NCLEX UWorld 2024
When do *advanced directives* go into effect? - ANSwhen person is *unable to speak for
him/herself* due to either:
1. *Mental Incapacity* - *coma *(GCS score ≤ 7)
2. *Aphasia*
(≠as soon as signed; directives can always be changed later by person)
When do *advanced directives* go into effect? - ANSwhen person is *unable to speak for
him/herself* due to either:
1. *Mental Incapacity* - *coma *(GCS score ≤ 7)
2. *Aphasia*
(≠as soon as signed; directives can always be changed later by person)
SBAR Communication Framekwork Components - ANS1. *S* = Situation - what *prompted* the
communication (eg *what* changes occurred)
2. *B* = Background - *pertinent information, relevant history, vital signs*
3. *A* = Assessment - nurse's assessment of the situation (*when* & *what changes* occurred)
4. *R* = Recommendation - *request* for *prescription* or *action* from HCP
SBAR Communication Framekwork Components - ANS1. *S* = Situation - what *prompted* the
communication (eg *what* changes occurred)
2. *B* = Background - *pertinent information, relevant history, vital signs*
3. *A* = Assessment - nurse's assessment of the situation (*when* & *what changes* occurred)
4. *R* = Recommendation - *request* for *prescription* or *action* from HCP
Appropriate order of actions when client found on floor - ANS1. *Assessment* of *physiological
stability* (ABCs)
2. *Assessment* of *injuries*
3. *Moving client*
4. *Notifications*
5. *Documentation*
Appropriate order of actions when client found on floor - ANS1. *Assessment* of *physiological
stability* (ABCs)
2. *Assessment* of *injuries*
3. *Moving client*
4. *Notifications*
5. *Documentation*
,Conditions of being *ineligible to leave AMA* - ANS1 *danger to self or others*
2. *lack of consciousness*
3. *Altered consciousness*
4. *Mental illness*
5. Being under *chemical influence*
6. *Court decision*
Conditions of being *ineligible to leave AMA* - ANS1 *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 - ANSNurse 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
Effective handoff communication components - ANSNurse 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* - ANS1. 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
*Risk factors* for *cervical cancer* - ANS1. 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? - ANS1. *calcium channel blockers* (diltiazem,
nifedipine, verapamil, etc)
2. *statins*
3. *SSRIs*
what medications interact with grapefruit? - ANS1. *calcium channel blockers* (diltiazem,
nifedipine, verapamil, etc)
2. *statins*
3. *SSRIs*
Risk associated with *stent placement* using the *femoral approach* - ANS*retroperitoneal
hemorrhage*
Risk associated with *stent placement* using the *femoral approach* - ANS*retroperitoneal
hemorrhage*
what are early signs of bleeding into the retroperitoneal space? - ANShypotension, back pain,
flank ecchymosis (grey turner sign), hematoma formation, diminshed distal pulses
what are early signs of bleeding into the retroperitoneal space? - ANShypotension, 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? - ANSbruising of the flanks and
retroperitoneal hemorrhage and is a bluish color
what is the grey-turner sign and what is it a sign of? - ANSbruising of the flanks and
retroperitoneal hemorrhage and is a bluish color
what are some physical signs of peripheral arterial disease? - ANSintermittent 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)
what are some physical signs of peripheral arterial disease? - ANSintermittent 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 - ANStachycardic like 90-110
, transplanted hearts are expected to be - ANStachycardic like 90-110
what is the priority intervention for pain with sickle cell crisis and why? - ANSadminister IV fluids
to reduce blood viscosity and restore perfusion to areas affected by vasoocclusion
what is the priority intervention for pain with sickle cell crisis and why? - ANSadminister IV fluids
to reduce blood viscosity and restore perfusion to areas affected by vasoocclusion
what is the purpose of continuous bladder irrigation? - ANSit is perscribed after TURP to
prevent obstruction of urine outflow by removing clotted blood from the bladder
what is the purpose of continuous bladder irrigation? - ANSit 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? - ANSmonitor quality of drainage, titrate the inflow
rate, and manurally irrigating as needed
what is the nurses care of monitoring CBI? - ANSmonitor quality of drainage, titrate the inflow
rate, and manurally irrigating as needed
characteristics of a basilar skull fracture - ANSperiorbital hematomas (raccoon eyes), csf fluid
rhinorrhea, and battle sign (behind the ear bruising)
characteristics of a basilar skull fracture - ANSperiorbital hematomas (raccoon eyes), csf fluid
rhinorrhea, and battle sign (behind the ear bruising)
immediate client care for basilar skull fracture - ANScervical spime immobilization, close
neurologic monitoring, and support of ABCs
immediate client care for basilar skull fracture - ANScervical spime immobilization, close
neurologic monitoring, and support of ABCs
vomiting with intake may mean - ANSviral or bacterial infection
vomiting with intake may mean - ANSviral or bacterial infection
tympanosomty tubes are placed for - ANSrecurrent otis medias
tympanosomty tubes are placed for - ANSrecurrent otis medias
nurse actions during a seizure - ANSassist 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)
When do *advanced directives* go into effect? - ANSwhen person is *unable to speak for
him/herself* due to either:
1. *Mental Incapacity* - *coma *(GCS score ≤ 7)
2. *Aphasia*
(≠as soon as signed; directives can always be changed later by person)
When do *advanced directives* go into effect? - ANSwhen person is *unable to speak for
him/herself* due to either:
1. *Mental Incapacity* - *coma *(GCS score ≤ 7)
2. *Aphasia*
(≠as soon as signed; directives can always be changed later by person)
SBAR Communication Framekwork Components - ANS1. *S* = Situation - what *prompted* the
communication (eg *what* changes occurred)
2. *B* = Background - *pertinent information, relevant history, vital signs*
3. *A* = Assessment - nurse's assessment of the situation (*when* & *what changes* occurred)
4. *R* = Recommendation - *request* for *prescription* or *action* from HCP
SBAR Communication Framekwork Components - ANS1. *S* = Situation - what *prompted* the
communication (eg *what* changes occurred)
2. *B* = Background - *pertinent information, relevant history, vital signs*
3. *A* = Assessment - nurse's assessment of the situation (*when* & *what changes* occurred)
4. *R* = Recommendation - *request* for *prescription* or *action* from HCP
Appropriate order of actions when client found on floor - ANS1. *Assessment* of *physiological
stability* (ABCs)
2. *Assessment* of *injuries*
3. *Moving client*
4. *Notifications*
5. *Documentation*
Appropriate order of actions when client found on floor - ANS1. *Assessment* of *physiological
stability* (ABCs)
2. *Assessment* of *injuries*
3. *Moving client*
4. *Notifications*
5. *Documentation*
,Conditions of being *ineligible to leave AMA* - ANS1 *danger to self or others*
2. *lack of consciousness*
3. *Altered consciousness*
4. *Mental illness*
5. Being under *chemical influence*
6. *Court decision*
Conditions of being *ineligible to leave AMA* - ANS1 *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 - ANSNurse 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
Effective handoff communication components - ANSNurse 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* - ANS1. 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
*Risk factors* for *cervical cancer* - ANS1. 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? - ANS1. *calcium channel blockers* (diltiazem,
nifedipine, verapamil, etc)
2. *statins*
3. *SSRIs*
what medications interact with grapefruit? - ANS1. *calcium channel blockers* (diltiazem,
nifedipine, verapamil, etc)
2. *statins*
3. *SSRIs*
Risk associated with *stent placement* using the *femoral approach* - ANS*retroperitoneal
hemorrhage*
Risk associated with *stent placement* using the *femoral approach* - ANS*retroperitoneal
hemorrhage*
what are early signs of bleeding into the retroperitoneal space? - ANShypotension, back pain,
flank ecchymosis (grey turner sign), hematoma formation, diminshed distal pulses
what are early signs of bleeding into the retroperitoneal space? - ANShypotension, 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? - ANSbruising of the flanks and
retroperitoneal hemorrhage and is a bluish color
what is the grey-turner sign and what is it a sign of? - ANSbruising of the flanks and
retroperitoneal hemorrhage and is a bluish color
what are some physical signs of peripheral arterial disease? - ANSintermittent 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)
what are some physical signs of peripheral arterial disease? - ANSintermittent 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 - ANStachycardic like 90-110
, transplanted hearts are expected to be - ANStachycardic like 90-110
what is the priority intervention for pain with sickle cell crisis and why? - ANSadminister IV fluids
to reduce blood viscosity and restore perfusion to areas affected by vasoocclusion
what is the priority intervention for pain with sickle cell crisis and why? - ANSadminister IV fluids
to reduce blood viscosity and restore perfusion to areas affected by vasoocclusion
what is the purpose of continuous bladder irrigation? - ANSit is perscribed after TURP to
prevent obstruction of urine outflow by removing clotted blood from the bladder
what is the purpose of continuous bladder irrigation? - ANSit 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? - ANSmonitor quality of drainage, titrate the inflow
rate, and manurally irrigating as needed
what is the nurses care of monitoring CBI? - ANSmonitor quality of drainage, titrate the inflow
rate, and manurally irrigating as needed
characteristics of a basilar skull fracture - ANSperiorbital hematomas (raccoon eyes), csf fluid
rhinorrhea, and battle sign (behind the ear bruising)
characteristics of a basilar skull fracture - ANSperiorbital hematomas (raccoon eyes), csf fluid
rhinorrhea, and battle sign (behind the ear bruising)
immediate client care for basilar skull fracture - ANScervical spime immobilization, close
neurologic monitoring, and support of ABCs
immediate client care for basilar skull fracture - ANScervical spime immobilization, close
neurologic monitoring, and support of ABCs
vomiting with intake may mean - ANSviral or bacterial infection
vomiting with intake may mean - ANSviral or bacterial infection
tympanosomty tubes are placed for - ANSrecurrent otis medias
tympanosomty tubes are placed for - ANSrecurrent otis medias
nurse actions during a seizure - ANSassist 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)
