Clients with chronic bronchitis typically develop
rhonchi (ie, sonorous wheezes), which are continuous, low-pitched adventitious
breath sounds that resemble moaning or snoring.
Educational objective:Auscultation of coarse crackles indicates the presence of fluid
or mucus in the lower respiratory tract. This may indicate pulmonary edema or
pulmonary fibrosis. Administration of a loop diuretic (eg, bumetanide) is appropriate
for treating pulmonary edema.
A nurse is caring for a client who had a transurethral resection of the prostate
and is receiving continuous bladder irrigation by gravity. Which of the
following tasks can the nurse delegate to unlicensed assistive personnel?
Select all that apply.
1.Calculating the difference between irrigant intake and total drainage output
2.Cleaning around the catheter insertion site daily
3.Immediately notifying the nurse if the client reports pain
4.Increasing the irrigation rate when the urine becomes more red than pink
5.Measuring the total volume of output in the drainage collection bag
Continuous bladder irrigation is prescribed following surgical transurethral resection
of the prostate and prevents obstruction of urine outflow by removing clotted blood
from the bladder. A 3-way catheter is used to continuously infuse the solution into
the bladder by gravity. The catheter drains urine, irrigant solution, and blood into a
collection bag.
The registered nurse (RN) should consider the five rights of delegation when
, Page 3 of 438
delegating to unlicensed assistive personnel (UAP):
Catheter care is a routine, noncomplex task that may be safely delegated to UAP
(Option 2).
Any client reports of pain or bladder spasms to UAP should be immediately
conveyed to the RN because these symptoms may indicate obstruction (Option 3).
Measuring output is routine data measurement. UAP should report the volume to the
RN, who will determine the adequacy of drainage (Option 5).
(Option 1) Clots or kinks may obstruct drainage and cause a smaller volume of
outflow than inflow. The nurse should calculate this difference to determine the need
to reestablish patency using manual irrigation.
(Option 4) The irrigation rate should be titrated to maintain light-pink outflow drainage
with few clots. It is not within the UAP's scope of practice to titrate the inflow rate or
to monitor drainage quality.
Educational objective:To maintain patency of a continuous bladder irrigation system,
the registered nurse (RN) must monitor the quality of drainage, titrate the inflow rate,
and manually irrigate as needed. The RN may delegate routine tasks (eg, catheter
care, measuring output) to unlicensed assistive personnel.
The nurse on the antepartum unit is performing shift assessments of several
clients that are pregnant. Which client assessment is the priority to report to
the health care provider?
1. Client with gestational diabetes mellitus reporting dysuria
2.Client with hyperemesis gravidarum with a blood pressure of 95/58 mm Hg
3.Client with oligohydramnios and a reactive fetal nonstress test
4.Client with preeclampsia with 3+ reflexes and 2 beats of clonus
Clients with preeclampsia are at risk for developing preeclampsia-associated seizure
activity (eg, eclampsia) due to increased central nervous system irritability. The
presence of neurologic manifestations (eg, hyperreflexia, clonus) may indicate
worsening preeclampsia and can precede seizure activity (Option 4). This client is at
the most immediate risk of harm and is the priority to report to the health care
provider.
, Page 4 of 438
To assess for clonus, the nurse firmly dorsiflexes the foot with 1 hand while
supporting the leg and ankle with the other hand. The abnormal finding of positive
clonus is identified when rhythmic, jerking "beats" of the foot are present as the foot
is released and allowed to fall back into plantar flexion.
(Option 1) Clients with gestational diabetes mellitus are more susceptible to infection
(eg, urinary tract infection, vaginal yeast infection). Although the client's report of
dysuria may indicate a urinary tract infection, the assessment findings do not indicate
immediate risk.
(Option 2) Hyperemesis gravidarum usually affects clients in the first trimester and is
characterized by severe nausea and vomiting that can lead to dehydration,
hypotension, electrolyte imbalances, and nutritional deficits. This client should be
assessed for further symptoms of hypotension (eg, dizziness, blurry vision) before
notifying the health care provider.
(Option 3) Oligohydramnios indicates low amniotic fluid, which may lead to umbilical
cord compression and fetal compromise. However, a reactive nonstress test is a
reassuring finding.
Educational objective:Hyperreflexia and clonus are abnormal findings that may
indicate worsening preeclampsia and impending seizure activity.
The nurse prepares to administer potassium chloride to a client through a
peripherally inserted IV line. Which of the following are appropriate nursing
interventions related to administration of this medication? Select all that apply.
1.
Administer as IV bolus2.Assess IV site frequently3.Assess renal function
laboratory results and urine output4.Place client on cardiac monitor5.Verify
that IV pump infusion is not >10 mEq/hr (10 mmol/hr)
Potassium chloride (KCl) is commonly prescribed to correct or prevent hypokalemia.
The normal range for serum potassium is 3.5-5.0 mEq/L (3.5-5.0 mmol/L).
Potassium is commonly lost through diarrhea, vomiting, and diuretic use. Appropriate
nursing interventions when administering KCl IV should include:
Frequent monitoring of the IV insertion site for extravasation to prevent tissue
necrosis because Potassium is a vesicant (Option 2).
Frequent monitoring of renal function laboratory results (eg, blood urea nitrogen,
creatinine) and urine output as clients with impaired renal function are unable to
excrete potassium and other electrolytes effectively, potentially leading to toxicity
