UWORLD NCLEX EXAM 2023 -2024 LATEST EXAM 300

UWORLD NCLEX EXAM 2023 -2024 LATEST EXAM 300

QUESTIONS AND CORRECT DETAILED ANSWERS

WITH RATIONALES (VERIFIED ANSWERS )

|ALREADY GRADED A+

The spouse brings a client to the emergency department due to erratic behavior and expressions of despair. The emergency department is extremely busy with many clients. When the triage nurse asks if the client feels suicidal now, the client shrugs the shoulders. What initial action should the triage nurse take? - ANSWER- Place the client in an inside hallway with one-on-one observation.

The orthopedic health care provider instructs a client with a fractured femur, who has been non-weight bearing for the past 5 weeks, to progress to full weight bearing on the right leg. which advanced crutch gait that most closely resembles normal walking should the office nurse teach the client? - ANSWER- 4-point gait

- there are 5 crutch gaits: 2-, 3-, 4-point, swing-to, and swing-through

`A nurse administers an intramuscular (IM) injection using the Z-track method technique. Place the steps in chronological order. All options must be used. - ANSWER- 4. Pull the skin 1-1 1/2" (2.5-3.5 cm) laterally and away from the injection site.

• Hold the skin taut with non-dominant hand and insert needle at a 90-

degree angle.

• Inject medication slowly with dominant hand while maintaining

traction 1 / 4

• Wait 10 seconds after injecting the medication and withdraw the

needle.Release the hold on the skin, allowing the layers to slide back to their original position.

• Apply gentle pressure at the injection site but do not massage.

The clinic nurse is teaching a client about levothyroxine, which the health care provider has prescribed for newly diagnosed hypothyroidism.Which statement made by the client indicates that further teaching is needed? - ANSWER- "If this makes my stomach upset, I will take it with an antacid."

• will impair the absorption of levothyroxine (Synthroid). -- Antacids,

calcium and iron preparations.

• should take levothyroxine on an empty stomach, preferably in the

morning, separately from other medications

The nurse is reviewing laboratory results for several prenatal clients.Which finding is most important to report to the health care provider? - ANSWER- Client at 24 weeks gestation with hemoglobin of 9 g/dL (90 g/L) and hematocrit of 29%

• during the second half of pregnancy, the fetus beings to store iron,

depleting maternal stores. Hemoglobin <11 g/dL in the first or third trimester or <10.5 g/dL in the second trimester is considered low.

A client with obesity has just started taking orlistat. Which statement by the client indicates a need for further teaching? - ANSWER- "I have started taking a daily multivitamin with my dinner-time dose of medication." 2 / 4

• Orlistat is a lipase inhibitor that prevents the breakdown and absorption

of fats from the intestine - interferes with fat-soluble vitamin uptake

The nurse on the medical-surgical unit receives report on assigned clients. Which client warrants immediate attention? - ANSWER- Client with epigastric pain after endoscopic retrograde cholangiopancreatography.

• Perforation or irritation of these areas during the procedure can cause

acute pancreatitis, a potentially life-threatening complication after an

ERCP: s/s - acute epigastric or left upper quadrant pain, often radiating

to the back, and a rapid rise in pancreatic enzymes (amylase. lipase)

The home health care nurse reviews the laboratory results for 4 clients.Which laboratory value is most important for the nurse to report to the health care provider? - ANSWER- Client with rheumatoid arthritis taking adalimumab has a WBC count of 14,000/mm3

Which emergency department client would be allowed to leave against medical advice after the risks are discussed with the primary health care provider? - ANSWER- Client with coffee-ground emesis from chronic use of high-dose aspirin.

• Issues that can make a client ineligible to leave AMA include danger to

self or others, lack of consciousness, altered consciousness, mental illness, being under chemical influence, or a court decision. Parents may not refuse life-, limb-, or organ- saving treatment on behalf of their

minor child for religious or personal reasons: if the parents deny critical

treatments to the child, the hospital may seek protective custody

• / 4

Which of the following are examples of medical battery? Select all that apply. - ANSWER- 3. The nurse administers 2 mg of morphine PRN to a difficult, alert client but tells the client it is saline.

• The nurse inserts a needed urinary catheter even though a competent

client refuses it

The nurse is preparing to administer a scheduled dose of metoclopramide IV to a client with diabetic gastroparesis. Which clinical finding causes the nurse to question the prescription? - ANSWER- Sucking lip motions.

• Metoclopramide is a commonly used antiemetic medication that treats

nausea, vomiting, and gastroparesis by increasing gastrointestinal motility and promoting stomach emptying. With extended use and/or high doses, metoclopramide may lead to the development of tardive dyskinesia, a movement disorder that is characterized by uncontrollable motions and is often irreversible.

Clinical manifestations of tardive dyskinesia: Facial - ANSWER- - Lip

movement - smacking, sucking, puckering

• tongue movement - protrusion, curling
• grimace
• brow furrow or twitch
• excess blinking

Clinical manifestations of tardive dyskinesia: extremities - ANSWER- -

foot tap

• hand wringing
• / 4