NCLEX Uworld [ACTUAL EXAM] LATEST VERSION
[QUESTIONS AND ANSWERS] WITH PRACTICE EXAM
DETAILED AND VERIFIED FOR GUARANTEED PASS- LATEST
UPDATE 2025 GRADED A
Appropriate order of actions when client found on floor - CORRECT ANSWER 1.
*Assessment* of *physiological stability* (ABCs)
2. *Assessment* of *injuries*
3. *Moving client*
4. *Notifications*
5. *Documentation*
Conditions of being *ineligible to leave AMA* - CORRECT ANSWER 1 *danger to
self or others*
2. *lack of consciousness*
3. *Altered consciousness*
4. *Mental illness*
5. Being under *chemical influence*
6. *Court decision*
Effective handoff communication components - CORRECT ANSWER Nurse
should:
1. Provide *identifying information* (eg client's name and room number)
2. Note *care priorities* and upcoming or outstanding tasks (eg time to replace
medication infusion bag, need to perform delayed wound care and cause of delay)
3. Provide *exact, pertinent information* (eg medication dose, time, measurable
outcomes)
4. Include *multidisciplinary plans* (eg radiology examinations, family meetings,
physical therapy)
5. Relay significant client changes in a clear manner
*Risk factors* for *cervical cancer* - CORRECT ANSWER 1. Infection with high-
risk HPV strains
2. History of sexually transmitted diseases
3. Early onset of sexual activity
4. Multiple or high-risk sexual partners
5. Immunosuppression
6. Oral contraceptive use
7. Low SES
8. Tobacco use
,what medications interact with grapefruit? - CORRECT ANSWER 1. *calcium
channel blockers* (diltiazem, nifedipine, verapamil, etc)
2. *statins*
3. *SSRIs*
Risk associated with *stent placement* using the *femoral approach* - CORRECT
ANSWER *retroperitoneal hemorrhage*
what are early signs of bleeding into the retroperitoneal space? - CORRECT
ANSWER hypotension, back pain, flank ecchymosis (grey turner sign), hematoma
formation, diminshed distal pulses
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 of hyperglycemia - CORRECT ANSWER - polydipsia,
- polyuria,
- restless,
- confused,
- bg over 200,
- fatigue,
- headache
- blurred vision
- kussmaul resp
Interventions to resolve TPN-associated hyperglycemia - CORRECT ANSWER -
reduce amount of carbohydrate in TPN solution
- slow down infusion rate
- administer subcutaneous insulin
, 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
[QUESTIONS AND ANSWERS] WITH PRACTICE EXAM
DETAILED AND VERIFIED FOR GUARANTEED PASS- LATEST
UPDATE 2025 GRADED A
Appropriate order of actions when client found on floor - CORRECT ANSWER 1.
*Assessment* of *physiological stability* (ABCs)
2. *Assessment* of *injuries*
3. *Moving client*
4. *Notifications*
5. *Documentation*
Conditions of being *ineligible to leave AMA* - CORRECT ANSWER 1 *danger to
self or others*
2. *lack of consciousness*
3. *Altered consciousness*
4. *Mental illness*
5. Being under *chemical influence*
6. *Court decision*
Effective handoff communication components - CORRECT ANSWER Nurse
should:
1. Provide *identifying information* (eg client's name and room number)
2. Note *care priorities* and upcoming or outstanding tasks (eg time to replace
medication infusion bag, need to perform delayed wound care and cause of delay)
3. Provide *exact, pertinent information* (eg medication dose, time, measurable
outcomes)
4. Include *multidisciplinary plans* (eg radiology examinations, family meetings,
physical therapy)
5. Relay significant client changes in a clear manner
*Risk factors* for *cervical cancer* - CORRECT ANSWER 1. Infection with high-
risk HPV strains
2. History of sexually transmitted diseases
3. Early onset of sexual activity
4. Multiple or high-risk sexual partners
5. Immunosuppression
6. Oral contraceptive use
7. Low SES
8. Tobacco use
,what medications interact with grapefruit? - CORRECT ANSWER 1. *calcium
channel blockers* (diltiazem, nifedipine, verapamil, etc)
2. *statins*
3. *SSRIs*
Risk associated with *stent placement* using the *femoral approach* - CORRECT
ANSWER *retroperitoneal hemorrhage*
what are early signs of bleeding into the retroperitoneal space? - CORRECT
ANSWER hypotension, back pain, flank ecchymosis (grey turner sign), hematoma
formation, diminshed distal pulses
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 of hyperglycemia - CORRECT ANSWER - polydipsia,
- polyuria,
- restless,
- confused,
- bg over 200,
- fatigue,
- headache
- blurred vision
- kussmaul resp
Interventions to resolve TPN-associated hyperglycemia - CORRECT ANSWER -
reduce amount of carbohydrate in TPN solution
- slow down infusion rate
- administer subcutaneous insulin
, 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
