NCLEX PASSPOINT MANAGEMENT OF CARE
A nurse is caring for a client diagnosed with ovarian cancer. Diagnostic testing reveals that the cancer has spread outside the pelvis. The client has previously undergone a right oophorectomy and received chemotherapy. The client now wants palliative care instead of aggressive therapy. The nurse determines that the care plan's priority nursing diagnosis should be:
acute pain. Explanation: Palliative care for the client with advanced cancer includes pain management, emotional support, and comfort measures. The client is in the hospital, so home maintenance doesn't apply at this time. The client has chosen palliative care, so she isn't noncompliant. The client's decision is not based on a knowledge deficit about chemotherapy because she has previously had treatments with chemotherapy.
The nurse is working as charge nurse on a medical-surgical unit. The nurse is providing orientation for a newly hired RN. Which action by the new RN requires immediate attention?
administering oral tetracycline with milk to a client with cellulitis Explanation: Dairy products inhibit the absorption of tetracycline, decreasing the effectiveness of the antibiotic. All the other activities are not appropriate, but would not cause as much potential harm as the administration of tetracycline with milk. Anaerobic bacteria would not likely grow in a superficial wound. Herpes zoster vaccine is recommended for clients who are older adults (60 years or older). Pressure garments are used after graft wounds heal and during the rehabilitation phase after a burn injury, and should be discussed when the client is ready for rehabilitation, not when the client is admitted.
A severely dehydrated adolescent admitted to the hospital with hypotension and tachycardia undergoes evaluation for electrolyte disturbances. The client's history includes anorexia nervosa and a 20-lb (9.1-kg) weight loss in the past month. She is 5′ 7″ (1.7 m) tall and weighs 80 lb (36.3 kg). Which nursing intervention takes highest priority?
initiating caloric and nutritional therapy as ordered Explanation: A client with anorexia nervosa is at risk for death from self-starvation. Therefore, initiating caloric and nutritional therapy takes highest priority. Behavioral modification (in which client privileges depend on weight gain) and psychotherapy (which addresses the client's low self-esteem, guilt, anxiety, and feelings of hopelessness and depression) are important aspects of care but are secondary to stabilizing the client's physical condition. Monitoring vital signs and weight is important in evaluating nutritional therapy but doesn't take precedence over providing adequate caloric intake to ensure survival.
A client who requested a do-not-resuscitate (DNR) order upon admission to the hospital now states a desire for the medical team to do everything possible to help the client get better. The client is concerned about the DNR order. Which response by the nurse is best?
"It isn't a problem to rescind your DNR order; I'll let your physician know your wishes right away." Explanation: Telling the client that it is not a problem to rescind the order is the best response. The client is allowed to rescind a DNR order at any time. The client makes the decision about a DNR order with input from the physician and does not need to talk to family members. The nurse should not imply with a question that perhaps revising the DNR would be more appropriate than rescinding it. The client has not expressed concern about feeling discomfort, so it would be inappropriate for the nurse to address that concern.
A client is upset to learn that corticosteroids need to be taken to control symptoms of systemic lupus erythematosus (SLE). While the nurse is preparing to administer medication, the client refuses to take it, stating, "This is turning me into an old woman before my time." What is the best response by the nurse?
Ask about the medication side effects that are a concern and explain why suddenly stopping the drug can cause problems. Explanation: It is important to explore the client's concerns regarding the side effects. As a follow-up, it is important to reinforce what is the desired effect of the drug. It is critical to explain the importance of not suddenly discontinuing its use. Explaining the symptoms of the disease does not identify the reasons for the client's concern. Encouraging the client to take the medication or documenting the refusal does not identify the concerns.
A mother reports she cannot afford the antibiotic azithromycin, which was prescribed by the health care provider (HCP) for her toddler's otitis media. What is the nurse's best response?
Confer with the HCP about whether a less expensive drug could be prescribed. Explanation: The nurse must act as an advocate for the client when the client cannot afford treatment. It may be possible to substitute a less expensive antibiotic. Correct procedure includes contacting the HCP to explain the mother's economic situation and request a substitution. For example, amoxicillin is more economical than azithromycin. If it is not possible to use another antibiotic, then the nurse can explore other avenues with the mother and/or social worker.
A client with chronic obstructive pulmonary disease presents with respiratory acidosis and hypoxemia. The client tells the nurse that they don't want to be placed on a ventilator. What action should the nurse take?
Notify the physician immediately to have the physician determine client competency. Explanation: Three requirements are necessary for informed decision-making: the decision must be given voluntarily; the client making the decision must have the capacity and competence to understand; and the client must be given adequate information to make the decision. In light of the client's respiratory acidosis and hypoxemia, the client might not be competent to make this decision. The physician should be notified immediately so the physician can determine client competency. The physician, not the nurse, is responsible for discussing the implications of a DNR order with the client. The Patient's Bill of Rights entitles the client to make decisions about the care plan, including the right to refuse recommended treatment. The client's family may oppose the client's decision. Consulting the palliative care group isn't appropriate at this time and must be initiated by a physician order.
There has been a car accident involving four vehicles on a remote highway. The nearest emergency department is 15 minutes away. Which victim should be transported by helicopter rather than an ambulance to the nearest hospital?
a middle-aged female with cold, clammy skin; heart rate of 120 bpm; and is unconscious Explanation: The middle-aged female is likely in shock; she is classified as a triage level I, requiring immediate care. The child with moderate trauma is classified as triage level III, urgent, and can be treated within 30 min. The man with asthma and the man with the severe headache are classified as emergent, triage level II, and can be transported by ambulance and reach the hospital within 15 min.
Which adolescent would the nurse determine needs further evaluation?
a young adolescent boy who restricts his food and fluid intake to be able to box in a lower weight class Explanation: Restricting intake to lose weight is a first step toward an eating disorder for males as well as females, so this behavior should be investigated further, especially since males of this age are usually unconcerned about their weight. Quick mood changes are common in young adolescents, particularly girls. Such mood changes should not be considered problematic if the adolescent is not experiencing trouble in major areas of his/her life. Experimenting with alcohol or other substances is fairly common in the teen years, but one or two uses do not generally lead to addiction. The negative effect of the coughing may be a deterrent to further use. Religious questioning and exploration of "dark" subjects is common among teens and is part of the development of mature thinking. In the absence of other signs of depression, it does not warrant further evaluation.
The nursing team consists of one RN, one LPN, and one unlicensed assistive personnel (UAP). Which assignment should the RN delegate to the LPN?
administering daily am medications Explanation: LPNs should be assigned higher level skills in stable, predictable situations. Lower level custodial skills should be assigned to UAP. A new tracheostomy may be unstable. The task of suctioning should be retained by the RN.
Which client is the best candidate for a vaginal birth after a caesarean (VBAC)?
client who had a breech presentation in her last pregnancy, and this pregnancy is a vertex pregnancy Explanation: The best candidate for a VBAC is a woman who had a cesarean section in her last birth because of a problem related to the infant that is not repeated in this pregnancy. The woman with the breech presentation in her last birth and a vertex pregnancy in this pregnancy would be the best candidate, especially if she had other vaginal births. The woman who was unable to dilate beyond 6 cm (failure to progress) may try a VBAC but is likely to experience the same problem with this birth. The woman with the very large infant is likely to experience cephalopelvic disproportion with this birth if she experienced cephalopelvic disproportion with her last infant who was large. A classic cesarean birth scar is a contraindication for a VBAC because that type of scar may not be strong enough to withstand the stress of hours of uterine contractions and may result in a uterine disruption.
The nurse is teaching the client to self-administer insulin. Which approach to establishing learning goals will likely be most effective? When the goals are established by the:
client, nurse, pharmacist, and health care provider, so the client can participate in planning care with the entire team. Explanation: Learning goals are most likely to be attained when they are established mutually by the client and members of the health care team, including the nurse, pharmacist, and health care provider. Learning is motivated by perceived problems or goals arising from unmet needs. The perception of the unmet needs must be the client's; however, the nurse, pharmacist, and health care provider help the client arrive at his or her own perception of the need or reason to learn.
The unlicensed assistive personnel (UAP) approaches the nurse and states, "The client doesn't know what caused him to be so depressed. He must not want to tell me because he doesn't trust me yet." In responding to this staff member, which statement by the nurse will help the UAP understand the client's illness?
"Endogenous depression is biochemical and isn't caused by an outside stressor or problem. The client can't tell you why he's depressed because he really doesn't know." Explanation: The cause of endogenous depression is believed to be biochemical and not a reaction to a loss. It is caused by an imbalance or decreased availability of norepinephrine, serotonin, and possibly dopamine, so the client cannot identify a specific outside cause or a loss. Reactive depression is a reaction to a loss or a stressor. It is wrong to consider that lack of trust or slow thinking are reasons why the client will not identify the cause of his depression. Problems and stressors from past childhood conflicts may be present; however, the client can discuss them with the staff when he is willing or able.
A nurse is discussing verbal orders with the charge nurse. Which statement made by the nurse indicates understanding of verbal orders? Select all that apply.
"I can take a verbal order from the health care provider if my client is unresponsive and has bradycardia." "I can take a verbal order from the health care provider if a client who is in respiratory distress is being intubated." "I can take a verbal order from the health care provider if a client experiences cardiac arrest." Explanation: The nurse can take verbal orders if a client is unresponsive and has bradycardia, if a client is being intubated because of respiratory distress, or if a client experiences cardiac arrest. These are emergency situations. The nurse cannot take a verbal order because a health care provider is being paged to another unit, if the health care provider walks into a client's room and gives the nurse a verbal order, or if the client needs an extra dose of furosemide because the client's weight is up from the previous day. These are not emergency situations.
A psychiatric nurse in the emergency department is assigned to care for a group of clients. Which client should the nurse see first?
A client who states she was sexually assaulted an hour ago. Explanation: A rape or assault of any kind is a crisis situation and the primary nursing focus should be safety for the client. In addition to the psychological crisis, the client could have physiologic injuries that need immediate medical attention. The client with a panic disorder does have acute symptoms of anxiety, but is not in crisis. The client off their medication and worsening depressive symptoms is a concern but is not in immediate danger.
A nurse is working on a medical unit at a unionized hospital that has insufficient nurses and staff to provide competent care to the clients. What should the nurse do? Select all that apply.
Accept the assignment and make a written protest to the administration. Complete an unsafe staffing form and provide care as safely as possible. Explanation: The nurse must accept the assignment or be liable for negligence and abandonment. The nurse should fill out an unsafe staffing form as soon as possible as this may be evidence to provide protection in the case of a medical error during the shift. Refusing the assignment is illegal and abandonment. Verbal notification can be provided but is not the best action as there is not a record of the conversation if a problem occurs. Clients should never know that staffing is unsafe as this will create unnecessary anxiety or stress for the client.
A nurse is taking care of two clients who have a prescription to receive a blood transfusion of packed red blood cells at the same time. The first client's blood pressure dropped from the preoperative value of 120/80 mm Hg to a postoperative value of 100/50 mm Hg. The second client is hospitalized because he developed dehydration and anemia following pneumonia. After checking the patency of their IV lines and vital signs, what should the nurse do next?
Call for and hang the first client's blood transfusion. Explanation: When two clients are to receive blood at the same time, the nurse should call for and hang the clients' transfusions separately to avoid error. The nurse should call for and hang the first client's blood first because this client has experienced a change in blood pressure over a short period of time. The nurse should next call and hang the second client's blood transfusion as there is no indication that this client is unstable at this time. The nurse should not call for both units of transfusions at the same time due to the increased risk of misidentification. The nurse should not verify compatibility of both units at the same time due to the increased risk of misidentification. It is not necessary to involve two nurses because the second client can wait until the nurse has time to hang the blood.
When making rounds on the pediatric neurology unit, the nurse manager notes that, when giving IV medications, many of the staff nurses are disconnecting the flush syringe first and then clamping the intermittent infusion device. The nurse manager is concerned that the nurses do not understand the benefits of positive pressure technique and turbulence flow flush in preventing clots. After the nurse manager discusses the problem with the staff educator, which intervention would be the most effective way to improve the nursing practice?
Create a poster presentation on the topic with a required posttest. Explanation: A poster presentation is an eye-catching way to disseminate information that can be used to educate nurses on all shifts. The addition of the posttest will verify that the poster information has been received. Because of the large volume of emails the typical employee receives, information sent this way might be overlooked. If several nurses are observed not using the most current practice, it is quite possible many more do not understand it. Thus, a larger scale plan is needed. Posting an article will not assure that the information is read.
The nurse preceptor overhears a student nurse talking to a grieving mother, whose child was stillborn, about her own pregnancy and fears about experiencing a loss. The student nurse and mother make arrangements for the student to pick up the client's maternity clothes and baby furniture on the weekend. What is the preceptor's most appropriate action?
Discuss the situation with the nursing student after the visit has ended. Explanation: The nurse has a professional responsibility to discuss this situation with the nursing student in private. The student needs to know that these actions are insensitive to the grieving parents and are unprofessional regardless of whether the client has agreed to it or even initiated the idea. These student actions do not value therapeutic boundaries between health care providers and their clients in the community. It may be appropriate to discuss it with the contact person from the student's academic institution; however, the first action should be to discuss it with the student in private.
A nurse notices that a large number of clients who receive oxytocin to induce labor vomit as the infusion is started. The nurse assesses the situation further and discovers that these clients received no instruction before arriving on the unit and haven't fasted for 8 hours before induction. How should the nurse intervene?
Initiate a unit policy involving staff nurses, certified nurse-midwives, and physicians in teaching clients before labor induction. Explanation: The best intervention by the nurse is to initiate a unit policy that involves the multidisciplinary team. This approach creates an atmosphere of collegiality and professionalism with the goal of providing the best care for clients in labor. Telling the physicians they need to teach their clients blames the physician and doesn't promote multidisciplinary teamwork. Reporting the physicians is unnecessary because nothing indicates that the physicians provided inferior care. The nurse can approach the medical staff about initiating a protocol order that allows the nursing staff to administer promethazine; however, this option doesn't address the current problem — the lack of client education.
A client with suspected inhalation anthrax is admitted to the emergency department. Which action by the nurse takes the highest priority?
Monitor vital signs and oxygen saturation every 15 to 30 minutes. Explanation: Monitoring vital signs and oxygen saturation every 15 to 30 minutes takes priority. Suctioning the client as needed to obtain a sputum specimen may be necessary, but assessing the client for changes in their respiratory status takes priority. Assessing intake and output and providing adequate hydration are important steps for liquefying secretions; however, they don't take priority. Reassuring the client that intubation and mechanical ventilation is temporary is inappropriate. The client may not require intubation and mechanical ventilation; however, if they do, the nurse can't predict the length of time it may be necessary.
The nurse on the surgical unit is passing 0900 medications to a client using an electronic medication administration record (eMAR). Place the medication steps in the correct sequential order (from first to last) for safe medication administration by the nurse. All options must be used.
Open the computer program and enter the user ID and password. Select the correct client from the list of clients. Access the client's eMAR and select/prepare the medication(s) for 0900. Verify the client's name, birthday, and armband against the eMAR. Administer and document the medications in the eMAR. Log out of the client's eMAR and monitor the client for any reactions. Explanation: The correct sequence of steps for med administration are to (1) open the computer program and enter the user ID and password, (2) Select the correct client from the list of clients, (3) Access the client's eMAR and select/prepare the medication(s) for 0900, (4) Verify the client's name, birthday, and armband against the eMAR, (5) Administer and document the medications in the eMAR, (6) Log out of the client's eMAR and monitor the client for any expected or unexpected reactions.
A client who is legally blind must undergo a colonoscopy. The nurse is helping the healthcare provider obtain informed consent. When obtaining informed consent from a client who is visually impaired, the nurse should take which step?
Read the consent form to the client and ask if there are any questions. Explanation: The nurse should read the consent form to the client and make sure that the client understands all the information. The healthcare provider should answer any questions the client has before the consent form is signed. The client's family doesn't need to be present, and there is no need to contact the client's closest relative. A client who is legally blind may sign the consent form.
A nurse is providing home care to a client with a foot ulcer related to diabetes. The client needs daily insulin injections. Family caregivers do not possess the technical skills to inject insulin. Which should the nurse keep in mind?
The nurse needs to be creative in integrating the technical and relational aspects of care. Explanation: The nurse needs to be creative in integrating the technical and relational aspects of care. The current reimbursement system does not recognize the family's nontechnical contributions to client care. Nurses are expected to educate family caregivers to conduct the skilled task where possible. In this case, the nurse can teach the family caregivers to inject insulin. Family caregivers can be perceived to be unsupportive of good care if the families do not follow through.
Which example may illustrate a breach of confidentiality and security of client information?
The nurse provides information over the phone to the client's family member who lives in a neighboring state. Explanation: Providing information over the phone to a family member without knowing whether the client wants the family member to know the information is a breach of confidentiality and security of client information. Providing information to a caregiver involved in the care of a client is not a breach in confidentiality, while providing information to a professional not involved in the care of the client is a breach in confidentiality. Client information should not be discussed in public areas such as elevators or the cafeteria. Logging off a computer that displays client data is an appropriate method of protecting client confidentiality and information.
The nurse is assigned to care for the following clients. Which client should the nurse see first?
a client diagnosed with hypothyroidism and a heart rate of 48 beats per minute Explanation: A heart rate of 48 beats per minute may have significant implications for cardiac output and hemodynamic stability. Clients with Graves disease usually have a rapid heart rate, but 94 beats per minute is a normal finding. The diabetic client may need sliding-scale coverage, which is not urgent. Clients with Cushing disease frequently have dependent edema.
The nurse is completing discharge teaching with a client who had a long hospital stay. The client gives the nurse a handmade sweater for the personal nursing care. What is the best response by the nurse? Select all that apply.
"My hospital has a policy that does not allow a nurse to accept gifts." "I appreciate the gift but it not appropriate for me to take a personal gift." Explanation: The nurse can explain the hospital policy and appropriateness of the nurse client relationship. The responses of "thank you for recognizing my work, I will enjoy wearing this sweater," "I cannot take this gift while I am working," and "maybe I can meet you for coffee next week," enter into the personal life of the nurse and client. The nurse client relationship does not encourage socializing with clients.
When a nurse enters a client's room, the client frowns and states, "I've had my damn light on for 20 minutes. It's about time you got here. I'm sick of this place and the staff." The nurse's best response would be:
"You seem upset this morning." Explanation: To be therapeutic, the nurse should respond to the content of the client's statements. This client is obviously angry. A restatement or summary of what the nurse heard the client say is appropriate. By making an introduction or apologizing, the nurse would ignore the client's expressed feelings. Repeating the client's statement as a question indicates either skepticism about the client's statement or ignorance of the client's needs and would likely fuel the client's anger.
The nurse has received a change-of-shift report. The nurse should assess which client first?
a 72-year-old admitted 2 days ago with a blood alcohol level of 0.08 who has exhibited agitation, fearfulness, and sleeplessness over the last 36 hours Explanation: The 72-year-old client admitted with an elevated blood alcohol level has shown signs of alcohol withdrawal syndrome, which tends to be more severe in older adults. The nurse should monitor this client for signs and symptoms of withdrawal to ensure the client's safety. The onset of delirium tremens or alcohol withdrawal delirium, the most severe form of withdrawal, is usually 48 to 96 hours following the last drink. The client with the chest tube is not in any distress and has no pressing needs. For an older client who has had GI bleeding, a hemoglobin of 13.8 g/dL (138 g/L) is within normal limits. After assessing all clients' needs, the nurse will prepare the client who had an appendectomy for discharge as soon as possible.
