NCLEX Uworld LATEST VERSION [QUESTIONS AND ANSWERS] WITH PRACTICE
EXAM DETAILED AND VERIFIED FOR GUARANTEED PASS- LATEST UPDATE
2025 GRADED A
what is the grey-turner sign and what is it a sign of? - CORRECT ANSWER
bruising of the flanks and retroperitoneal hemorrhage and is a bluish color
what are some physical signs of peripheral arterial disease? - CORRECT ANSWER
intermittent calf muscle pain?, rest pain, hair loss, decreased peripheral pulses, cool,
dry, shiny skin, thick brittle nails, gangrene, ulcers (all of these are in the extremities)
transplanted hearts are expected to be - CORRECT ANSWER tachycardic like 90-
110
what is the priority intervention for pain with sickle cell crisis and why? - CORRECT
ANSWER administer IV fluids to reduce blood viscosity and restore perfusion to
areas affected by vasoocclusion
what is the purpose of continuous bladder irrigation? - CORRECT ANSWER it is
perscribed after TURP to prevent obstruction of urine outflow by removing clotted blood
from the bladder
what is the nurses care of monitoring CBI? - CORRECT ANSWER monitor quality
of drainage, titrate the inflow rate, and manurally irrigating as needed
characteristics of a basilar skull fracture - CORRECT ANSWER periorbital
hematomas (raccoon eyes), csf fluid rhinorrhea, and battle sign (behind the ear
bruising)
immediate client care for basilar skull fracture - CORRECT ANSWER cervical
spime immobilization, close neurologic monitoring, and support of ABCs
vomiting with intake may mean - CORRECT ANSWER viral or bacterial infection
tympanosomty tubes are placed for - CORRECT ANSWER recurrent otis medias
nurse actions during a seizure - CORRECT ANSWER assist them to lie down is
standing/sitting, put them on side for patent airway, loosen tight clothing, give oxygen as
needed, remove objects from immediate area, document time and duration of seizure
(for tests are done later to see which type of seizure and maybe what exacerates it)
never put anything in mouth or restrain them since musclec ontractions can occur
during a seizure
,what are some early symptoms of ICP? - CORRECT ANSWER altered LOC,
headache, abnormal reathing, rise in bp, slow pulse, vomiting
client who has a TIA is often placed on - CORRECT ANSWER prophylactic
antithrombotic treatment like aspirin or clopidogrel
glascow coma scale ranges from - CORRECT ANSWER 3-15; 3 being worst 15
being best condition (8 or below in a coma)
what are the 3 components? - CORRECT ANSWER eye opening
motor response
verbal response
what is a primary component in TPN? - CORRECT ANSWER glucose, so the
nurse should be monitoring blood glucose and be assessing for signs of hyperglycemia
when a client is on TPN, the nurse must assess for hyperglycemia why? - CORRECT
ANSWER bc a primary component is glucose. therefore the nurse must be
assessing to see if the client is getting too much glucose (hoerglycemia). and with a
large urinary output like 4800, this could indicate symptoms of hyperglycemia
signs og hyperglycemia - CORRECT ANSWER polydipsia, polyuria, restless,
confused, bg over 200, fatigue, kussmaul resp
what is the goal for mass casualty events? - CORRECT ANSWER do the greatest
good for the greatest number of people
keep in mind that disaster triage ranks the likelihood of survival with treatment, not
necessarily the severity of the injury - CORRECT ANSWER
what are the 4 categories for triaging? - CORRECT ANSWER immediate (red tag)-
life threatening injuries with good prognosis once treated
delayed (yellow)- injuries requiring treatment within hours
minimal (green tag)- injuries requiring treatment within a few days
expectant (black tag)- extensive injuries, poor prognosis regardless of treatment
rule of nines - CORRECT ANSWER head: 4.5 front 4.5 back
torso: 18 front 18 back
each arm: 4.5 front 4.5 back (each arm is 9 total)
each leg: 9 front 8 back (each is 18 total)
genitals: 1
extrapyramidal side effects - CORRECT ANSWER ACUTE DYSTONIC
REACTION: sudden onset sustained muscle contractions
,AKATHISIA: restlessness with inability to sit still
drug induce PARKINSONISM: tremor, rigidity, bradykinies, masked like faces
AKINISIA: loss of involuntary movement
TARDIVE DYSKININIA
NEUROLEPTIC MALIGNANT SYNDROME
dont give morphine if RR under 12 bc it can cause - CORRECT ANSWER
respiratory depression
airborne precautions - CORRECT ANSWER tuberculosis, varicella, and rubeola
(measles)
wear N95 respirator (and other as needed like for splashes)
ALSO (neg pressure room and HEPA)
clients suspected are to wear a surgical mask after triage
UAP soft wrist restraints can: - CORRECT ANSWER do ROM exercises
reapply wrist restraints
report changes in skin to nurse
turn/reposition client in bed
a client with major depression and severe weight loss needs what type of diet? -
CORRECT ANSWER high in calories and protein, also foods that are easy to
chew and dont require a lot of energy bc they may have a low energy level
examples: while milk/dairy, granola muffins, pottoes, meat fish eggs, pasta
also small frequent meals
memorize MAOIs and remember - CORRECT ANSWER they cant eat foods high
in tyramine like aged cheese, yogurt, fermented foods, beer, red wine, cocolate,
avocados
do not give lasix to a pneumonia patient with fine crackles bc they dont result from heart
failure or edema - CORRECT ANSWER
you can give pneumonia patient exportants, antibiotics, mucolytics, antipyretics,
analgesics, and antinflammatories
examples are - CORRECT ANSWER Mucinex, Ibuprofin,
decerebrate posturing (toes point down and amrs/legs straight out) is a sign of -
CORRECT ANSWER severe brain damage
near drowning hypothermia - CORRECT ANSWER warm iv fluids, blankets, and
air
also will find weak and thready pulse
, a client is not dead until warm and dead!!! - CORRECT ANSWER nc sometimes a
pt is so cold that a pulse cannot be felt
intussusception
causes intestinal obstruction - CORRECT ANSWER ileum telescopes into cecum,
pain obstruction, edema, compression of BVs, bowel ischemia, rectal bleeing
(CURRANT JELLY stools)
signs of intussusceotion - CORRECT ANSWER inital periodic pain with legs drawn
up to abdomen, pain is severe and progressive though, inconsolable crying,
blood/mucousy stools "current jelly"
how is it treated? - CORRECT ANSWER an air enema
guaifenesin (Mucinex) - CORRECT ANSWER expecorant med that inc resp fluids
and thins secretions to facilitate expectoration
erythropoeitin Epogen - CORRECT ANSWER stimulates bone marrow to make
RBCs and combats the effects of chemo and used for kidney disease
when is hemoccult done? - CORRECT ANSWER when hidden (occult) blood is
suspected due to dark and tarry stool
treat intussusception with - CORRECT ANSWER AIR ENEMA
tetraology of fallot - CORRECT ANSWER exacerbation can happen when infant or
child cries, becomes upset, or is feeding
you immediately place them in KNEE CHEST position
hemolytic uremic syndrome - CORRECT ANSWER life threatening complication of
e. coli diarhea
what are the signs? - CORRECT ANSWER anemia (pallor), low platelets
(petechiae and purpura, and acute kidney injury (low UO)
cognitive behavioral therapy (CBT) 5 basic components - CORRECT ANSWER
education about pts disorder
self observing and monitoring
relaxation techniques
cognitive restructuring
behavioral strategies
speicen collection from a foley is considered sterile and should not be delegated to uap
- CORRECT ANSWER
EXAM DETAILED AND VERIFIED FOR GUARANTEED PASS- LATEST UPDATE
2025 GRADED A
what is the grey-turner sign and what is it a sign of? - CORRECT ANSWER
bruising of the flanks and retroperitoneal hemorrhage and is a bluish color
what are some physical signs of peripheral arterial disease? - CORRECT ANSWER
intermittent calf muscle pain?, rest pain, hair loss, decreased peripheral pulses, cool,
dry, shiny skin, thick brittle nails, gangrene, ulcers (all of these are in the extremities)
transplanted hearts are expected to be - CORRECT ANSWER tachycardic like 90-
110
what is the priority intervention for pain with sickle cell crisis and why? - CORRECT
ANSWER administer IV fluids to reduce blood viscosity and restore perfusion to
areas affected by vasoocclusion
what is the purpose of continuous bladder irrigation? - CORRECT ANSWER it is
perscribed after TURP to prevent obstruction of urine outflow by removing clotted blood
from the bladder
what is the nurses care of monitoring CBI? - CORRECT ANSWER monitor quality
of drainage, titrate the inflow rate, and manurally irrigating as needed
characteristics of a basilar skull fracture - CORRECT ANSWER periorbital
hematomas (raccoon eyes), csf fluid rhinorrhea, and battle sign (behind the ear
bruising)
immediate client care for basilar skull fracture - CORRECT ANSWER cervical
spime immobilization, close neurologic monitoring, and support of ABCs
vomiting with intake may mean - CORRECT ANSWER viral or bacterial infection
tympanosomty tubes are placed for - CORRECT ANSWER recurrent otis medias
nurse actions during a seizure - CORRECT ANSWER assist them to lie down is
standing/sitting, put them on side for patent airway, loosen tight clothing, give oxygen as
needed, remove objects from immediate area, document time and duration of seizure
(for tests are done later to see which type of seizure and maybe what exacerates it)
never put anything in mouth or restrain them since musclec ontractions can occur
during a seizure
,what are some early symptoms of ICP? - CORRECT ANSWER altered LOC,
headache, abnormal reathing, rise in bp, slow pulse, vomiting
client who has a TIA is often placed on - CORRECT ANSWER prophylactic
antithrombotic treatment like aspirin or clopidogrel
glascow coma scale ranges from - CORRECT ANSWER 3-15; 3 being worst 15
being best condition (8 or below in a coma)
what are the 3 components? - CORRECT ANSWER eye opening
motor response
verbal response
what is a primary component in TPN? - CORRECT ANSWER glucose, so the
nurse should be monitoring blood glucose and be assessing for signs of hyperglycemia
when a client is on TPN, the nurse must assess for hyperglycemia why? - CORRECT
ANSWER bc a primary component is glucose. therefore the nurse must be
assessing to see if the client is getting too much glucose (hoerglycemia). and with a
large urinary output like 4800, this could indicate symptoms of hyperglycemia
signs og hyperglycemia - CORRECT ANSWER polydipsia, polyuria, restless,
confused, bg over 200, fatigue, kussmaul resp
what is the goal for mass casualty events? - CORRECT ANSWER do the greatest
good for the greatest number of people
keep in mind that disaster triage ranks the likelihood of survival with treatment, not
necessarily the severity of the injury - CORRECT ANSWER
what are the 4 categories for triaging? - CORRECT ANSWER immediate (red tag)-
life threatening injuries with good prognosis once treated
delayed (yellow)- injuries requiring treatment within hours
minimal (green tag)- injuries requiring treatment within a few days
expectant (black tag)- extensive injuries, poor prognosis regardless of treatment
rule of nines - CORRECT ANSWER head: 4.5 front 4.5 back
torso: 18 front 18 back
each arm: 4.5 front 4.5 back (each arm is 9 total)
each leg: 9 front 8 back (each is 18 total)
genitals: 1
extrapyramidal side effects - CORRECT ANSWER ACUTE DYSTONIC
REACTION: sudden onset sustained muscle contractions
,AKATHISIA: restlessness with inability to sit still
drug induce PARKINSONISM: tremor, rigidity, bradykinies, masked like faces
AKINISIA: loss of involuntary movement
TARDIVE DYSKININIA
NEUROLEPTIC MALIGNANT SYNDROME
dont give morphine if RR under 12 bc it can cause - CORRECT ANSWER
respiratory depression
airborne precautions - CORRECT ANSWER tuberculosis, varicella, and rubeola
(measles)
wear N95 respirator (and other as needed like for splashes)
ALSO (neg pressure room and HEPA)
clients suspected are to wear a surgical mask after triage
UAP soft wrist restraints can: - CORRECT ANSWER do ROM exercises
reapply wrist restraints
report changes in skin to nurse
turn/reposition client in bed
a client with major depression and severe weight loss needs what type of diet? -
CORRECT ANSWER high in calories and protein, also foods that are easy to
chew and dont require a lot of energy bc they may have a low energy level
examples: while milk/dairy, granola muffins, pottoes, meat fish eggs, pasta
also small frequent meals
memorize MAOIs and remember - CORRECT ANSWER they cant eat foods high
in tyramine like aged cheese, yogurt, fermented foods, beer, red wine, cocolate,
avocados
do not give lasix to a pneumonia patient with fine crackles bc they dont result from heart
failure or edema - CORRECT ANSWER
you can give pneumonia patient exportants, antibiotics, mucolytics, antipyretics,
analgesics, and antinflammatories
examples are - CORRECT ANSWER Mucinex, Ibuprofin,
decerebrate posturing (toes point down and amrs/legs straight out) is a sign of -
CORRECT ANSWER severe brain damage
near drowning hypothermia - CORRECT ANSWER warm iv fluids, blankets, and
air
also will find weak and thready pulse
, a client is not dead until warm and dead!!! - CORRECT ANSWER nc sometimes a
pt is so cold that a pulse cannot be felt
intussusception
causes intestinal obstruction - CORRECT ANSWER ileum telescopes into cecum,
pain obstruction, edema, compression of BVs, bowel ischemia, rectal bleeing
(CURRANT JELLY stools)
signs of intussusceotion - CORRECT ANSWER inital periodic pain with legs drawn
up to abdomen, pain is severe and progressive though, inconsolable crying,
blood/mucousy stools "current jelly"
how is it treated? - CORRECT ANSWER an air enema
guaifenesin (Mucinex) - CORRECT ANSWER expecorant med that inc resp fluids
and thins secretions to facilitate expectoration
erythropoeitin Epogen - CORRECT ANSWER stimulates bone marrow to make
RBCs and combats the effects of chemo and used for kidney disease
when is hemoccult done? - CORRECT ANSWER when hidden (occult) blood is
suspected due to dark and tarry stool
treat intussusception with - CORRECT ANSWER AIR ENEMA
tetraology of fallot - CORRECT ANSWER exacerbation can happen when infant or
child cries, becomes upset, or is feeding
you immediately place them in KNEE CHEST position
hemolytic uremic syndrome - CORRECT ANSWER life threatening complication of
e. coli diarhea
what are the signs? - CORRECT ANSWER anemia (pallor), low platelets
(petechiae and purpura, and acute kidney injury (low UO)
cognitive behavioral therapy (CBT) 5 basic components - CORRECT ANSWER
education about pts disorder
self observing and monitoring
relaxation techniques
cognitive restructuring
behavioral strategies
speicen collection from a foley is considered sterile and should not be delegated to uap
- CORRECT ANSWER
