NCLEX - uWorld Test 1 || with Errorless Answers.
A nurse is performing cardiopulmonary resuscitation (CPR) on an adult at a swimming pool. A
bystander brings the automated external defibrillator (AED). The nurse notes that the victim is
wet and wearing a transdermal medication patch on the upper right chest. Which action is
appropriate?
1. Continue compressions while the AED analyzes the client's heart rhythm
2.Do not use the AED and continue CPR until paramedics arrive
3.Place the AED pad on the opposite side of the transdermal patch
4.Remove the transdermal patch and wipe the chest before applying AED pads correct answers
Cardiac arrests require prompt use of an automated external defibrillator (AED), if available,
because evidence shows that early defibrillation is associated with increased cardiopulmonary
resuscitation (CPR) success. An AED is a portable device that administers an electric shock to
attempt restoration of normal cardiac electrical activity during cardiac arrest when used with
other resuscitative measures (eg, chest compressions, medication).
To maximize the effectiveness of shock(s) administered by an AED and increase safety to those
providing aid, the client's chests should be dry, free of residue, and cleaned of any barriers to
conduction (eg, chest hair, transdermal patches) (Option 4).
(Option 1) When the AED announces that it is ready for rhythm analysis, compressions are
paused and rescuers are to remain clear of the client. The AED will then dictate if a shock is
needed, or if CPR should be resumed.
(Option 2) The AED should be turned on and AED pads applied as soon as it is available; its use
should not be delayed.
(Option 3) AED pads should not be placed over medication patches because this interferes with
conduction and can burn the skin and would not be effective if placed on the opposite side. The
transdermal patch should be removed and any residue wiped away before placing the appropriate
pad on the right side of the chest.
,Educational objective:An automated external defibrillator (AED) is used as soon as possible for
improved cardiopulmonary resuscitation outcomes. Transdermal patches should be removed, and
the chest wiped to promote AED pad adherence and prevent burns.
While the nurse is transporting a client to a new unit, the client's chest tube drainage system falls
off the bed and the tube becomes dislodged from the chest wall. What is the nurse's priority
action?
1) Activate the hospital emergency response system
2) Apply supplemental oxygen and quickly transport to the new unit
3) Check the client's respiratory pattern and effort and oxygen saturation
4) Firmly cover the insertion site with the palm of a clean. gloved hand. correct answers Chest
tubes are inserted into the pleural cavity to facilitate drainage of air (pneumothorax), blood
(hemothorax), or other fluids. Chest tubes are sutured in place, but dislodgement can occur. If
this happens, a sterile occlusive dressing (eg, petrolatum gauze) must immediately be placed
over the insertion site until the health care provider can assess the client and insert a new chest
tube. If such dressings are not immediately available, the nurse should cover the insertion site
with something clean and occlusive (eg, gloved hand) to prevent air from entering the pleural
cavity (Option 4).
(Option 1) The nurse should cover the site and assess the client prior to activating the emergency
response system.
(Option 2) It may be necessary to provide supplemental oxygen if a chest tube is accidentally
dislodged. This intervention would be done after the site is occluded.
(Option 3) After the chest tube insertion site is covered, the client should be reassessed. The
nurse should not delay covering the chest tube site as pneumothorax or tension pneumothorax
may occur quickly.
Educational objective:Chest tubes are inserted into the pleural cavity to drain air
(pneumothorax), blood (hemothorax), or other fluids. If the tube is accidentally dislodged, a
sterile occlusive dressing is placed over the site. If such dressings are not immediately available,
a clean gloved hand can be placed over the site to prevent air entry into the pleural space. After
dressing the site, the nurse should reassess the client and notify the health care provider
immediately.
,The charge nurse is responsible for making room assignments for multiple clients. Which pair of
client assignments to a shared room is appropriate?
1) Client with blood loss anemia and client with intractable diarrhea
2) Client with gastroenteritis and client with chemotherapy-induced nausea and vomiting
3) Client who had a bowel resection 1 day ago and client with asthma exacerbation
4) Client who had a total hip arthroplasty and client with influenza correct answers When making
room assignments, it is important to remember that a client with an active or suspected infection
should not be paired with a client who has a fresh surgical wound or is immunocompromised. A
client having an asthma exacerbation does not have an infection and is not at risk for spreading
infection to a client who had recent bowel resection surgery (Option 3).
(Option 1) A client with uncontained or excessive excretions, drainage, or secretions (eg, profuse
diarrhea, draining wounds) is more likely to spread infection, if present, and therefore should be
assigned to a private room.
(Option 2) The client who has chemotherapy-induced nausea and vomiting is likely
immunocompromised secondary to the chemotherapy and is therefore vulnerable to infection
from a client with gastroenteritis.
(Option 4) A client who has a fresh surgical wound has an increased risk of infection and should
not be paired with a client with an active influenza infection, which is transmitted through the
droplet route.
Educational objective:When preparing room assignments, the nurse should not place a client
who has a fresh surgical wound or is immunocompromised in a room with a client who has an
active or suspected infection.
The nurse in the cardiac intensive care unit receives report on 4 clients. Which client should the
nurse assess first?
1) Client who is receiving IV antibiotics for infective endocarditis with a temperature of 101.5 F
(38.6 C)
2) Client who underwent coronary artery stent placement via femoral approach 3 hours ago and
is reporting severe back pain
3) Client who underwent coronary bypass graft surgery 3 days ago and has swelling in the leg
used for the donor graft
, 4) Client who underwent heart transplantation 2 months ago with sustained sinus tachycardia of
110/min at rest. correct answers A client who undergoes percutaneous coronary intervention
(PCI) and intracoronary stent placement using the femoral approach is at increased risk for
retroperitoneal hemorrhage. Administration of antithrombotic drugs before, during, and after PCI
can exacerbate potentially life-threatening bleeding from the femoral artery.
Hypotension, back pain, flank ecchymosis (eg, Grey Turner sign), hematoma formation, and
diminished distal pulses can be early signs of bleeding into the retroperitoneal space and require
immediate intervention (eg, notify health care provider, serial complete blood count, CT scan of
the abdomen) (Option 2).
(Option 1) Infective endocarditis is often associated with cardiac valve disease and requires long-
term antibiotic therapy (4-6 weeks). Characteristic manifestations include fever, myalgia, chills,
joint pain, anorexia, and petechiae.
(Option 3) Some clients notice swelling in the leg used for donor venous graft (interruption of
blood flow). Elevating the leg and wearing compression stockings can help decrease symptoms.
(Option 4) During heart transplantation, the donor heart is cut off from the autonomic nervous
system (denervated), altering the heart rate during rest and exercise after the procedure. The heart
rate of the transplanted heart is expected to be at the high end of normal or tachycardic (eg, 90-
110/min).
Educational objective:Percutaneous coronary intervention via the femoral approach places the
client at increased risk for retroperitoneal hemorrhage, which can be exacerbated by
antithrombotic drugs. Back pain, hypotension, flank ecchymosis (eg, Grey Turner sign),
hematoma formation, and diminished distal pulses can be early signs of bleeding into the
retroperitoneal space and require immediate intervention.
The nurse is reviewing the medical history of a client who has sustained a right tibia/fibula
fracture from a fall. The nurse identifies which finding as most likely to hinder healing?
1) BMI of 29.5 kg/m2
2) Family history of osteoporosis
3) history of daily glass of wine
4) peripheral arterial disease correct answers Bone healing depends on multiple factors,
including nutrition, adequate circulation, and age. A client with peripheral arterial disease has
decreased perfusion to the extremities due to atherosclerotic changes in the arteries. Without
A nurse is performing cardiopulmonary resuscitation (CPR) on an adult at a swimming pool. A
bystander brings the automated external defibrillator (AED). The nurse notes that the victim is
wet and wearing a transdermal medication patch on the upper right chest. Which action is
appropriate?
1. Continue compressions while the AED analyzes the client's heart rhythm
2.Do not use the AED and continue CPR until paramedics arrive
3.Place the AED pad on the opposite side of the transdermal patch
4.Remove the transdermal patch and wipe the chest before applying AED pads correct answers
Cardiac arrests require prompt use of an automated external defibrillator (AED), if available,
because evidence shows that early defibrillation is associated with increased cardiopulmonary
resuscitation (CPR) success. An AED is a portable device that administers an electric shock to
attempt restoration of normal cardiac electrical activity during cardiac arrest when used with
other resuscitative measures (eg, chest compressions, medication).
To maximize the effectiveness of shock(s) administered by an AED and increase safety to those
providing aid, the client's chests should be dry, free of residue, and cleaned of any barriers to
conduction (eg, chest hair, transdermal patches) (Option 4).
(Option 1) When the AED announces that it is ready for rhythm analysis, compressions are
paused and rescuers are to remain clear of the client. The AED will then dictate if a shock is
needed, or if CPR should be resumed.
(Option 2) The AED should be turned on and AED pads applied as soon as it is available; its use
should not be delayed.
(Option 3) AED pads should not be placed over medication patches because this interferes with
conduction and can burn the skin and would not be effective if placed on the opposite side. The
transdermal patch should be removed and any residue wiped away before placing the appropriate
pad on the right side of the chest.
,Educational objective:An automated external defibrillator (AED) is used as soon as possible for
improved cardiopulmonary resuscitation outcomes. Transdermal patches should be removed, and
the chest wiped to promote AED pad adherence and prevent burns.
While the nurse is transporting a client to a new unit, the client's chest tube drainage system falls
off the bed and the tube becomes dislodged from the chest wall. What is the nurse's priority
action?
1) Activate the hospital emergency response system
2) Apply supplemental oxygen and quickly transport to the new unit
3) Check the client's respiratory pattern and effort and oxygen saturation
4) Firmly cover the insertion site with the palm of a clean. gloved hand. correct answers Chest
tubes are inserted into the pleural cavity to facilitate drainage of air (pneumothorax), blood
(hemothorax), or other fluids. Chest tubes are sutured in place, but dislodgement can occur. If
this happens, a sterile occlusive dressing (eg, petrolatum gauze) must immediately be placed
over the insertion site until the health care provider can assess the client and insert a new chest
tube. If such dressings are not immediately available, the nurse should cover the insertion site
with something clean and occlusive (eg, gloved hand) to prevent air from entering the pleural
cavity (Option 4).
(Option 1) The nurse should cover the site and assess the client prior to activating the emergency
response system.
(Option 2) It may be necessary to provide supplemental oxygen if a chest tube is accidentally
dislodged. This intervention would be done after the site is occluded.
(Option 3) After the chest tube insertion site is covered, the client should be reassessed. The
nurse should not delay covering the chest tube site as pneumothorax or tension pneumothorax
may occur quickly.
Educational objective:Chest tubes are inserted into the pleural cavity to drain air
(pneumothorax), blood (hemothorax), or other fluids. If the tube is accidentally dislodged, a
sterile occlusive dressing is placed over the site. If such dressings are not immediately available,
a clean gloved hand can be placed over the site to prevent air entry into the pleural space. After
dressing the site, the nurse should reassess the client and notify the health care provider
immediately.
,The charge nurse is responsible for making room assignments for multiple clients. Which pair of
client assignments to a shared room is appropriate?
1) Client with blood loss anemia and client with intractable diarrhea
2) Client with gastroenteritis and client with chemotherapy-induced nausea and vomiting
3) Client who had a bowel resection 1 day ago and client with asthma exacerbation
4) Client who had a total hip arthroplasty and client with influenza correct answers When making
room assignments, it is important to remember that a client with an active or suspected infection
should not be paired with a client who has a fresh surgical wound or is immunocompromised. A
client having an asthma exacerbation does not have an infection and is not at risk for spreading
infection to a client who had recent bowel resection surgery (Option 3).
(Option 1) A client with uncontained or excessive excretions, drainage, or secretions (eg, profuse
diarrhea, draining wounds) is more likely to spread infection, if present, and therefore should be
assigned to a private room.
(Option 2) The client who has chemotherapy-induced nausea and vomiting is likely
immunocompromised secondary to the chemotherapy and is therefore vulnerable to infection
from a client with gastroenteritis.
(Option 4) A client who has a fresh surgical wound has an increased risk of infection and should
not be paired with a client with an active influenza infection, which is transmitted through the
droplet route.
Educational objective:When preparing room assignments, the nurse should not place a client
who has a fresh surgical wound or is immunocompromised in a room with a client who has an
active or suspected infection.
The nurse in the cardiac intensive care unit receives report on 4 clients. Which client should the
nurse assess first?
1) Client who is receiving IV antibiotics for infective endocarditis with a temperature of 101.5 F
(38.6 C)
2) Client who underwent coronary artery stent placement via femoral approach 3 hours ago and
is reporting severe back pain
3) Client who underwent coronary bypass graft surgery 3 days ago and has swelling in the leg
used for the donor graft
, 4) Client who underwent heart transplantation 2 months ago with sustained sinus tachycardia of
110/min at rest. correct answers A client who undergoes percutaneous coronary intervention
(PCI) and intracoronary stent placement using the femoral approach is at increased risk for
retroperitoneal hemorrhage. Administration of antithrombotic drugs before, during, and after PCI
can exacerbate potentially life-threatening bleeding from the femoral artery.
Hypotension, back pain, flank ecchymosis (eg, Grey Turner sign), hematoma formation, and
diminished distal pulses can be early signs of bleeding into the retroperitoneal space and require
immediate intervention (eg, notify health care provider, serial complete blood count, CT scan of
the abdomen) (Option 2).
(Option 1) Infective endocarditis is often associated with cardiac valve disease and requires long-
term antibiotic therapy (4-6 weeks). Characteristic manifestations include fever, myalgia, chills,
joint pain, anorexia, and petechiae.
(Option 3) Some clients notice swelling in the leg used for donor venous graft (interruption of
blood flow). Elevating the leg and wearing compression stockings can help decrease symptoms.
(Option 4) During heart transplantation, the donor heart is cut off from the autonomic nervous
system (denervated), altering the heart rate during rest and exercise after the procedure. The heart
rate of the transplanted heart is expected to be at the high end of normal or tachycardic (eg, 90-
110/min).
Educational objective:Percutaneous coronary intervention via the femoral approach places the
client at increased risk for retroperitoneal hemorrhage, which can be exacerbated by
antithrombotic drugs. Back pain, hypotension, flank ecchymosis (eg, Grey Turner sign),
hematoma formation, and diminished distal pulses can be early signs of bleeding into the
retroperitoneal space and require immediate intervention.
The nurse is reviewing the medical history of a client who has sustained a right tibia/fibula
fracture from a fall. The nurse identifies which finding as most likely to hinder healing?
1) BMI of 29.5 kg/m2
2) Family history of osteoporosis
3) history of daily glass of wine
4) peripheral arterial disease correct answers Bone healing depends on multiple factors,
including nutrition, adequate circulation, and age. A client with peripheral arterial disease has
decreased perfusion to the extremities due to atherosclerotic changes in the arteries. Without
