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UWorld NCLEX-RN TEST 2 QUESTIONS WITH COMPLETE SOLUTIONS 2025 GRADED A+ PASS, Exams of Nursing

University of London (Lond)Nursing

UWorld NCLEX-RN TEST 2 QUESTIONS WITH COMPLETE SOLUTIONS 2025 GRADED A+ PASS UWorld NCLEX-RN TEST 2 QUESTIONS WITH COMPLETE SOLUTIONS 2025 GRADED A+ PASS

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UWorld NCLEX-RN TEST 2 QUESTIONS WITH COMPLETE
SOLUTIONS 2025 GRADED A+ PASS
The nurse is caring for the client with increased intracranial pressure. The nurse
would note which trend in vital signs if the intracranial pressure is rising?
1. Increasing temperature, increasing pulse, increasing respirations, decreasing
blood pressure
2. Increasing temperature, decreasing pulse, decreasing respirations, decreasing
blood pressure
3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing
blood pressure
4. Decreasing temperature, increasing pulse, decreasing respirations, increasing
blood pressure - ANSWERS-2. Increasing temperature, decreasing pulse,
decreasing respirations, increasing blood pressure
A change in vital signs may be a late sign of increased intracranial pressure.
Trends include increasing temperature and blood pressure and decreasing pulse
and respirations. Respiratory irregularities also may occur.
The nurse has established a goal to maintain intracranial pressure (ICP) within the
normal range for a client who had a craniotomy 12 hours ago. What should the
nurse do? Select all that apply.
1. Encourage the client to cough to expectorate secretions.
2. Elevate the head of the bed 15 - 20 degrees.
3. Contact the HCP if ICP is >15 mmHg.
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Download UWorld NCLEX-RN TEST 2 QUESTIONS WITH COMPLETE SOLUTIONS 2025 GRADED A+ PASS and more Exams Nursing in PDF only on Docsity!

UWorld NCLEX-RN TEST 2 QUESTIONS WITH COMPLETE

SOLUTIONS 2025 GRADED A+ PASS

The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising?

  1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure
  2. Increasing temperature, decreasing pulse, decreasing respirations, decreasing blood pressure
  3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure
  4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure - ANSWERS-2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may occur. The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a client who had a craniotomy 12 hours ago. What should the nurse do? Select all that apply.
  5. Encourage the client to cough to expectorate secretions.
  6. Elevate the head of the bed 15 - 20 degrees.
  7. Contact the HCP if ICP is >15 mmHg.
  1. Monitor neurologic status using the Glasgow Coma Scale.
  2. Stimulate the client with active range-of-motion exercises. - ANSWERS-2, 3, 4 The nurse should maintain ICP by elevating the head of the bed 15 - 20 degrees and monitoring neurologic status. An ICP >15 mmHg with 20 to 25 mmHg as upper limits of normal indicates increased ICP, and the nurse should notify the HCP. Coughing and range of motion exercises will increase ICP and should be avoided in the early postoperative stage. What should the nurse do first when a client with a head injury begins to have clear drainage from the nose?
  3. Compress the nares
  4. Tilt the head back
  5. Collect the drainage
  6. Administer an antihistamine for postnasal drip - ANSWERS- The clear drainage must be analyzed to determine whether it is nasal drainage or CSF. The nurse should not give the client tissues because it is important to know how much leakage of CSF is occurring. Compressing the nares will obstruct the drainage flow. It is inappropriate to tilt the head back, which would allow the fluid to drain down the throat and not be collected for a sample. It is inappropriate to administer an antihistamine because the drainage may not be from postnasal drip. A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present?
  7. Fluid is clear and tests negative for glucose.
  8. Fluid is grossly blood in appearance and has a pH of 6

statement suggests that the family understand the measures to use when caring for the client?

  1. We need to discourage him from wearing eyeglasses.
  2. We need to place objects in his impaired field of vision.
  3. We need to approach him from the impaired field of vision.
  4. We need to remind him to turn his head to scan the lost visual field. - ANSWERS- Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses, if they are available. What is the expected outcome of thrombolytic drug therapy for stroke?
  5. Increased vascular permeability
  6. Vasoconstriction
  7. Dissolved emboli
  8. Prevention of hemorrhage - ANSWERS- Thrombolytic enzyme agents are used for clients with a thrombotic stroke to dissolve emboli, this reastablishing cerebral perfusion. They do not increase vascular permeability, cause vasoconstriction, or prevent further hemorrhage. The nurse sees a client walking in the hallway who begins to have a seizure. What should the nurse do in order of priority from first to last? All options must be

used.

  1. Maintain a patent airway.
  2. Record the seizure activity observed.
  3. Ease the client to the floor.
  4. Obtain vital signs. - ANSWERS-3, 1, 4, 2 To protect the client from falling, the nurse first should ease the client to the floor. It is important to protect the head and maintain a patent airway since altered breathing and excessive salivation can occur. The assessment of the postictal period should include level of consciousness and vital signs. The nurse should record details of the seizure once the client is stable. The events preceding the seizure, timing with descriptions of each phase, body parts affected and sequence of involvement, and autonomic signs should be recorded. The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply.
  5. Padding the side rails of the bed.
  6. Placing an airway at the bedside.
  7. Placing the bed in the high position
  8. Putting a padded tongue blade at the head of the bed
  9. Placing oxygen and suction equipment at the bedside
  10. Flushing the intravenous catheter to ensure that the site is patent. - ANSWERS- 1, 2, 5, 6 Seizure precautions may vary from agency to agency, but they generally have some common features. Usually, an airway, oxygen, and suctioning equipment
  1. Establish IV access
  2. Place the client on droplet precautions
  3. Prepare the client for lumbar puncture - ANSWERS-3. Place the client on droplet precautions. The client with suspected bacterial meningitis should be placed on droplet precaution isolation until the causative agent has been identified and appropriate treatment is initiated. Meningococcal meningitis and Haemophilus influenzae type B meningitis are highly transmissible to others, and the client must remain on droplet isolation until these can be ruled out. Precautions can usually be discontinued 24 hours after beginning antibiotic therapy. Viral meningitis and other types of bacterial meningitis (ie, other than meningococcal meningitis) usually do not require droplet precautions. (Option 1) Although assessment is a priority and meningeal signs should be checked, the nurse can only safely perform these assessments once droplet precautions are in place. (Options 2 and 4) A peripheral IV catheter should be inserted to provide fluids. Subsequently, preparation for lum Four children are brought to the emergency department. Which child should be assessed first?
  4. A 13-month-old who ingested an unknown quantity of children's multivitamins
  5. A 15-month-old with a fever of 100.5 F (38.1 C) after being vaccinated
  6. A 3-year-old with a forehead laceration and colorless nasal drainage
  1. A 4-year-old with enlarged tonsillar lymph nodes who is crying in pain - ANSWERS- Clear, colorless fluid draining from the nose or ears after head trauma is suspicious for cerebrospinal fluid (CSF) leakage (Option 3). When the drainage is clear, dextrose testing can be used to determine if the drainage is CSF. However, the presence of blood would make this test unreliable as blood also contains glucose. This child is at risk for intracerebral bleeding and meningitis. Vascular compromise may occur with even minimal head trauma; therefore, the nurse should evaluate any changes in level of consciousness and temperature as well as assess the head and neck for subcutaneous bleeding. The nurse should anticipate a CT scan of the head and neck and prophylactic antibiotics. (Option 1) Iron ingestion is the major concern with vitamin toxicity in children. However, children's formulations contain minimal or no iron. As a result, ingestion of an unknown quantity is unlikely to cause serious toxicity. This A client comes to the emergency department with diplopia and recent onset of nausea. Which statement by the client would indicate to the nurse that this is an emergency?
  2. "I am very tired, and it's hard for me to keep my eyes open."
  3. "I don't feel good, and I want to be seen."
  4. "I have not taken my blood pressure medicine in over a week."
  5. "I have the worst headache I've ever had in my life." - ANSWERS- A ruptured cerebral aneurysm is a surgical emergency with a high mortality rate. Cerebral aneurysms are usually asymptomatic unless they rupture; they are often

The vagus nerve is stimulated when bearing down; this temporarily slows the heart and decreases cardiac output, leading to potential cardiac complications in clients with heart disease (Option 3). Straining increases intra-abdominal and intrathoracic pressure and should be avoided in clients diagnosed with portal hypertension related to cirrhosis due to the risk of variceal bleeding (Option 5). The maneuver increases intraocular pressure and is contraindicated in clients with glaucoma and recent eye surgery (Option 6) A client is admitted to the hospital for severe headaches. The client has a history of increased intracranial pressure (ICP), which has required lumbar punctures to relieve the pressure by draining cerebrospinal fluid. The client suddenly vomits and states, "That's weird, I didn't even feel nauseated." Which action by the nurse is the most appropriate?

  1. Document the amount of emesis
  2. Lower the head of the bed
  3. Notify the health care provider (HCP)
  4. Offer anti-nausea medication - ANSWERS- Unexpected and projectile vomiting without nausea can be a sign of increased ICP, especially in the client with a history of increased ICP. The unexpected vomiting is related to pressure changes in the cranium. The vomiting can be associated with headache and gets worse with lowered head position. The most appropriate action is to obtain a full set of vital signs and contact the HCP immediately.

(Option 1) Documentation is important, but it is not the priority action. (Option 2) The head of the bed should be raised, not lowered, for clients with suspected increased ICP. Raising the head of the bed to 30 degrees helps to drain the cerebrospinal fluid via the valve system without lowering the cerebral blood pressure. (Option 4) The vomiting is caused not by nausea but by pressure changes in the cranium. Anti-nausea medications are often not effective. Decreasing intracranial pressure will help the vomiting. Educa The nurse is caring for a client after a motor vehicle accident. The client's injuries include 2 fractured ribs and a concussion. The nurse notes which of the following as expected neurological changes for the client with a concussion? Select all that apply.

  1. Asymmetrical pupillary constriction
  2. Brief loss of consciousness
  3. Headache
  4. Loss of vision
  5. Retrograde amnesia - ANSWERS-2, 3, 5 A concussion is considered a minor traumatic brain injury and results from blunt force or an acceleration/deceleration head injury. Typical signs of concussion
  1. Infuse bolus of IV normal saline
  2. Prepare to assist with lumbar puncture
  3. Transport client for head CT scan - ANSWERS- Meningitis is an inflammation of the meninges covering the brain and spinal cord. The key clinical manifestations of bacterial meningitis include fever, severe headache, nausea/vomiting, and nuchal rigidity. Other symptoms include photophobia, altered mental status, and other signs of increased intracranial pressure (ICP). In a hypotensive client with sepsis, the priority of care is fluid resuscitation to increase the client's blood pressure (Option 2). In addition to IV fluid administration, interventions and prescriptions for a client with sepsis and meningitis may include: Administer vasopressors. Obtain relevant labs and blood cultures prior to administering antibiotics. Administer empiric antibiotics, preferably within 30 minutes of admission (Option 1). This client will continue to decline without antibiotic therapy. Prior to a lumbar puncture (LP), obtain a head CT scan as increased ICP or mass lesions ma A client with a brain tumor is admitted for surgery. The health care provider prescribes levetiracetam. The client asks why. What is the nurse's response?
  4. "It destroys tumor cells and helps shrink the tumor."
  1. "It prevents seizure development."
  2. "It prevents blood clots in legs."
  3. "It reduces swelling around the tumor." - ANSWERS- Levetiracetam (Keppra) is a medication often used to treat seizures in various settings. It has minimal drug-drug interactions compared to phenytoin and is often the preferred antiepileptic medication. (Option 1) Chemotherapy and radiation therapy would kill tumor cells and reduce tumor size. (Option 3) Hospitalized clients and clients with malignancy are at higher risk for venous thromboembolism. These clients would benefit from anticoagulation (eg, heparin, enoxaparin, rivaroxaban, apixaban). (Option 4) Dexamethasone, a corticosteroid, is used to treat cerebral edema associated with a brain injury/tumor by decreasing inflammation. Educational objective: Levetiracetam (Keppra) is a medication often used to treat seizures in various settings. Corticosteroids are used to reduce inflammation and cerebral edema in clients with brain injury and tumors. A highly intoxicated client was brought to the emergency department after found lying on the sidewalk. On admission, the client is awake with a pulse of 70/min and blood pressure of 160/80 mm Hg. An hour later, the client is lethargic, pulse is 48/min, and blood pressure is 200/80 mm Hg. Which action does the nurse anticipate taking next?
  1. 65-year-old with suspected brain tumor waiting to be admitted for biopsy who reports throbbing headache and had emesis of 250 mL
  2. 70-year-old with atrial fibrillation and a closed-head injury waiting for brain imaging who reports a headache and had emesis of 200 mL - ANSWERS-A client with a neurological injury (eg, head trauma, stroke) is at risk for cerebral edema and increased intracranial pressure (ICP), a life-threatening situation. The client with atrial fibrillation may also be taking anticoagulants (eg, warfarin, rivaroxaban, apixaban, dabigatran), making a life-threatening intracranial bleed even more dangerous. The nurse should perform a neurologic assessment (eg, level of consciousness, pupil response, vital signs) immediately. (Option 1) Autonomic dysreflexia (eg, throbbing headache, flushing, hypertension) is a life-threatening condition caused by sensory stimulation that occurs in clients who have a spinal cord injury at T6 or higher. This is not the priority assessment as this client's injury is at L3. This client likely has acute urinary retention and needs catheterization. (Option 2) Phenytoin toxicity commonly presents with neurologic manifestations such as gait distur