Uworld NCLEX RN test || All Answers are Valid
A nurse receives the following change-of-shift morning report for the assigned clients. Which
client should the nurse assess first? correct answers Client 2 days postoperative receiving fluids
infusing at 125 mL/hr, with a Foley catheter and urine output of 100 mL during the last 8 hours.
A new nurse is caring for an adolescent transgender client. What question would be appropriate
when assessing the client's gender identity? correct answers "How would you describe your
gender?"
The nurse is caring for a client who was just resuscitated following an out-of-hospital cardiac
arrest. The client does not follow commands and remains comatose. What intervention does the
nurse anticipate being added to the client's plan of care? correct answers Obtaining equipment
and cold fluids for induction of therapeutic hypothermia.
- Neurologic injury is the most common cause of mortality in clients who have had cardiac
arrest, particularly ventricular fibrillation or pulseless ventricular tachycardia.
- inducing therapeutic hypothermia in these clients within 6 hours of arrest and maintaining it for
24 hours has been shown to decrease mortality rates and improve neurologic outcomes.
Therapeutic hypothermia. correct answers Following a cardiac arrest (particularly ventricular
fibrillation or pulseless ventricular tachycardia), to prevent neurological injury, the client is
cooled to 89.6-93.2 F for 24 hours before rewarming.
-Accomplished by cooling blankets, ice placed in the groin, axillae, and sides of the neck, and
cold IV fluids.
- Nurse must closely assess the cardiac monitor because bradycardia is common.
- monitor core body temp, blood pressure, and skin for thermal injury.
- MAP to be kept >80 mm Hg
- Apply neuroprotective strategies: elevate HOB to 30 degrees.
, An adult client is admitted with back pain and found to have a metastatic tumor tumor on the
spine. The health care provider (HCP) explains that the client has few months to live and is likely
to become totally paralyzed below the waist soon. The next day, the client tells the nurse of
wanting to be discharged despite the HCP's recommendation that the client stay a few more days.
Which is the most appropriate initial response by the nurse? correct answers "Tell me more about
your need to leave the hospital."
The nurse assesses a client who is receiving methotrexate for rheumatoid arthritis. Which
statement by the client is most concerning? correct answers "I have small, purple spots all over
my skin."
Methotrexate correct answers An antirheumatic drug prescribed to treat rheumatoid arthritis. Acts
by interfering with folic acid metabolism, which inhibits DNA synthesis and cell production.
- Adverse effects: bone marrow suppression, hepatotoxicity, GI irritation
- managed by dose reduction or discontinuation of the medication
Drug induced bone marrow suppression correct answers Methotrexate induced; leads to anemia,
leukopenia, and thrombocytopenia
Thrombocytopenia correct answers platelet count <100,000/mm3
- characterized by petechiae, purpura, and/or other signs of bleeding like melena, hematemesis,
bleeding gums.
Petechiae correct answers Small, purple hemorrhagic spots.
A 12-month-old is found to have moderately elevated blood lead level. Which of the following is
the most serious concern for this child? correct answers Neurocognitive impairment.
Lead poisoning correct answers Blood Lead Level (BLL) screenings are recommended at ages 1
and 2, and up to age 6
A nurse receives the following change-of-shift morning report for the assigned clients. Which
client should the nurse assess first? correct answers Client 2 days postoperative receiving fluids
infusing at 125 mL/hr, with a Foley catheter and urine output of 100 mL during the last 8 hours.
A new nurse is caring for an adolescent transgender client. What question would be appropriate
when assessing the client's gender identity? correct answers "How would you describe your
gender?"
The nurse is caring for a client who was just resuscitated following an out-of-hospital cardiac
arrest. The client does not follow commands and remains comatose. What intervention does the
nurse anticipate being added to the client's plan of care? correct answers Obtaining equipment
and cold fluids for induction of therapeutic hypothermia.
- Neurologic injury is the most common cause of mortality in clients who have had cardiac
arrest, particularly ventricular fibrillation or pulseless ventricular tachycardia.
- inducing therapeutic hypothermia in these clients within 6 hours of arrest and maintaining it for
24 hours has been shown to decrease mortality rates and improve neurologic outcomes.
Therapeutic hypothermia. correct answers Following a cardiac arrest (particularly ventricular
fibrillation or pulseless ventricular tachycardia), to prevent neurological injury, the client is
cooled to 89.6-93.2 F for 24 hours before rewarming.
-Accomplished by cooling blankets, ice placed in the groin, axillae, and sides of the neck, and
cold IV fluids.
- Nurse must closely assess the cardiac monitor because bradycardia is common.
- monitor core body temp, blood pressure, and skin for thermal injury.
- MAP to be kept >80 mm Hg
- Apply neuroprotective strategies: elevate HOB to 30 degrees.
, An adult client is admitted with back pain and found to have a metastatic tumor tumor on the
spine. The health care provider (HCP) explains that the client has few months to live and is likely
to become totally paralyzed below the waist soon. The next day, the client tells the nurse of
wanting to be discharged despite the HCP's recommendation that the client stay a few more days.
Which is the most appropriate initial response by the nurse? correct answers "Tell me more about
your need to leave the hospital."
The nurse assesses a client who is receiving methotrexate for rheumatoid arthritis. Which
statement by the client is most concerning? correct answers "I have small, purple spots all over
my skin."
Methotrexate correct answers An antirheumatic drug prescribed to treat rheumatoid arthritis. Acts
by interfering with folic acid metabolism, which inhibits DNA synthesis and cell production.
- Adverse effects: bone marrow suppression, hepatotoxicity, GI irritation
- managed by dose reduction or discontinuation of the medication
Drug induced bone marrow suppression correct answers Methotrexate induced; leads to anemia,
leukopenia, and thrombocytopenia
Thrombocytopenia correct answers platelet count <100,000/mm3
- characterized by petechiae, purpura, and/or other signs of bleeding like melena, hematemesis,
bleeding gums.
Petechiae correct answers Small, purple hemorrhagic spots.
A 12-month-old is found to have moderately elevated blood lead level. Which of the following is
the most serious concern for this child? correct answers Neurocognitive impairment.
Lead poisoning correct answers Blood Lead Level (BLL) screenings are recommended at ages 1
and 2, and up to age 6
