UWORLD Questions to Review

The nurse is caring for assigned clients. The nurse should first assess the client who:

1. Has infective endocarditis and a temprature of 101.5F (38.6)

2. Had a heart transplant 2 months ago and has sustained sinus tachycardia of 110/min at rest

3. Had coronary stent placement via the femoral artery 3 hours ago and reporting severe back pain

4. Had coronary CABG sx 3 days ago and is reporting swelling of extremity used for donor graft

Had coronary stent placement via the femoral artery 3 hours ago and reporting severe back pain.

Nurse caring for client who sustained fracture of the right tibia and fibula. Which factors increase risk for delayed bone helaing?

1. BMI of 29.5 kg/m²

2. Family Hx of Osteoporosis

3. Hx of PAD

4. 1 Glass of wine per day

Hx of PAD.

Nurse is caring for a client who is recieving a transfusion of packed RBC’s through a PICC. During transfusion client recieves new Rx for IV Amphotericin B. It would be most appropriate to:

1. Administer Amphotericin B through an open lumen of PICC

2. Insert PVAD and administer Amphotericin B

3. Interrupt transfusion and adminsiter Amphotericin B

4. Wait 1 hour after infusion is complete to administer Amphotericin B

Wait 1 hour after infusion is complete to administer Amphotericin B.

(Amphotericin B is an anitfungal medication with has similar adverse effects to blood transfusion reaction i.e., chilss fever, hypotension, kidney injury. Best action is to complete in order to distinguish between transfusion and medication reaction.)

Client chest tube reinserted and connected to new water seal drainge system. What would require a follow-up:

1. Continuous bubbling in the water seal chamber

2. 150 mL sanguineous drainage 1 hour after chest tube reinsertion

3. Water level in the water-seal chamber rises with inhalation and falls with exhalation

4. Diminished breath sounds on the right side of the chest

5. Pleuritic chest pain on deep inspiration

• Continuous bubbling in the water seal chamber

  • Indicates an air leak; unless gentle bubbling which is expected in suction control chamber

• 150 mL sanguineous drainage 1 hour after chest tube reinsertion

  • Drainage > 100 mL indicative of possible hemmorhage or chest tube complication

Nurse is triaging clients at the site of a manufacturing plant explosion. Which of the following clients should the nurse ensure is transported to the hospital first?

1. A client who has laceration on the left lower arm

2. A client who has an open fracture of the right tibia and an absent right pedal

3. A client who has partial thickness burns on both of the hands

4. A client who has a large, open head wound and a GCS of 3

• A client who has an open fracture of the right tibia and an absent right pedal

  • Emergent (RED) highest priority: Life-threatening injuries with high porbablityh of survival if immeidate tx done

  • Urgent (YELLOW): Serious injuries requiring tx in 30 mins - 2 hours

  • Nonurgent (GREEN): Injuries requiring tx but can wait >= 2 hours

  • Expectant (BLACK): Extensive injuries with poor prognosis regardless of tx

Nurse comments on a public post maintained by group of nurses. Which following posr breaches client confidentiality?

1. I private messaged everyone a cute story about our sweet client with dementia

2. The client in room 5 is positive for flu so remeber to get flu vaccines

3. Wash hands well if you cared for room 4, client’s cultures are positive for C. Diff.

4. Cleint acuity has been high lately, but I am grateful to work with supportive staff members

5. It breaks my heart that our client with paraplegia was so neglected by the family

• I private messaged everyone a cute story about our sweet client with dementia

• The client in room 5 is positive for flu so remeber to get flu vaccines

• Wash hands well if you cared for room 4, client’s cultures are positive for C. Diff.

• It breaks my heart that our client with paraplegia was so neglected by the family

Nurse prepping to put urinary catheter in male client. Which of the following action should the nurse take?

1. Apply sterile gloves

2. Place client in the semi-Fowler’s

3. Cleanse the meatus with antiseptic-coated swab sticks

4. Use the nondominant hand to grasp the penis below the glans

5. Insert cather tubing 3 inches (7.6 cm) and inflate the balloon

• Apply sterile gloves

• Cleanse the meatus with antiseptic-coated swab sticks

• Use the nondominant hand to grasp the penis below the glans

Nurse taught client with ESRD and Hyperkalemia about diet modifications. Which would indicate correct understanding.

1. Black beans and rise, slices tomatoes, & cantaloupe

2. Grilled chicken breat, white bread, & applesauce

3. Hamburger patty, whole wheat bread, & carrot sticks

4. Poached salmon, a baked potato, & strawberries

• Grilled chicken breat, white bread, & applesauce

  • Clients with ESRD cannto excrete K+ so avoid leaft greens, cruciferous vegetables (broccoli, cauliflower, etc.), legumes, melons, bananas, strawberries, milk, milk products, beef, fish, shellfish, whole grains, etc.

Nurse is teaching client who has new prescription for risperidone. Which of the following statements bu the client woudl require follow-up?

1. I will contact my health care provider if I have a fever or muscle stiffness

2. I may become shaky & restless when I am agitated

3. I may sleep more often when taking this medication

4. I will try to change positions slowly

• I may become shaky & restless when I am agitated

  • 2nd Gen antipsychotic meds used to treat schizophrenia, BP, etc.

  • Can have EPS → Restlessness, fidgeting, parkinsonism, & tardive dyskinesia

Nurse talking to staff who states: “Client has a hx of SUD and keeps requesting pain meds. I just administered NS instead of morphine because it is too early for another dose of morphine”. Which actions should the nurse take next?

1. Report the incident to the facility’s thics committee

2. Follow facility protocol for completeing an incident report

3. Instruct the staff member to document the incident and notify the unit manager

4. Instruct the staff member to notify the health care provider about the client’s uncontrolled pain

Instruct the staff member to notify the health care provider about the client’s uncontrolled pain.

Nurse caring for client recieving sedation and mechinical ventilation. Client coughs and expels the ET tube. Which of the following actions should the nurse take first?

1. Assess the respiratory reate and breath sounds to ensure adequate ventilation

2. Activate the emergency response team to manage potential cardiac arrest

3. Deliver rescure breaths with a bag valve mask resucitator and 100% O2

4. Notify the HCP and prepare for reintubation

• Deliver rescure breaths with a bag valve mask resucitator and 100% O2

  • Accidental extubation is a medical emergency. Always remain with the client, protect the airway using head-tilt-chin-lift or the jaw-thrust-maneuver (if spinal injury); and devliver breaths using bag-valve-mask resusicatator with 100% O2 until reintubation achieved

Nurse is preparing to adminsiter lithium to client. Which medications should nurse hold for clarification?

1. Hydrochlorothiazide

2. Acetaminophen

3. Suladiazine

4. Metformin

• Hydrochlorothiazide

  • Thiazide diuretics have higher chance to increase Lithium concentration

Nurse in ER caring for pediatric patients. Nurse should first assess client who:

1. Is unable to eat or drink without vomiting

2. Has bruising behind the ears after sustaining a sports injury

3. Has recently placed tympanostomy tube that has fallen out

4. Has external fixator and increased pain at the pin insertion sites

• Has bruising behind the ears after sustaining a sports injury

  • S&S of Basilar Skull Fracture → Associated with intracranial injury close to the brainstem, therefore priority

Nurse planning care for client with BP I disorder who is having an acute manic episode. Which intervention is the priority?

1. Assist the client with dressing by giving step by step instructions

2. Collaborate with unit staff to set consistent limits on manipulative behaviours

3. Secure the client’s credit cards to prevent compulsive spending and bankruptcy

4. Offer high calorie snacks the client can ear while abulating during activities

• Offer high calorie snacks the client can ear while abulating during activities

  • When in mania, nurse should prioritize physiological over psychological or self-fulfillment needs

Alzheimer Disease vs Delirium

AD: Irreversible, Hallucinations, Speech Changes

Delirium: Reversible, Acute, Hallucinations, Speech Changes

Nurse assessing development of milestones of a 4 year old client. Which of the following would be an expected age-related finding?

1. Draws a circle

2. Uses a spoon and fork

3. Sits quietly for 30 minutes

4. Jumps rope with both feet

5. Walks up and down stairs

• Draws a circle

• Uses a spoon and fork

• Walks up and down stairs

Nurse enters client’s room who begins to have a seizure while sitting in a chair. What actions should the nurse take?

1. Hold the client’s arms and legs in place

2. Insert a flexible nasopharyngeal airway

3. Move the client from the chair to the floor

4. Note the time at the start of the seizure activity

5. Adminsiter O2 if client becomes cyanotic

• Move the client from the chair to the floor

• Note the time at the start of the seizure activity

• Adminsiter O2 if client becomes cyanotic

Nurse assessing client with dark skin who has DIC. Which of the following would be the best to assess for petechia?

1. Buccal mucosa and conjunctivae of the eye

2. Palms of the hands and soles of the feet

3. Skin over the sacrum and the heels

4. Nail beds of the fingers and toes

Buccal mucosa and conjunctivae of the eye

The home-health nurse is assessing the safety of the home environment for a pediatric client/ Follow up required if:

1. Family lives in a rural area

2. The house is heated by wood burning stove

3. The house was built in 1983

4. The client’s parents are unemployed and have limited financial resources

• The house is heated by wood burning stove

  • Is a fire hazard, and may cause physiological damage from smoke inhalation or burns

Nurse is interpreting the results of clinet’s TB skin test and notes 11 mm area of induration. Client emigrated from a country with a high prevalnce of TB one year ago and is asymptomatic. Which of the following actions should the nurse take?

1. Request an order for a CXR from the HCP

2. Ask th eclient about a Hx of bacille Calmette-Guerin vaccination

3. Wear a surgical mask and protective gown when caring for the client

4. Document the negative result in the client’s electronic medical record

5. Encourage the client to obtain a second TB skin test in 1 week

• Request an order for a CXR from the HCP

• Ask th eclient about a Hx of bacille Calmette-Guerin vaccination

  • Order CXR to identify latent TB from active disease

  • Ask about bacille Calmette-Guerin (BCG) vaccination as this can cause a false-positive PPD test result

Nurse preparing to administer thrombolytic therapy to a client who has right-sided paralysis and slurred speech. Which of the follwoing findings would be a contraindication to thrombolytic therapy?

1. BP of 175/100

2. Gallbladder sx 2 months ago

3. Symptom onset 12 hours ago

4. Absence of a gag reflex

• Symptom onset 12 hours ago

  • Clients have 3-4.5 hour window from onset of symptoms ro recieve t-PA to achieve full effectiveness of thrombolytic therapy

Nurse caring for client in soft wrist restraints. Which of the following iinterventions should the nurse include in the client’s plan of care?

1. Perform a neurovascular ax every hour

2. Assess the client’s need for restraints every 12 hours

3. Remove the restraints for a trial discontinuation every 4 hours

4. Offer fluids, nutrition, and toileting every 2 hours and as needed

5. Release the restraints to perform range-of-motion exercises every 2 hours

• Perform a neurovascular ax every hour

• Offer fluids, nutrition, and toileting every 2 hours and as needed

• Release the restraints to perform range-of-motion exercises every 2 hours

Nurse is teaching a client who has constipation. Which of the following information should the nurse include?

1. Increase your daily exercise level

2. Try to eat more legumes every day

3. Do not ignore the urge to have a BM

4. Drink more caffeinated beverages such as tea and soda

5. Take an OTC laxative every other day if needed

• Increase your daily exercise level

• Try to eat more legumes every day

• Do not ignore the urge to have a BM

  • Avoid using laxatives and enemas unless prescribed by a HCP.

Nurse is preparing to administer insulin lispro at 1700 to a client with DM. The nurse should recognize that the client is at highest risk for hypoglycemia during which of the following time frames?

1. 1730-2000

2. 1900-2200

3. 2000-0700

4. 2100-0500

• 1730-2000

  • Rapid-acting insulin peak within 30 mins - 3 hours after administration

Nurse discovers SL Mitrazipine was adminsitered through client’s percutaneous endoscopic gastronomy tube. After assessing the client for adverse reactionss, the nurse should next:

1. Document the error on an incident report

2. Inform the nurse manager about the error

3. Disclose the medication error the the client

4. Notify the prescribing HCP

• Notify the prescribing HCP

  • Client safety is the priority

Nurse in ER is peaking to client’s spouse who insists on being present in the room while the client is receiving CPR. Which of the following actions should the nurse take?

1. Allow the spouse into the room and provide a chair

2. Tell the spouse that the resuscitation is difficult to witness

3. Call the chaplain to sit with the spouse outside the room

4. Ask a staff member to escort the spouse to the waiting room

Allow the spouse into the room and provide a chair

Client admitted to the hospital for RLL Pneumonia. IV abs and supp O2 via NP initiated in the ED. Client takes no home medications but admits to recreational drug use.

Client now reporting new muscle pains, abd cramping, nausea, & diarrhea. The client is alert and restless, and piloerection si noted. The client’s pupils are dilated, and lacrimation is present. Bowel sounds are hyperactive and neurologic examination is normal.

The nurse suspects the client is withdrawing from _________ and should anticipiate _________

• Opioids. Buprenorphine.

  • Treatments include Opioid agonist medications such as Buprenorphine to prevent withdrawl symptoms

Client report sudden-onset vomiting and epigastric pain after a high fat meal. Client takes no medications and does not use alcohol or recreational drugs.

• Actions to take: Administer opioid analgesic, administer NS

  • NS to prevent hypovolemia and dehydration d/t third spacing

• Potential Condition: Pancreatitis

  • Cholecystitis present with epigastric pain that may radiate up to RUQ. Serum lipase wouldn’t be elevated unless gallstones blocking common bile duct leading to pancreatitis

• Parameters to monitor: Pain level, blood glucose level

  • Pancreatic damage and inflammation can impair insulin release

A transfusion was initiated 40 minutes after packed RBC’s were received from the blood bank via a 20-guage peripheral IV with NS. The RN was unavailable for blood product verification. The blood product was verified with the unlicensed assistive personnel. The client is now anxious and diaphoretic and reports lower back pain rated as 7 on a scale of 0-10. The rate of transfusion is decreased, and the HCP is notified. Which of the following nurse actions require further education on blood transfusions?

• Transfusion was initiated 40 mins after packed RBC’s were received from the blood bank

  • >30 mins shouldn’t be used and should be returned to the blood bank as chances for bacterial growth is >

• The blood product was verified with the UAP

  • Can only verify with another licensed nurse

• Rate of transfusion is decreased

  • Priority should be to stop the transfusion in transfusion reaction

For each finding below, specify if the finding is consistent with the disease process of acute hemolytic transfusion reaction. sip

A transfusion was initiated 40 minutes after packed RBC’s were received from the blood bank via a 20-guage peripheral IV with NS. The RN was unavailable for blood product verification. The blood product was verified with the unlicensed assistive personnel. The client is now anxious and diaphoretic and reports lower back pain rated as 7 on a scale of 0-10. The rate of transfusion is decreased, and the HCP is notified. The HCP is at the bedside. The urinary catheter drainage bag has dark red urine. The client has not itching, hives, or angioedema, and the lung sounds are normal. Specify if the intervention is anticipated or unanticipated for the care of the client.

• Anticipated

  • Stop the transfusion

  • Remain with the client and assess vital signs

  • Connect new tubing and infuse NS

  • Send the blood product bah and tubing to the blood bank

• Unanticipated

  • Administer IM epinephrine (in anaphylactic reaction not hemolytic reaction)

A transfusion was initiated 40 minutes after packed RBC’s were received from the blood bank via a 20-guage peripheral IV with NS. The RN was unavailable for blood product verification. The blood product was verified with the unlicensed assistive personnel. The client is now anxious and diaphoretic and reports lower back pain rated as 7 on a scale of 0-10. The rate of transfusion is decreased, and the HCP is notified. The HCP is at the bedside. The urinary catheter drainage bag has dark red urine. The client has not itching, hives, or angioedema, and the lung sounds are normal. The blood transfusion was stopped. The bloo product bag and tubing were sent to the blood bank. The blood bank notified the nurse of a ABO incompatibility with the client’s blood type ad donor blood. What is the priority intervention for the nurse?

1. Administer IV fluid bolus

2. Collect urine sample

3. Initiate continuous cardiac monitoring

4. Obtain a new type and crossmatch

• Administer IV fluid bolus

  • For aggressive hydration with NS for hemodynamic stabilization and prevention of kidney injury

Nurse is providing discharge instructions to a client receiving Oxybutynin for overreactive bladder. Which client statement indicates that further teaching is required?

1. I am looking forward to our summer vacation at the beach

2. I plan to eat more fruits and vegetables to prevent constipation

3. I should no drive until I know how this drug affects me

4. I will drink at least 6-8 glasses of water daily

• I am looking forward to our summer vacation at the beach

  • Oxybutynin is an anticholinergic used to tx overreactive bladder; it can cause decreased sweat production, which can lead to hyperthermia. Nurse should instruct the client to be cautious in hot weather and during physical activity

Nurse is teaching a group of parents at a community health fair about prevention of epiglottitis. Which of the following information should the nurse include?

1. Standard immunizations can reduce the risk for epiglottitis

2. The majority of epiglottitis cases are cause by smoke inhalation

3. Exposure to dust and animal dander can increase the risk for epiglottitis

4. Antiviral therapy should be initiated after contact with an individual who has epiglottitis

• Standard immunizations can reduce the risk for epiglottitis

  • Hemophilus influenzas type b (Hib) infections can be prevented via standard immunizations administered during infancy

Nurse caring for client with liver cirrhosis. Which of the following requires immediate follow up?

1. Black, tarry stool

2. Bright red-streaked stool

3. Light gray clay-colored stool

4. Small, dry, rocky stool

• Black, tarry stool

  • Caused by digested blood indicative of active upper GI bleed or bleeding esophageal varices

Client with hypothyroidism has been receiving levothyroxine for the past 12 months. Lab tests show elevated TSH. Which of the following statements would be appropriate for the nurse to make?

1. Talk half your prescribed dose of levothyroxine in the morning and half in the evening

2. Levothyroxine may be temporarily held until your TSH level is rechecked in 3 weeks

3. Expect your HCP to increase your prescribed dose of levothyroxine

4. Levothyroxine should be taken with a calcium supplement to increase its effectiveness

• Expect your HCP to increase your prescribed dose of levothyroxine

  • Hypothyroidism → Low serum thyroid hormone levels → Increased TSH levels

Nurse is caring for an infant who is not breathing. The nurse activates the emergency response system. Which of the following actions should the nurse take next?

1. Gather supplies for ET intubation

2. Administer IV epinephrine

3. Palpate the brachial artery for a pulse

4. Begin chest compressions

Palpate the brachial artery for a pulse

Nurse caring for a client with Schizophrenia who is experiencing auditory hallucinations and has a new prescription for an oral antipsychotic. Which of the following actions should the nurse take?

1. Provide music for the client

2. Use gentle touch to calm the client

3. Instruct the client to ignore the hallucinations

4. Tell the client the medications will alleviate the hallucinations within a few hours

• Provide music for the client

  • Provide activities to distract the client from the hallucinations

Nurse is making client assignments for UAP. Which of the following statements by the nurse would provide the best direction about the assignment?

1. Notify me if the client in room 2 has a systolic BP < 100 mm Hg

2. Closely observe the client in room 1 because the client is at risk for falling

3. Ensure that the client in room 3 ambulates several times during the shift

4. Obtain the vital signs of the clients in rooms 1 through 4 this morning

• Notify me if the client in room 2 has a systolic BP < 100 mm Hg

  • Providing specific and measurable instructions gives the UAP the best directions for completing a task

Which assignment is the most appropriate for a new graduate nurse?

1. 36-year-old client with post op venous thromboembolism who is to be started on the institution’s IV Heparin therapy protocol this morning

2. 56-year-old client with newly diagnosed cancer, schedules for a total laryngectomy this morning, who is now refusing surgery

3. 68-year-old client with MS. 2 days post op open cholecystectomy with recurrent mucous plugs who is scheduled for a bronchoscopy this morning

4. 80-year-old client, 3 days post op colectomy with peritonitis, who was mentally alert before and develops new-onset confusion this morning

• 68-year-old client with MS. 2 days post op open cholecystectomy with recurrent mucous plugs who is scheduled for a bronchoscopy this morning

Nurse is checking client’s O2 reading. Nurse shoudl understand that the accuracy of the reading may be affected if the client is currently experiencing:

1. Fever

2. Tachycardia

3. Hypotension

4. Tachypnea

• Hypotension

Client is admitted with lower UTI from obstructing ureteral stone. Which tasks can the RN delegate to the experienced UAP?

1. Assisting the client in completing a health history form

2. Collecting a urine specimen for culture and sensitivity

3. Instructing the client to strain urine when voiding

4. Measuring and documenting urine output

5. Monitoring the color and characteristics of urine output

• Collecting a urine specimen for culture and sensitivity

• Measuring and documenting urine output

Which of the following would be appropriate for the nurse to assign to the UAP?

1. Assisting a client to ambulate to the toilet

2. Changing the pouch on a newly created colostomy

3. Reapplying a client’s nasal cannula if it is accidentally removed

4. Taking and documenting vital signs in the electronic medical record

5. Notifying the nurse if a client’s respiratory rate is greater than 20/min

• Assisting a client to ambulate to the toilet

• Reapplying a client’s nasal cannula if it is accidentally removed

• Taking and documenting vital signs in the electronic medical record

• Notifying the nurse if a client’s respiratory rate is greater than 20/min

Which of the following can the nurse delegate to the UAP?

1. Ambulate an oxygen-dependent client to the bathroom

2. Assist client the dentures to perform oral care after the client’s meal

3. Document pulse oximetry of a client with COPD

4. Instruct a client with pneumonia on use of the incentive spirometer

5. Turn and reposition a client with pneumonia

• Ambulate an oxygen-dependent client to the bathroom

• Assist client the dentures to perform oral care after the client’s meal

• Document pulse oximetry of a client with COPD

• Turn and reposition a client with pneumonia

Diabetic client is prescribed metoclopramide. Which of the following side effects must the nurse teach the client to report immediately to the HCP?

1. Excess blinking of eyes

2. Dry mouth

3. Dull headache

4. Lip smacking

5. Puffing of cheeks

• Excess blinking of eyes

• Lip smacking

• Puffing of cheeks

  • EPS → Tardive Dyskinesia major i.e., blinking excessively, puffing of cheeks, lip smacking, etc.

Client in ER sustained partial thickness burns to all anterior body surfaces below neck. Using the rule of nines, what percentage of total body surface area affected should the nurse document?

• 46%

  • Anterior Arm BIL → 4.5% x 2 = 9%

  • Anterior Chest → 18%

  • Perineal Area → 1%

  • Anterior Leg BIL → 9% x 2 = 18%

  • 9% + 18% + 4.5% + 1% + 18% = 46% Total Burn

Nurse teaching on nutrition and feeding practices for young children. What should the nurse recommend as the best snack for a toddler?

1. ½ cup orange juice

2. Dry, sweetened cereal

3. Raw carrot sticks

4. Slices of cheese

• Slices of cheese

  • Safe, nutrient dense, and no potential for foodborne illness (i.e., raw, unpasteurized foods)

Nurse admitting a client at 39 weeks’ gestation who is scheduled for labor due to oligohydramnios. When considering the indication for induction, the nurse should anticipate the need for:

1. Amnioinfusion to alleviate cord compression

2. Forceps-assisted vaginal birth

3. Intermittent fetal monitoring during labor

4. Oxytocic medication to prevent postpartum hemorrhage

• Amnioinfusion to alleviate cord compression

Nurse is caring for a school-aged client with newly diagnosed ADHD. The nurse should recognize that the client is at risk for developing:

1. Delayed physical development

2. Delusions

3. Low self-esteem

4. Paranoia

• Low self-esteem

Nurse is caring for client who is receiving enteral feedings after sustaining severe burns to the face. Which of the following statements by the nurse would indicate a correct understanding of why the client is receiving enteral feedings instead of parenteral nutrition?

1. Enteral feeding help maintain gut integrity and prevent stress ulcers

2. Hyperglycemia occurs with parenteral nutrition but not with enteral feedings

3. Enteral feedings can be used to extended durations, and parental nutrition cannot

4. Ther is a higher calorie and nutrient content in enteral feedings than in parental nutrition

• Enteral feeding help maintain gut integrity and prevent stress ulcers