passpoint fundamentals

A client is 2 days post small bowel resection with a placement of an ostomy in the right lower quadrant. The nurse is teaching the client to apply an ostomy appliance to the client's abdomen. Which client action would indicate to the nurse that the teaching was successful?

"These life stressors place you at moderate risk for illness." Holmes and Rahe's theory of stress response suggests that all life events, whether positive or negative, cause stress.

A palliative care nurse is caring for a client with end stage pancreatic cancer who is reporting severe pain. The healthcare provider orders morphine sulfate 4mg IV stat followed by morphine sulfate 2mg IV q 1h prn pain. The drug available in a multidose ampule of 2mg/mL. How many mL does the nurse administer for the initial dose? Record your answer as a whole number.

2 4mg/2 mg x 1 mL = 2 mL

A client is recovering from abdominal surgery and has a nasogastric (NG) tube inserted. Which is the expected outcome of inserting the NG tube in the client's gastrointestinal tract?

A referral. Referring is the process of sending or guiding a client to another source for assistance.

A nurse-manager must include which items as part of the personnel budget?

Administering a client's tube feeding A tube feeding is within the scope of practice of the LPN/VN. The CNA's scope of practice includes assisting a client to ambulate and reminding a client to use the bathroom.

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 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.

A community health nurse provides a client with information about a local support group for those with multiple sclerosis. Providing this information is an example of which choice?

Dysfunctional Dysfunctional grief is intense grief that does not result in reconciliation of feelings, such as this client is experiencing.

A child with a nut allergy presents with a severe reaction for the third time in 3 months. The parent says, "I am having trouble with the food labels." What should the nurse do first?

Continue to assess the client, allowing the officer to assume responsibility for the handcuffs. n this situation, the police officer has applied the restraint and has taken responsibility for the restraint.

A nurse working in the emergency department is concerned that a client, who is in police custody, is handcuffed to the stretcher. The nurse asks the police officer to remove the cuffs, but the officer refuses. What should be the next action by the nurse?

Good Samaritan laws are designed to protect the caregiver in emergency situations Good Samaritan laws are designed to protect the caregiver in emergency situations. If the nurse stopped to provide care, legally there is protection.

The client has sore nares while a nasogastric (NG) tube is in place. Which nursing measure would be most appropriate to help alleviate the client's discomfort?

Position electrodes on the chest. Take vital signs. Administer the prescribed dose of morphine. Obtain a history of which drugs the client has used recently. The nurse should first connect the client to the monitor by attaching the electrodes. Electrocardiography can be used to identify myocardial ischemia and infarction, rhythm and conduction disturbances, chamber enlargement, electrolyte imbalances, and the effects of drugs on the client's heart.

Which action is a priority for the nurse when finding medications at a client's bedside?

Remove the medications from the room and discard them into an appropriate disposal bin. Disposing of the medications in the appropriate manner reflects best practice of nursing and medication administration.

The client is wearing graduated compression stockings and begins to report leg pain in the right leg. Place the steps in order taken to accurately assess this client. All options much be used.

Remove the stockings. Assess the skin for redness and the leg for swelling. Assess for warmth discrepancies in both legs. Measure the calves of both legs. Notify the healthcare provide When a client reports pain in one or both legs, the stockings should be removed and the extremities assessed for deep vein thrombosis.

The charge nurse on the postpartum unit has received a report about a client who has just experienced a fetal demise and will be ready for transfer out of the labor unit in about 2 hours. The client has asked her primary nurse if she can stay on the obstetrical unit since she has found support from the nursing staff there. What action should the charge nurse on the postpartum unit take?

Talk to the mother first and decide on a location that is mutually agreeable. The nurse on the postpartum unit should discuss with the client what her wishes are and mutually agree on a location.

A client has an intravenous line in place for 3 days and begins to state discomfort at the insertion site. Based on the nurse's progress note, what condition has most likely occurred?

The client assesses the stoma and the surrounding skin before placing the new appliance. For a client with an ostomy, maintaining skin integrity is a priority. The client should inspect the area with each appliance change for skin integrity issues.

A nurse is reluctant to provide care at an accident scene. Which legal definition is true regarding the provision of nursing care?

The nurse must file an incident or adverse event report Nurses who witnessed the event are responsible for entering the information.

Twenty-four hours after a bone marrow aspiration, the nurse is evaluating the client's postprocedure status. Which outcome is expected?

There is no bleeding at the aspiration site After a bone marrow aspiration, the puncture site should be checked every 10 to 15 minutes for bleeding. For a short period after the procedure, bed rest may be prescribed.

A nurse has an order to administer an I.M. injection of iron dextran to a client. Which action is correct for an I.M. injection?

Withdraw the needle and release the skin. I.M. iron dextran should be given by intramuscular injection using a z-tract technique. When giving an I.M. injection using the z-track technique, the nurse pulls the skin laterally away from the injection site, inserts the needle at a 90-degree angle, waits 10 seconds after injecting the medication, and then withdraws the needle and releases the skin. No massage is used with a z-tract injection.

The nursing team on an oncology unit consists of a registered nurse (RN), a licensed practical/vocational nurse (LPN/VN), and one unlicensed assistive personnel (UAP). Which client should be assigned to the RN?

a 52-year-old client with lung cancer admitted for acute dyspnea Ongoing assessment by the RN is required to evaluate the client with dyspnea to monitor for potential deterioration of the respiratory status.

A nurse is obtaining a sterile urine specimen from a client's indwelling urinary catheter. During the procedure, the nurse should

aspirate urine from the tubing port, using a sterile syringe and needle To collect urine properly, the nurse should aspirate it from a port, using a sterile syringe and needle after cleaning the port.

When preparing a client with a draining vertical incision for ambulation, where should a nurse apply the thickest portion of a dressing?

at the base of the wound When a client is ambulating, gravity causes the drainage to flow downward. Covering the base of the wound with extra dressing will contain the drainage.

A client is 12 hours post abdominal inguinal hernia repair done under general anesthesia. The practitioner orders to progress diet as tolerated. Which tray should the nurse choose for this client?

broth, gelatin cubes, and tea To begin the patient's transition to eating a regular diet, the nurse will first choose a clear-liquid diet.

The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which documentation format is most likely to promote this goal?

coughing when drinking liquids n Parkinson disease, dysarthria, or impaired speech, results from a disturbance in muscle control. Muscle rigidity, not flaccidity, causes resistance to passive muscle stretching.

A 2-year-old child is being examined in the emergency department for epiglottitis. Which assessment finding supports this diagnosis?

decompression After abdominal surgery, the reason for inserting a NG tube is to decompress the gastrointestinal tract until peristaltic action returns.

An older adult client shares with the nurse having never gotten over the grief of losing a parent 22 years ago. The client states that the parent completed suicide and the client found the parent and called for emergency assistance. The nurse assesses that the client is experiencing which type of grief?

infiltration The assessment findings of pallor, swelling, skin that is cool to the touch at the intravenous insertion site, and a normal WBC count all indicate infiltration.

A nurse writes a note in a client's chart that says: "The physician is incompetent because the physician ordered the incorrect drug dosage." This statement may lead to a charge of

libel. Libel refers to written communication that harms a person's reputation. Assault is an unjustifiable attempt or threat to touch or injure another person.

The nurse is monitoring a client during a procedure and assesses that the client can respond purposefully to verbal commands and can manage the airway. The nurse documents that the client is at which level of sedation?

moderate sedation/analgesia This is an example of moderate sedation/analgesia, because the client can respond purposefully to verbal commands or tactile stimulation and does not require airway management.

When assessing a dark-skinned client for cyanosis, what area of the body will best reveal cyanosis?

oral mucous membranes In dark-skinned clients, cyanosis can best be detected by examining the conjunctiva, lips, and oral mucous membranes

During gentamicin therapy, the nurse should monitor a client's

serum creatinine level During gentamicin therapy, the nurse should monitor a client's serum creatinine level because the most notable adverse reactions to aminoglycoside therapy are nephrotoxicity and ototoxicity.

A client has been experiencing abdominal cramps, diarrhea, and concentrated urine for the past 2 days. Which signs would be included in a focused assessment?

signs of dehydration, including loss of weight; poor tissue turgor; and dry, cracked mucous membranes When a client has abdominal cramps and diarrhea, there is a loss of extra fluids from the body. Through a focused assessment, the nurse should assess for a fluid volume deficit. This would be indicated by signs of dehydration and weight loss.

The client is admitted to the telemetry unit due to chest pain. The client has polysubstance abuse, and the nurse assesses that the client is anxious and irritable and has moist skin. What should the nurse do in order of priority from first to last? All options must be used.

signs of dehydration, including loss of weight; poor tissue turgor; and dry, cracked mucous membranes When a client has abdominal cramps and diarrhea, there is a loss of extra fluids from the body. Through a focused assessment, the nurse should assess for a fluid volume deficit. This would be indicated by signs of dehydration and weight loss.

The nurse at a health fair is evaluating a client's completed questionnaire about stress-related life events. The client scored 168 points on the Holmes and Rahe stress scale. Which statement by the nurse provides appropriate interpretation of the impact of stressors on the client's health?

tactile This client is responsive to tactile stimulation, because the client responded when the nurse touches the skin.

A client requests that the nurse assist with spiritual counselling. What is the most important factor for the nurse to apply when determining how to best offer spiritual counselling?

the nurse's comfort and knowledge level related to the process of spiritual counselling A nurse who feels competent to counsel the client may assist the client in achieving spiritual goals through spiritual counselling.

Which action is a priority when a nurse is preparing to administer a transfusion of platelets?

tripod position The child being in the tripod position (sitting up and leaning forward) supports the diagnosis of epiglottitis because this position facilitates breathing.

The nurse is caring for a client who has been admitted from a situation involving domestic abuse. Which action is a correct component in the nursing plan of care?

documenting the situation and providing support for the victim The nurse must carefully and adequately document the assessment of the abused victim in the chart (not an incident or occurrence report).

A nurse is preparing a client for bronchoscopy. Which instruction is appropriate for the nurse to give to the client?

"Don't eat for 6 hours prior to the procedure." Bronchoscopy involves visualization of the trachea and bronchial tree. To prevent aspiration of stomach contents into the lungs, the nurse should instruct the client not to eat or drink anything for approximately 6 hours before the procedure.

The nurse is performing discharge teaching for a client who experienced a recent heart attack. The client reports feeling excited and ready to go home and "get on with life." What response by the nurse is most appropriate?

"What are your plans for when you get home and back to getting on with your life?" When preparing the client for discharge, the nurse investigates the client's understanding of the teaching and readiness for discharge by asking open-ended questions when possible.

The registered nurse (RN) is supervising for the evening shift at a long-term care facility. The RN is working with 3 certified nursing assistants (CNA) and a licensed practical/vocational nurse (LPN/VN). Which aspect of care is most appropriately delegated to the LPN/VN?

Apply a water-soluble lubricant to the nares. Applying a water-soluble lubricant to the nares helps alleviate sore nares when an NG tube is in place.

The family of a deceased client has yet to make funeral arrangements. What should the nurse expect to be done with the body?

Prepare it for storage in the facility's morgue refrigerator The client's body may be placed in the hospital's morgue refrigerator if mortuary arrangements are not made before the client's death.

As part of a quality improvement team, the nurse uses the plan-do-study-act method to address unit-based alarm fatigue. The team has interviewed stakeholders to identity opportunities for reducing alarms and collaborated with the equipment vendors to gather alarm data. What should the nurse do next?

Analyze the patterns to identify which devices account for the most alarms. After gathering alarm data, the nurse should "study" or analyze the data to identify which devices account for the most alarms.

The nurse is monitoring a client during moderate sedation. The client is laying on the gurney with eyes closed and opens the eyes and moans when the nurse touches the shoulder, but not when the nurse says the client's name. The nurse charts the client responds to what type of stimuli?

anticipated overtime payments for staff Personnel budgets include salaries, benefits, anticipated overtime costs, and potential salary increases.

A nurse is caring for a terminally ill client. The nurse assesses the client for identification of the psychosocial stage of acceptance. Place the five stages of death and dying in the order in which Elisabeth Kübler-Ross noted that they most often occur. All options must be used.

denial and isolation anger bargaining depression acceptance Elisabeth Kübler-Ross outlined similarities to psychosocial responses to impending death or loss. Duration during each stage may vary or even overlap from individual to individual. According to Kübler-Ross, the five stages of death and dying are denial and isolation, anger, bargaining, depression, and acceptance.

What is the nurse expected to do when filing a report about an incident of finding an elderly client with mild dementia on the floor?

narrative notes One of the advantages of a narrative notes model of documentation is that it allows nurses to describe clinical encounters in their own terms, as they understand them.

A client is admitted to the hospital with aspiration pneumonia secondary to progression of Parkinson disease. Which assessment finding should the nurse anticipate?

obtaining a written informed consent Special transfusion sets should be used when administering platelets. A written consent should be obtained and this is the priority before obtaining equipment.