Passpoint Exam 1

A client tells a nurse that she's going to breast-feed her neonate but she isn't sure what she should eat. Which client statement requires further teaching?

"I'll take all the same medications I was taking before my pregnancy."

A client from a correctional facility is admitted to the hospital wearing handcuffs. The nurse caring for the client needs to provide morning care and notices the two correctional officers socializing with the nursing staff at the desk. What is the best action by the nurse in this situation?

Insist that the officers stay in the room at all times.

A nurse is developing a plan to teach a parent how to reduce an infant's risk of developing otitis media. Which direction should the nurse include in the teaching plan?

Place the infant in an upright position when giving a bottle.

The nurse is caring for a client during a prolonged hospital stay for congestive heart failure. The client has a prescription for thigh high antiembolism stockings. In regard to the antiembolism stockings, what is the priority action by the nurse?

Remeasure the client's legs routinely

A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas (ABG) is drawn, yielding the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect?

Respiratory acidosis

A preschooler goes into cardiac arrest. When performing cardiopulmonary resuscitation (CPR) on a child, how should the nurse deliver chest compressions?

With the heel of one hand

After total hip replacement, a client is receiving epidural analgesia to relieve pain. Which action is a nursing priority for this client?

assessing for sensation in the legs

After a laminectomy, the client states, "The doctor said that I can do anything I want to." Which activity that the client intends to do indicates the need for further teaching?

sweeping the front porch

A nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. Which statement to the client would the nurse use to describe a healthy stoma?

"At first, the stoma may bleed slightly when touched."

The nurse is caring for a client with possible immune deficiency. Which subjective data would be most indicative?

"Just as I get over a virus, it seems that I get another."

The mother of an infant being admitted to the hospital is crying and very upset. Which statement by the nurse would be most therapeutic?

"What's making you cry right now?"

The most important responsibility of the nurse is to prioritize and ensure that routine nursing measures on non-critical clients are assigned. The nurse is performing which functions?

Delegation

The client attends two sessions with the dietitian to learn about diet modifications to minimize gastroesophageal reflux. The teaching would be considered successful if the client decreases the intake of which foods?

Fats

A physician orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question?

Heparin sodium

What information should the nurse provide to the client who is receiving warfarin?

International Normalized Ratio (INR) is used to assess effectiveness

The nurse is assessing a client with a cervical injury for autonomic dysreflexia. The nurse should assess the client for:

Sudden, severe hypertension

A client comes to the emergency department with symptoms of chest pain radiating down the left arm, dyspnea, and diaphoresis. An electrocardiogram (EKG) shows ST segment elevation and the client is diagnosed with an ST segment-elevation myocardial infarction (STEMI). To determine if the client is a candidate for thrombolytic therapy, which question should the nurse ask?

"What time did your chest pain start?"

The nurse is suctioning a client who had a laryngectomy. What is the maximum amount of time the nurse should suction the client?

10 seconds

After undergoing small-bowel resection, a client is prescribed metronidazole 500 mg I.V. The mixed I.V. solution contains 100 milliliters. A nurse is to run the drug over 30 minutes. The drip factor of the available I.V. tubing is 15 gtt/ml. What is the drip rate? Record your answer using a whole number.

50

A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia?

Dyspnea and wheezing

A 19-year-old client comes to the emergency department with acute asthma. His respiratory rate is 44 breaths/min, and he is in acute respiratory distress. What is the nurse's priority action?

Give a bronchodilator by nebulizer

A client is admitted to the hospital with a diagnosis of suspected pulmonary embolism. Prescriptions include oxygen 2 to 4 L/min per nasal cannula, oximetry at all times, and IV administration of 5% dextrose in water at 100 mL/h. The client has increasing dyspnea and has a respiratory rate of 32 breaths/minute. The oxygen flow rate is set at 2 L/min. What should the nurse do first?

Increase the oxygen flow rate from 2 to 4 L/min.

Which laboratory test should be monitored closely by the nurse while the client is receiving heparin therapy?

activated partial thromboplastin time (APTT)

A home health nurse sees a client with end-stage chronic obstructive pulmonary disease (COPD). An outcome identified for this client is preventing infection. Which finding indicates that this outcome has been met?

decreased oxygen requirements

A client wants to avoid methods of birth control that contain estrogen. Which method would be the nurse recommend?

depot medroxyprogesterone acetate injection

Which signs and symptoms accompany a diagnosis of pericarditis?

fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR)

A nurse is caring for a client who had a three-vessel coronary bypass graft 4 days earlier. The client's cholesterol profile is as follows: total cholesterol 265 mg/dl (6.845 mmol/L), low-density lipoprotein (LDL) 139 mg/dl (3.603 mmol/L), and high-density lipoprotein (HDL) 32 mg/dl (0.829 mmol/L). The client asks the nurse how to lower their cholesterol. The nurse should tell the client that

the nurse will ask the dietitian to talk with the client about modifying their diet

A client is being transferred from the recovery room to the medical surgical nursing unit. The nurse from the recovery room should report which information to the nurse in the medical surgical unit? Select all that apply.

type of surgery fluids infusing including rate and type of fluid current vital signs amount of blood loss

A nurse is providing cardiopulmonary resuscitation (CPR) to a child, age 4. The nurse should

use the heel of one hand for sternal compressions.

A nurse is to give a client a 325-mg aspirin suppository. The client has diarrhea and is in the bathroom. The best nursing approach at this time would be to

withhold the suppository and notify the client's physician

The nurse is assessing a client whose history includes type 2 diabetes and atrial fibrillation, treated with warfarin. The client tells the nurse that the client began taking ginseng supplements several days ago in an effort to boost the immune system. After providing health education, what is the nurse's priority action?

Collaborate with the care team to have the client's prothrombin time and international normalized ratio (INR) assessed

Which performance improvement strategy helps prevent adverse reactions to blood products?

confirming client identification with two qualified health professionals

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."

An older adult who experienced a brief delirium realizes that the condition was caused by prescription medication intoxication. Which statement indicates the need for further education?

"I get medicines from three different doctors and they don't all know what I'm taking."

The nurse teaches the parent of a child with sickle cell anemia about managing the disease and preventing complication. What statement by the parent indicates the need for further education about sickle cell anemia?

"I know she doesn't have as much pain as she acts like she has."

A client is entering the alcohol treatment program for the fourth time in 5 years. Which statement by the nurse will be most helpful to the client?

"I'm a nurse in the program. The staff and I will help you through the program."

A nurse is talking with a client who recently attempted suicide. The client asks the nurse not to tell anyone about their conversation. How should the nurse respond?

"If information is important to your care, I'll need to share it with the rest of your health care team."

The nurse teaches the mother of a child newly diagnosed with insulin dependent diabetes about the principles of a healthy eating plan. Which statement by the mother indicates effective teaching?

"Snacks are used to keep blood glucose at acceptable levels during times when the insulin level peaks."

For a client with asthma, the health care provider (HCP) prescribes albuterol, two puffs twice a day via a metered-dose inhaler (MDI), and beclomethasone, two puffs twice a day via MDI. How should the nurse instruct the client to administer these drugs?

"Take the albuterol first and follow with beclomethasone two times a day."

The nurse is caring for a client prescribed IV heparin for treatment of thromboembolism. The client is prescribed 18 units/kg/hr. The client weighs 145 lb (66 kg). The heparin comes from the pharmacy as 25,000 units in 250 mL of D5W. How many mL/hr should this client receive? Round to the nearest whole number.

12

A 4-year-old child is ordered to receive 25 mL/hour of intravenous solution. The nurse is using a pediatric microdrip (60 gtt/mL) chamber to administer the medication. For how many drops per minute would the microdrip chamber be set? Record your answer using a whole number.

25

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.

A nurse is attempting to resuscitate a neonate. Thirty seconds of chest compressions have been completed. The neonate's heart rate remains less than 60 bpm. Epinephrine is given. What is the expected outcome for a neonate who has received epinephrine during resuscitation?

A normal heart rate

Which factor is most important for the nurse to consider when determining the angle at which to insert the needle for a subcutaneous injection?

Amount of subcutaneous tissue

A school-age child is admitted to the hospital with newly diagnosed insulin-dependent diabetes mellitus. On admission at 1000, his blood glucose is 180 mg/dL (10 mmol/L). He receives 2 units of regular insulin subcutaneously at 1030. What should the nurse include in the plan of care?

Assess the child beginning at 1230 for shakiness, feelings of anxiety, or decreased level of consciousness.

A 67-year-old client will be discharged to home with imipramine. Which information would be most important for the nurse to include when instructing the client and spouse about the medication?

Avoid alcohol

A multigravid client at 34 weeks' gestation visits the hospital because she suspects that her water has broken. After testing the leaking fluid with nitrazine paper, the nurse confirms that the client's membranes have ruptured when the paper turns which color?

Blue

While caring for a client who has sustained a myocardial infarction (MI), the nurse notes eight premature ventricular contractions (PVCs) in 1 minute on the cardiac monitor. The client is receiving an IV infusion of 5% dextrose in water (D5W) at 125 mL/h and oxygen at 2 L/min. What should the nurse do first?

Notify the health care provider (HCP)

The team leader has noticed a sharp increase in medication errors associated with IV antibiotic administration over the last 2 months. The group that could offer resources for tracking medication errors and improving care outcomes is the:

Quality Improvement and Risk Management Department

An older infant who has been injured in an automobile accident is to wear a splint on the injured leg. The mother reports that the infant has become mobile even while wearing the splint. What should the nurse advise the mother to do?

Remove any unsafe items from the area in which the infant is mobile

A client has undergone a laparoscopic cholecystectomy. Which instruction should the nurse include in the discharge teaching?

Report bile-colored drainage from any incision

The client was found not breathing and was transported to the hospital. A family member states the client may have taken too much pain medication because the client frequently forgets if the medication was taken. Which observation(s) by the nurse indicates therapeutic effect of naloxone hydrochloride in the client? Select all that apply.

Reverses decreased respiratory rate of 10. Reverses blood pressure of 90/58. Reverses decreased level of consciousness.

A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan?

Risk for injury

A 15-year-old primigravid client at approximately 16 weeks' gestation tells the nurse that she has been experiencing an occasional sharp pain from the fundus to her pubic bone on the left side. The nurse determines that the client is most likely experiencing which complication?

Round ligament pain

Parents of a neonate who is 32 weeks of age ask the nurse, "Why does he have a feeding tube in his nose?" What is the nurse's best response?

The sucking, swallowing, and breathing are not coordinated.

A client who follows a vegetarian diet was referred to a dietitian for nutritional counseling for anemia. Which client outcome indicates that the client needs further nutritional counseling?

The client drinks coffee or tea with meals.

A female client who is hospitalized for an eating disorder weighs 15 lb (6.8 kg) less than the ideal body weight. Which goal is a priority for this client?

The client gains 1 lb (0.5 kg) per week.

A client arrives in the emergency department reporting intense pain in the abdomen and tells the nurse that it feels like a heartbeat in the abdomen. Which nursing assessment would indicate potential rupture of an aortic aneurysm?

The client reports increasing severe back pain.

When the nurse is caring for the client with a saline-only peripherally inserted central catheter (PICC line), what should the nurse do to maintain the catheter?

Utilize a 10-mL saline flush to maintain line patency

When prioritizing a client's care plan based on Maslow's hierarchy of needs, a nurse's first priority would be

administering pain medication.

A child admitted to the pediatric ward experiences an adverse reaction to a medication. After reviewing the medical record and speaking with the parents, the nurse identifies that they recently adopted this child from overseas, and there is no available medical history on the child. The nurse's priority action should be to:

assess and monitor the child, document the adverse event, and reassure the parents of the child's safety.

A client with type 2 diabetes mellitus who is taking metformin is scheduled for a computed tomography (CT) with contrast of the abdomen tomorrow. Which priority nursing assessment is done before the procedure?

ensuring that the metformin has been withheld for 48 hours prior to the scan

A client in labor is attached to an electronic fetal monitor (EFM). Which finding by an EFM indicates adequate uteroplacental and fetal perfusion?

fetal heart rate variability within 5 to 10 beats/minute

A positive tuberculin skin test indicates that a client

has produced an immune response.

The nurse evaluates the client's ability to instill eyedrops correctly. The client correctly demonstrates the procedure when the client:

instills the eyedrops into the conjunctival sac.

Which of the following actions is correct when the student nurse assesses the fontanels of a 6-week-old infant?

palpating the fontanels gently while the infant sits on the parent's lap

The correct procedure for collecting a urine specimen from an indwelling catheter is to:

remove urine from the drainage tube with a sterile needle and syringe and place urine from the syringe into the specimen container.

Which conditions or situations are most likely to result in difficulty sleeping? Select all that apply

shift work excessive worry or anxiety caffeine intake in the evening sleep apnea

The nurse observes the client instill eye drops. The client says, "I just try to hit the middle of my eyeball so the drops do not run out of my eye." What should the nurse tell the client about this method of instilling eye drops? This method may cause:

Corneal injury

A nurse is evaluating the external fetal monitoring strip of a client who is in labor. She notes decreases in the fetal heart rate (FHR) that start with the beginning of the client's contraction and return to baseline before the end of the contraction. What term does the nurse use to document this finding?

Early decelerations

The nurse is caring for a client with functional neurologic symptom disorder who has experienced pseudoseizures. What intervention is appropriate for the nurse to perform?

Encourage the client to discuss feelings about the pseudoseizures

A client has refused to take a shower since being admitted 4 days earlier and tells a nurse, "There are poison crystals hidden in the showerhead. They'll kill me if I take a shower." Which nursing action is most appropriate?

accepting these fears and allowing the client to take a sponge bath

The nurse reads the chart entry for a client who attends group therapy and uses cannabis daily: 2/10 1700 The client is congested, with a dry hacking cough. The client could not verbalize treatment goals when asked in the group session. The client laughed when the therapist gave each participant a worksheet to fill out and bring back to the next group, and stated, "I'm not doing that." What health problem is this client experiencing because of extended cannabis use?

amotivational syndrome

A nurse is caring for a client diagnosed with acute kidney injury with an indwelling urinary catheter. The nurse notes that the total urine output for the previous 24 hours is 35 ml. What action should the nurse perform first?

Scan the client's bladder to determine if residual volumes are present