11/22/23 Passpoint Practice #2 (Quiz 7)

11. A client is to take methotrexate orally for severe rheumatoid arthritis. What should the nurse tell the client about taking this drug? Select all that apply. "You should avoid the chance of becoming bruised." "This drug will slow the progression of joint damage." "Increase your fluid intake to 3500 mL per day." "Limit or avoid the use of alcoholic drinks." "Your health care provider will monitor your blood work to determine liver disease and blood count." "Plan to increase the protein in your diet."

"This drug will slow the progression of joint damage." "You should avoid the chance of becoming bruised." "Your health care provider will monitor your blood work to determine liver disease and blood count." "Limit or avoid the use of alcoholic drinks." Explanation: Methotrexate is used for clients with rheumatoid arthritis to decrease the progression of the disease and relieve pain. Side effects of methotrexate include decreased white blood cells and platelets and the potential for liver disease. The nurse should instruct the client to avoid infection and report signs such as fever, chills, or cough. The client should avoid contact sports that could cause bruising. The client should also limit the amount of alcohol use to avoid liver damage. The client will have frequent blood tests to monitor liver enzymes and complete blood count. It is not necessary for the client to increase the protein in the diet or increase fluid intake to 3500 mL per day.

28. The nurse is leading a group session when the nurse notices that a member of the group is tearful and shaking. Which nursing actions would be therapeutic at this time? Select all that apply. allow the client to remain in the group and ignore the behavior direct a staff member to assist the client and continue with the group ask the client to leave the group and rejoin once feeling better redirect the group to another topic, which may evoke a less emotional response ask the client to share the emotions that the client is feeling apologize to the client and state that you did not mean to cause emotional pain

- Ask the client to share the emotions that the client is feeling - Direct a staff member to assist the client and continue with the group Explanation: In group therapy, a trained professional leads a small group of people with similar problems to discuss common issues. It is not uncommon for the group to evolve emotions on the topic being discussed. Groups are a safe place to share thoughts and feeling and often must work through negative content before positive outcomes surface. Because groups are a safe place to share emotions, asking the client to share their emotions is an appropriate action. A personal interaction with a supportive staff member is also an appropriate action. Ignoring the client or asking them to leave is discounting the client's feelings.

27. The nurse is developing a long-term care plan for an outpatient client diagnosed with dissociative identity disorder. Which intervention(s) should be included in this plan? Select all that apply. learning how to manage feelings, especially anger and rage trying different medicines to find one that eliminates the dissociative process selecting a method for alternate personalities ("alters") to communicate with each other, such as journaling identifying resources to call when there is a risk of suicide or self-mutilation joining several outpatient support groups that are process-oriented

- learning how to manage feelings, especially anger and rage - identifying resources to call when there is a risk of suicide or self-mutilation - selecting a method for alternate personalities ("alters") to communicate with each other, such as journaling Explanation: Managing suicidal thoughts, urges to self-mutilate, and intense anger are critical safety issues. Then, the focus can switch to communication methods for each alter and the integration issues. Process groups can be overwhelming when too much is revealed or when child alters are unable to understand the group content. There are no known medicines to stop the process of dissociating.

12. The nurse is administering vancomycin I.V. to a client. The pharmacy sent the correct dose, but it was to be administered 1 hour ago. What should the nurse do? Select all that apply. Complete any variance reports. Call the healthcare provider. Notify the pharmacy of the late medication so they can change the time of the next dose. Run the infusion as directed, and document the time it was started. Tell the nurse in the "hand-off" report that the medication and any associated labs need to be staggered.

-Notify the pharmacy of the late medication so they can change the time of the next dose. - Complete any variance reports. - Run the infusion as directed, and document the time it was started. - Tell the nurse in the "hand-off" report that the medication and any associated labs Explanation: The nurse should start the dose when available, noting the time the medication was started; also the pharmacy should be notified so they can schedule the next dose accordingly; pass on the information about the late medication in the hand-off report; and complete any variance reports. The nurse does not need to call the healthcare provider because the medication will still be given, only at a later time and the labs will have adjusted times so that the physician will still get the needed labs that reflect the medication was given.

13. The nurse observes that a client who has received midazolam for conscious sedation is having shallow respirations at a rate of 8 to10 breaths/min. The heart rate is 75 bpm; blood pressure is 95/65 mm Hg. What should the nurse do? Select all that apply. Encourage the client to deep-breathe. Contact the health care provider for a prescription for naloxone. Administer oxygen as prescribed. Have respiratory resuscitation equipment nearby. Notify the anesthesiologist.

Encourage the client to deep-breathe. Have respiratory resuscitation equipment nearby. Administer oxygen as prescribed. Explanation: The nurse should help the client take deep breaths. Resuscitation equipment should always be nearby when a client is recovering from anesthesia. The nurse can administer the oxygen as needed. The nurse does not need to contact the health care provider for a prescription for naloxone because naloxone is the antidote for morphine, not midazolam. It is not necessary to contact the anesthesiologist at this time.

3. A client is receiving CPR from paramedics as he arrives in the emergency department (ED). The paramedics are ventilating the client through an endotracheal tube placed prior to transport. During a pause in compressions, the cardiac monitor shows narrow QRS complexes and a heart rate of 55 bpm with a palpable pulse. Which action should the nurse take first? Administer 1 mg atropine IV Obtain an arterial blood gas (ABG) sample Check ET tube placement Start an IV line and administer amiodarone

Check ET tube placement Explanation: Endotracheal tube placement should be confirmed as soon as the client arrives in the ED. Once the airway is verified, oxygenation and ventilation should be confirmed using an end-tidal carbon dioxide monitor and pulse oximetry. Next, the nurse should establish IV access. If the client experiences symptomatic bradycardia, atropine should be administered as ordered. The ABG sample would verify effectiveness of CPR ventilations. Amiodarone is indicated for ventricular tachycardia, ventricular fibrillation, and atrial flutter.

19. A nurse is caring for a client with chronic renal failure. The nurse receives the arterial blood gas result pH-7.19, PCO2- 42mmHg (5.59 kPa), Po2- 88mm Hg (11.70 kPa), HCO3-15mEq/L (15.00 mmol/L). What are the priority action(s) by the nurse? Select all that apply. Prepare for possible seizures. Encourage rest. Administer sodium bicarbonate. Apply noninvasive positive-pressure ventilation. Record intake and output.

Encourage rest. Record intake and output. Prepare for possible seizures. Administer sodium bicarbonate. Explanation: The priority action by the nurse is seizure precautions, administering sodium bicarbonate to act as a bronchodilator, encouraging rest, and recording intake and output. Appling noninvasive positive-pressure ventilation is used for respiratory acidosis.

25. When caring for a multiparous client who is human immunodeficiency virus (HIV) positive and asking to breastfeed their neonate as soon as possible, the nurse should include which instruction about breast milk in the teaching plan? It has been found to contain the retrovirus HIV. It can be beneficial for the bonding process. It contains antibodies that can protect the neonate from HIV. It may help prevent the spread of the HIV virus.

It has been found to contain the retrovirus HIV. Explanation: Breast milk has been found to contain the retrovirus HIV. In general, birth parents are discouraged from breastfeeding if they are HIV positive because of the risk for possible transmission of the virus if the neonate is HIV negative. Breast milk does contain some immunoglobulins, but it does not protect the neonate from HIV infection.

24. To ensure safe postoperative care of a client after a total hip arthroplasty, which actions are most appropriate for the nurse to perform? Select all that apply. Teach the client not to cross the legs. Elevate the client's legs above the level of the heart. Limit movements resulting in internal rotation and adduction of the affected hip. Reduce extension and hyperextension of the affected hip. Use a pillow under the knees to prevent hip flexion.

Limit movements resulting in internal rotation and adduction of the affected hip. Teach the client not to cross the legs. Explanation: With a total hip replacement, correct positioning and movement is important to prevent dislocation. Dislocation after hip replacement is minimized when the client avoids movements resulting in internal rotation and adduction of the affected hip. Teaching the client not to cross the legs is important to prevent dislocation. Pillows under the knees may interfere with circulation. Extension and hyperextension should not interfere with hip movement; elevating the legs above the heart level would be incorrect and could result in dislocation.

18. A client returns from a laryngectomy and begins to cough violently, dislodging the tracheostomy tube. What is the priority action of the nurse? Attempt to reinsert the tracheostomy tube with the obturator in place. Assess the client's oxygen saturation and notify the healthcare provider. Cover the stoma with sterile gauze and place a 100% nonrebreather mask over the client's nose and mouth. Mask ventilate the client and prepare for orotracheal intubation when the healthcare provider arrives.

Mask ventilate the client and prepare for orotracheal intubation when the healthcare provider arrives. Explanation: The priority action for the nurse is to use mask ventilation and not to try to reinsert the tracheostomy tube with a new laryngectomy. A new tracheostomy stoma can close, causing the airway to occlude.

4. The nurse is asked to assess a client prior to having an arterial blood gas (ABG) sample drawn to determine if the client can safely undergo this test. What assessment should the nurse conduct? Palpate the radial artery for strength and rhythm. Gather a full set of vital signs. Perform an Allen's test. Review the client's baseline ABG results.

Perform an Allen's test. Explanation: An Allen's test to assess circulation should be performed first as this will determine if there is impaired radial artery circulation that would contraindicate having the ABG performed. The client can have a strong, regular radial pulse but still have impaired arterial blood flow to the region. Although the client's vital signs should be done, these are not directly related to the appropriateness of the ABG test. Previous ABG results will not have a bearing on whether this new test should be done.

7. A client who chronically snorts cocaine is brought to the emergency department due to a cocaine overdose. The client is experiencing delusions, hallucinations, mild respiratory distress, and mild tachycardia initially. What should the nurse do? Select all that apply. Induce vomiting. Place seizure pads on the bed. Monitor for respiratory acidosis. Encourage deep breathing. Monitor for metabolic acidosis. Administer PRN haloperidol as ordered.

Place seizure pads on the bed. Administer PRN haloperidol as ordered. Monitor for respiratory acidosis. Encourage deep breathing. Monitor for metabolic acidosis. Explanation: The cocaine was not swallowed, so inducing vomiting is not indicated. A cocaine overdose can produce seizures, paranoia, and respiratory and/or metabolic acidosis. Deep breathing will help decrease the respiratory distress and pulse rate.

20. A nurse is caring for a client with pulmonary edema whose respiratory status is declining. Chronologically arrange the nursing interventions to prioritize care. All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Administer furosemide 40 mg intravenously STAT. 2Position the client upright at a 45°angle. 3Call the health care provider. 4Insert an indwelling urinary catheter. 5Prepare suctioning equipment at the bedside. 6Initiate oxygen via nasal cannula at 2 L/minute.

Position the client upright at a 45°angle. Initiate oxygen via nasal cannula at 2 L/minute. Prepare suctioning equipment at the bedside. Call the health care provider. Administer furosemide 40 mg intravenously STAT. Insert an indwelling urinary catheter. Explanation: The order of priority moves from the simple to the complex for bedside interventions when a client is in respiratory distress. The nurse would first attempt to maximize respiratory excursion as much as possible by sitting the client up and then provide supplemental oxygen to minimize impending hypoxia. The nurse may initiate oxygen therapy as a nursing order. It is also important to have suction equipment readily available because the client may choke on oral secretions because of the pulmonary edema. After performing these interventions, the nurse would notify the health care provider and anticipate orders for administration of a diuretic (such as furosemide) and insertion of an indwelling urinary catheter to measure eventual output.

2. A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. What is the most important action by the nurse? Lower the head of the bed to improve cerebral perfusion Preventing secondary acute tubular necrosis Preparing to administer hypertonic saline or mannitol per provider order Elevate the head of the bed to reduce intraocular pressure

Preparing to administer hypertonic saline or mannitol per provider order Explanation: Hypertonic saline and mannitol promote osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces. Therefore these agents are often used as first-line agents to decrease ICP while preparing the client for surgery. Elevating the head of the bed can also help facilitate venous return, targeting a decrease in ICP, not intraocular pressure. Although it is important to closely monitor fluid and electrolytes, preventing acute kidney injury is secondary.

5. A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. What is the most important action by the nurse? Lower the head of the bed to improve cerebral perfusion Preventing secondary acute tubular necrosis Preparing to administer hypertonic saline or mannitol per provider order Elevate the head of the bed to reduce intraocular pressure

Preparing to administer hypertonic saline or mannitol per provider order Explanation: Hypertonic saline and mannitol promote osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces. Therefore these agents are often used as first-line agents to decrease ICP while preparing the client for surgery. Elevating the head of the bed can also help facilitate venous return, targeting a decrease in ICP, not intraocular pressure. Although it is important to closely monitor fluid and electrolytes, preventing acute kidney injury is secondary.

15. A nurse is developing a care plan for a client with hepatic encephalopathy. Which would be the goal(s) for the care for this client? Select all that apply. Administer lactulose to reduce blood ammonia levels. Provide food and fluids high in carbohydrates. Prevent constipation. Check the pupil reaction. Monitor coordination while walking. Encourage physical activity.

Prevent constipation. Administer lactulose to reduce blood ammonia levels. Monitor coordination while walking. Check the pupil reaction. Provide food and fluids high in carbohydrates. Explanation: Constipation leads to increased ammonia production. Lactulose is a hyperosmotic laxative that reduces blood ammonia by acidifying the colon contents, which retards the diffusion of nonionic ammonia from the colon to the blood while promoting its migration from the blood to the colon. Hepatic encephalopathy is considered a toxic or metabolic condition that causes cerebral edema; it affects a person's coordination and pupil reaction to light and accommodation. Food and fluids high in carbohydrates should be given because the liver is not synthesizing and storing glucose. Because exercise produces ammonia as a by-product of metabolism, physical activity should be limited, not encouraged.

6. A client on a stretcher in the emergency department begins to thrash around, slap the sheets, and yell, "Get these bugs off of me." The client is disoriented and has a blood pressure of 189/75 mm Hg and a pulse of 96 bpm. The friend who is with the client says, "My friend was drinking a lot 3 days ago and asked me for money to get more vodka, but I didn't have any." What should the nurse do in order of priority from first to last? All options must be used. put in order 1. Implement constant observation. 2Administer haloperidol and lorazepam IM as prescribe. 3Monitor vital signs every 15 minutes. 4Obtain a prescription to place the client in restraints, if needed. 5Chart the client's response to the interventions. 6Remind the client that they are in the hospital and the nurse is with them.

Remind the client that they are in the hospital and the nurse is with them. Implement constant observation. Administer haloperidol and lorazepam IM as prescribe. Monitor vital signs every 15 minutes. Obtain a prescription to place the client in restraints, if needed. Chart the client's response to the interventions. Explanation: After orienting the client to time and place, the nurse should assure constant observation of the client to prevent the client from getting hurt. The administration of the haloperidol and lorazepam are needed to quickly decrease the symptoms of delirium tremens (DTs) and lower the vital signs. Monitoring vital signs assesses the client's stability and need for additional medications. The nurse can ask another staff to contact the healthcare provider (HCP) to request a prescription for restraints in case the client becomes violent toward self or others. After the DT symptoms subside, the haloperidol would be stopped due to the decrease in the seizure threshold. Other detoxification protocols would then begin. Last, chart the client's response.

1. The nurse is caring for a client who has an endotracheal tube (ETT). What is the nurse's priority intervention to prevent oral ulceration related to an ETT? Provide oral care twice a day with a soft, moist oral swab. Suction the oral cavity with a flexible catheter every 4 hours. Use water-based lubricant on the lips every 8 hours. Reposition the tube from one side of mouth to the other per protocol frequency.

Reposition the tube from one side of mouth to the other per protocol frequency. Explanation: Pressure causes skin breakdown or ulceration, so repositioning the ET tube can best decrease this risk for oral ulcers. Extreme care must be taken to move the tube only laterally; it must not be pushed in or pulled out. The tape securing the tube must be changed daily. Oral care, suctioning, and lubricant will help keep skin clean, intact, and reduce the risk of further infection but will not reduce the risk for ulcers like tube repositioning will.

10. The nurse is preparing to flush the line of a client's tunneled central venous access device. What is the correct step sequence by the nurse? All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Clamp the catheter. 2Scrub hub and let dry completely. 3Unclamp the catheter. 4Inject the normal saline. 5Check for blood return. 6Attach prefilled saline syringe.

Scrub hub and let dry completely. Clamp the catheter. Attach prefilled saline syringe. Unclamp the catheter. Check for blood return. Inject the normal saline. Explanation: The nurse should scrub the hub and let dry completely to decrease the chance for central venous access infection. Then the catheter should be clamped so that air does not enter the line while attaching the prefilled syringe. After attaching the prefilled syringe, the nurse should then unclamp the catheter, assess for blood return, and if blood return present, inject the saline. Assessing for blood return ensures patency of the line.

21. The nurse would include which instructions in the teaching plan for a client with chronic sinusitis? Select all that apply. Report a temperature of 102°F (38.9°C) or higher. Avoid the use of caffeinated beverages. Limit fluid intake to 1,000 ml per 24 hours. Use normal saline nasal rinse properly. Perform postural drainage every day by placing the head lower than the feet.

Use normal saline nasal rinse properly. Report a temperature of 102°F (38.9°C) or higher. Explanation: The client with chronic sinusitis should be instructed on the proper use of normal saline nasal rinse to promote drainage of secretions. There is no need to limit caffeine intake. Performing postural drainage will inhibit removal of secretions, not promote it. Clients should elevate the head of the bed to promote drainage. Clients should report all temperatures higher than 100.4°F (38°C) because a temperature that high can indicate infection. The client should increase, not limit, fluid intake; a 24-hour fluid intake of 2,000 to 3,000 ml would be appropriate.

26. A newborn admitted with pyloric stenosis is lethargic and has poor skin turgor. The health care provider (HCP) has prescribed intravenous fluids of dextrose water with sodium and potassium. The baby's admission potassium level is 3.4 mEq/L (3.4 mmol/L). What should the nurse do first? Notify the HCP. Have the potassium level redrawn. Verify that the infant is urinating. Administer the prescribed fluids.

Verify that the infant is urinating. Explanation: Normal serum potassium levels are 3.5 to 4.5 mEq/L (3.5 to 4.5 mmol/L). Elevated potassium levels can cause life-threatening cardiac arrhythmias. The nurse must verify that the client has the ability to clear potassium through urination before administering the drug. Infants with pyloric stenosis frequently have low potassium levels due to vomiting. A level of 3.4 mEq/L (3.4 mmol/L) is not unexpected and should be corrected with the prescribed fluids. The lab value does not need to be redrawn as the findings are consistent with the infant's condition.

23. The nurse is obtaining a health history for a client with osteoporosis. What should the nurse ask the client about? Select all that apply. use of Vitamin K supplements amount of alcohol consumed daily dietary intake of fiber intake of fruit juices use of antacids

amount of alcohol consumed daily use of antacids dietary intake of fiber use of Vitamin K supplements Explanation: The nurse should ask the client about alcohol use because heavy alcohol use causes fluid excretion resulting in heavy losses of calcium in urine. If the client uses antacids containing aluminum or magnesium, a net loss of calcium can occur. If the client has a high-fiber diet, the fiber can bind up some of the dietary calcium. People with hip fractures have been found to have low vitamin K intakes; vitamin K plays an important role in the production of at least one bone protein. Fruit juices do not affect calcium absorption.

14. The nursing is caring for a newly admitted client with diabetes insipidus. When forming the plan of care, which nursing diagnoses are anticipated? Select all that apply. impaired physical mobility hyperglycemia anxiety activity intolerance self-care deficit fluid volume, excess

anxiety activity intolerance Explanation: Diabetes insipidus is characterized by excessive output of dilute urine. Common signs and symptoms include massive diuresis, dehydration, and thirst. Additional findings include malaise, lethargy, and irritability. Nursing diagnoses that aim at providing interventions to decrease the symptoms include Anxiety (irritability) and activity intolerance (due to lethargy). The client has a fluid volume deficit due to the excessive output of urine. Though the client urinates frequently, there is no reason to believe that there is an impaired physical mobility or self-care deficit. A client has symptoms of hyperglycemia with diabetes mellitus.

17. A young female client is diagnosed with hypothyroidism. What information should the nurse obtain when conducting a focused assessment? Select all that apply. rapid pulse decreased energy and fatigue constipation fine, thin hair with hair loss menorrhagia weight gain of 10 lb (4.5 kg)

decreased energy and fatigue weight gain of 10 lb (4.5 kg) constipation menorrhagia Explanation: Clients with hypothyroidism exhibit symptoms indicating a lack of thyroid hormone. Bradycardia, decreased energy and lethargy, memory problems, weight gain, coarse hair, constipation, and menorrhagia are common signs and symptoms of hypothyroidism.

9. The parents of a 15-year-old female with a history of disordered eating are concerned about her loss of 24 lb (10.9 kg) during the previous month. The nurse tells the parents that she'll give their daughter a comprehensive examination and make appropriate referrals. Which initial referrals should the nurse make? Select all that apply. psychiatric evaluation gynecologic examination dental assessment toxicology evaluation nutritional consult

nutritional consult psychiatric evaluation Explanation: A nurse must assess a client with disordered eating and create a care plan to stabilize body weight and prevent further weight loss. The nutritional consult helps determine nutritional needs to maintain body weight. A psychiatric evaluation establishes the baseline for a care plan to address the client's emotional needs, process the client's feelings and experiences, develop effective coping skills, and develop a realistic body image and positive self-image. After the adolescent's body weight stabilizes, she should have a dental assessment to identify dental problems resulting from malnutrition or purging. Although females with disordered eating may have amenorrhea, this adolescent shouldn't have a gynecologic examination unless a medical condition warrants one at a later time. She doesn't need a toxicology evaluation unless a severe substance-abuse problem is identified.

22. A client newly diagnosed with acute lymphocytic leukemia has a right subclavian central venous catheter in place. The nurse who is caring for the client is teaching a graduate nurse about central venous catheter care. The nurse should instruct the graduate nurse to change the dressing when? Select all that apply. every 72 hours when the dressing is becoming loose when the dressing is soiled when the site is reddened per hospital policy

per hospital policy when the dressing is becoming loose when the dressing is soiled when the site is reddened Explanation: Research demonstrates that central lines are a large infection risk for clients. The dressing must be clean, dry, and intact to be effective. Sterile dressing change is indicated when the dressing does not meet this criteria; otherwise it is changed per hospital policy.

16. The nurse is caring for a client with Cushing's disease. During change of shift report, which assessment laboratory data would the nurse anticipate communicating? Select all that apply. serum potassium level hemoglobin and hematocrit serum sodium level blood glucose level white blood cell count creatinine clearance total SUBMIT ANSWER

serum sodium level serum potassium level blood glucose level white blood cell count Explanation: Cushing's disease results in an excess cortisol in the blood typically caused by a pituitary tumor secreting adrenocorticotropic hormone (ACTH). ACTH stimulates the adrenal glands to produce cortisol. Cortisol is important in controlling blood pressure and metabolism. Electrolyte disturbance is common for the nurse to report. Sodium retention is typically accompanied by potassium depletion. Clients exhibit frequent hyperglycemia. The white blood cell count is commonly elevated because of an increased number of neutrophils. There is no impact of the hemoglobin or hematocrit or kidney function.

8. The nurse assesses a client experiencing alcohol withdrawal. Which symptom(s) would indicate that a client has alcohol withdrawal delirium? Select all that apply. thirst tachycardia abdominal cramping tachypnea dry, flushed skin hypertension

tachycardia tachypnea hypertension Explanation: When a client is developing impending alcohol withdrawal delirium, the initial symptoms are a fast pulse, fast respiratory rate, and elevated blood pressure. Red, flushed, dry skin and reports of thirst occur with diabetic ketoacidosis. Abdominal cramping and severe diarrhea are symptoms of opiate withdrawal.