NCLEX PassPoint Exam 1
A parent says that her family will soon be traveling abroad and asks why the drinking water in many regions must be boiled. The nurse should explain that, in addition to various types of dysentery, contaminated drinking water is most commonly responsible for the transmission of which disease? yellow fever brucellosis poliomyelitis typhoid fever
typhoid fever Water is the usual vehicle for spreading typhoid fever. Yellow fever is spread through insect bites. Brucellosis (undulant fever) is spread by contaminated cow's milk. Poliomyelitis is most probably spread through respiratory secretions.
A client diagnosed with obsessive-compulsive disorder arrives late for an appointment with the nurse at the outpatient clinic. During the interview, he fidgets restlessly, has trouble remembering what topic is being discussed, and says he thinks he is going crazy. Which statement by the nurse best deals with the client's feelings of "going crazy?" - "What do you mean when you say you think you're going crazy?" - "Most people feel that way occasionally." -"I don't know you well enough to judge your mental state." - "I haven't heard you make a crazy statement."
"What do you mean when you say you think you're going crazy?" When the client says he thinks he is "going crazy," it is best for the nurse to ask him what "crazy" means to him. The nurse must have a clear idea of what the client means by his words and actions. Using an open-ended question facilitates client description to help the nurse assess his meaning. The other statements minimize and dismiss the client's concern and do not give him the opportunity to openly discuss his feelings, possibly leading to increased anxiety.
A nurse is conducting a physical examination on a 2-month-old infant at the well-child examination. When measuring chest circumference, what is the standard anatomical landmark used? (Image Question)
Around the nipple line Head circumference and chest size measurements are often taken on newborns and infants to measure growth levels and development. These growth milestones reveal healthy brain growth and development. Chest circumference is most accurately measured by placing the measuring tape around the infant's nipples. Measuring above or below the nipples will yield a false measurement. The measurement would be taken after exhalation.
A nurse is providing health teaching on female sexuality and provides an illustration for education on the female anatomy. When discussing problems with sexual excitation, the nurse is correct to indicate which site as the area of sexual stimulation? (Image Question)
Clitoris Sexual excitement causes various physiological changes in the female body. The area associated with sexual stimulation is located near the vaginal entrance and behind the labia minora. The clitoris is directly associated with engorgement and climax.
A multigravid client at 34 weeks' gestation who is leaking amniotic fluid has just been hospitalized with a diagnosis of preterm premature rupture of membranes and preterm labor. The client's contractions are 20 minutes apart, lasting 20 to 30 seconds. Her cervix is dilated to 2 cm. The nurse reviews prescriptions (see chart). Which prescription should the nurse initiate first? Chart: Prescription: Continuous external fetal and contraction monitoring IV of D5LF @ 125 mL/hr I&O catheterization for urinalysis and culture and sensitivity Bethamethasome 12 mg IM daily x 2 days -Initiate fetal and contraction monitoring. -Start the intravenous infusion -Obtain the urine specimen. -Administer betamethasone.
Initiate fetal and contraction monitoring. The nurse should initiate fetal and contraction monitoring for this client upon arrival to the unit. This gives the nurse data regarding changes in fetal and maternal contraction status before completing the other prescriptions. Next, the betamethasone would be given to begin the maturation process for the fetal lungs. The nurse should then start an intravenous infusion to provide a line for immediate intravenous access, if needed, and provide hydration for the client. The nurse should obtain the urine specimen prior to administering any antibiotic therapy, if prescribed.
A client is given amiodarone in the emergency department for a dysrhythmia. Which finding indicates the drug is having the desired effect? -nurse's physical assessment of the client. -amount of pain medication the client is taking. -client's self-reporting of the pain experience. -family's response to the client's illness.
The number of premature ventricular contractions is decreasing.. Amiodarone is used for the treatment of premature ventricular contractions, ventricular tachycardia with a pulse, atrial fibrillation, and atrial flutter. Amiodarone is not used as initial therapy for a pulseless dysrhythmia.
A mother brings her 2-month-old son to the emergency department with a high fever and possible sepsis. The health care provider has prescribed a lumbar puncture, but the mother will not sign the consent until the father arrives to give permission. What should the nurse do? Report this to the social worker. Call the regional protective services for children. Wait until the father arrives. Inform the health care provider (HCP) that the mother has refused to have the procedure.
Wait until the father arrives. In the traditional Mexican household, the man is the head of the family and makes the major decisions. Efforts should be made to reach the father as soon as possible to acquire his permission. It is not necessary to contact the social worker at this point. The client has not refused the procedure, so it is premature to contact the HCP. This is not a situation of suspected child abuse.
Which clinical signs would indicate to a nurse caring for a terminally ill client that death may be imminent? -diminished urine output and Cheyne-Stokes respirations -Narrow pulse pressure and a body temperature of 98.6°F (37°C) -swallowing reflex and bowel sounds present -respirations regular at 18 breaths/min and weak pedal pulses
diminished urine output and Cheyne-Stokes respirations
The nurse is working on a birthing unit that has several unlicensed assistive personnel (UAP). The nurse should instruct the UAP assigned to several clients in labor to notify the nurse if the UAP notes any of the clients have which finding? an episode of nausea after administration of an epidural anesthetic contractions 3 minutes apart and lasting 40 seconds evidence of spontaneous rupture of the membranes sleeping after administration of IV nalbuphine
evidence of spontaneous rupture of the membranes The nurse expects the UAP assigned to several clients in labor to notify the nurse if the UAP observes that one of the clients has evidence of spontaneous rupture of the membranes. When the membranes rupture spontaneously, there is danger of a prolapsed cord, a medical emergency requiring a cesarean birth. Nausea may occur after administration of an epidural anesthetic, but this is not a priority or emergency. Having contractions that are 3 minutes apart and last for 40 seconds is normal during active labor. Because nalbuphine is an analgesic, it is normal for a client to fall asleep after intravenous administration of this drug.
To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction? "Lie down after meals to promote digestion." "Avoid coffee and alcoholic beverages." "Take antacids with meals." "Limit fluid intake with meals."
"Avoid coffee and alcoholic beverages." To prevent reflux of stomach acid into the esophagus, the nurse should advise the client to avoid foods and beverages that increase stomach acid, such as coffee and alcohol. The nurse also should teach the client to avoid lying down after meals, which can aggravate reflux, and to take antacids after eating. The client need not limit fluid intake with meals as long as the fluids aren't gastric irritants.
The nurse is teaching a client with trigeminal neuralgia how to minimize pain episodes. Which comments by the client indicate an understanding of the instructions? Select all that apply. "I'll eat food that is very hot." "I'll try to chew my food on the unaffected side." "I can wash my face with cold water." "Drinking fluids at room temperature should reduce pain." "If brushing my teeth is too painful, I'll try to rinse my mouth instead."
"I'll try to chew my food on the unaffected side." "Drinking fluids at room temperature should reduce pain." "If brushing my teeth is too painful, I'll try to rinse my mouth instead." Mechanical or thermal stimuli trigger the facial pain of trigeminal neuralgia. Chewing food on the unaffected side and rinsing the mouth rather than brushing teeth reduce mechanical stimulation. Drinking fluids at room temperature reduces thermal stimulation. Eating hot food and washing the face with cold water are likely to trigger pain.
The nurse has provided health teaching about physiologic changes that can be expected during the postpartum period to a postpartum client who is bottle-feeding her neonate. Which client statement indicates that this teaching has been effective? "I can expect to have heart palpitations for several weeks." "It's normal for me to have reddish lochia until my 6-week checkup." "Any varicosities I had during pregnancy will disappear within 2 weeks." "My menstrual flow should resume in approximately 6 to 10 weeks."
"My menstrual flow should resume in approximately 6 to 10 weeks." For clients who are bottle-feeding, menstrual flow usually returns in 6 to 10 weeks. Heart palpitations for several weeks are not normal and require further investigation. Reddish lochia at 6 weeks postpartum is not normal and warrants further evaluation. Although varicosities may fade, they rarely disappear completely after childbirth.
A nurse administers cefazolin instead of ceftriaxone to an 8-year-old with pneumonia. The client has suffered no adverse effects. The nurse tells the charge nurse of the incident but fears disciplinary action from reporting the error. What should the charge nurse should tell the nurse? - "If you do not report the error, I will have to." - "Reporting the error helps to identify system problems to improve client safety." - "Notify the client's health care provider to see if she wants this reported." - "This is not a serious mistake, so reporting it will not affect your position."
"Reporting the error helps to identify system problems to improve client safety." Client safety is enhanced when the emphasis on medication errors is to determine the root cause. All errors should be reported so systems can identify patterns that contribute to errors. Here, the similar names probably contributed to the error. The nurse who commits the error knows all the relevant information and is in the best position to report it. While the health care provider (HCP) should be notified, it is a nursing responsibility to report errors, not a HCP's choice. Relating mistakes to a nurse's position focuses on personal blame.
A client is receiving a bowel preparation of magnesium citrate the evening before a scheduled colonoscopy. Which factor should the nurse consider when providing care for this client? -Antidiarrheal medication should be given if the client has more than two loose stools. -Eating large meals should be encouraged to prevent weight loss. -The client may require fluid and electrolyte replacement. -Side rails should be raised at all times.
The client may require fluid and electrolyte replacement. Bowel preparation, which usually involves laxatives and sometimes enemas, may cause severe fluid and electrolyte loss. The nurse should monitor the client for dehydration and electrolyte loss. Diarrhea is expected after bowel preparation and shouldn't be treated. Most clients eat a light meal the evening before the procedure or are ordered a clear liquid diet. Raising the side rails may increase the risk of fall for a client with frequent diarrhea.
While making rounds, the nurse enters a client's room and finds the client on the floor between the bed and the bathroom. The nurse should first: -assist the client back to bed. -ask what the client was doing out of bed. -assess the client's current condition and vital signs. -activate the "Emergency Response" button.
assess the client's current condition and vital signs. The nurse's first priority is to complete an assessment of the client including assessment of airway, breathing, circulation, and vital signs as well as any change in level of consciousness or obvious injury. The nurse should not move the client or assist the client back to bed until after an assessment has been completed to prevent further injury. While it may be helpful to know what the client was doing out of bed in order to assess for potential confusion, the client's immediate safety is first priority. The nurse would not activate the "Emergency Response" button until an initial assessment was done to determine the need.
The nurse reviews the laboratory report of a child with leukemia (see exhibit). What does the nurse determine is the priority problem for this client? Exhibit (table): Test Traditional Units SI Units WBC 6,500 mm3 6.5 x 10^9/L Platelets 40,000 mm3 40 x 10^9/L HCT 41.2% 0.412 activity intolerance bleeding impaired tissue perfusion risk for infection
bleeding A normal platelet count is 150,000/μL to 400,000/μL (150 to 400 X 109/L). A platelet count of 40,000/μL (40 X 109/L) is low and puts the child at risk for injury, bruising, and bleeding. A hematocrit count of 41.2% (0.412) is normal; therefore, the child will have adequate oxygenation and tissue perfusion. The white count of 6,500 mm3 (6.5 X 109/L) is normal; therefore, the child has no increase in risk for infection.
The nurse is assessing a client who has a history of peripheral artery disease. The nurse observes that the left great toe is black. The nurse determines that the black color is caused by which factor? -atrophy -contraction -gangrene -rubor
gangrene The term gangrene refers to blackened, decomposing tissue that is devoid of circulation. Chronic ischemia and death of the tissue can lead to gangrene in the affected extremity. Injury, edema, and decreased circulation lead to infection, gangrene, and tissue death. Atrophy is the shrinking of tissue, and contraction is joint stiffening secondary to disuse. The term rubor denotes a reddish color of the skin.
A client is receiving epoetin alfa. Which findings indicate the effectiveness of the drug? -increase in white blood cells -decrease in blood glucose -increase in red blood cells -decrease in blood coagulation
increase in red blood cells Epoetin alfa is a man-made form of the protein human erythropoietin used to lessen the need for red blood cell transfusions. It stimulates the bone marrow to produce more red blood cells. The drug is used to treat anemia caused by chronic kidney disease, chemotherapy, and zidovudine, which is a drug used to treat HIV infection. The drug does not affect white blood cells or coagulation, nor does it cause blood glucose to decrease.
The nurse is assessing a neonate born to a mother with type 1 diabetes. Which finding is expected? -hypertonia -hyperactivity -large size -scaly skin
large size Women with diabetes mellitus generally have neonates who are large but physically immature. Other common findings in these infants are hypoglycemia, hypocalcemia, hyperbilirubinemia, polycythemia, renal thrombosis, and congestive anomalies. The neonates do not exhibit hypertonia, hyperactivity, or scaly skin.
A client with a modified radical mastectomy is being discharged. The client has been very reluctant to discuss the surgery or her situation. The nurse making assignments should delegate the client's care to the: -unlicensed assistive personnel (UAP) because the client is stable and being discharged. -same nurse who has cared for her the past 3 days, for continuity of care. -nurse in orientation who needs experience in discharge instructions. -nurse with the most bed baths, because this client will not need a bath.
same nurse who has cared for her the past 3 days, for continuity of care. Continuity of care is crucial for this client to feel more comfortable about asking questions and discussing her care at home. A UAP does not have the educational preparation (registered nursing license) to provide discharge instructions. It is not appropriate to assign this client to a nurse in orientation or one who needs assistance; the priority need is continuity of care.
A client with schizophrenia has been stable for some time. What action is most important for preventing relapse? -attending group therapy sessions -participating in family support meetings - going to social skills training sessions - taking prescribed medications consistently
taking prescribed medications consistently Although all of the choices are important for preventing relapse, compliance with the medication regimen is the priority in the treatment of schizophrenia.
The unlicensed assistive personnel (UAP) records a capillary blood glucose of 253 mg/dL (14.04 mmol/L) and the nurse administered insulin for coverage to the client. The UAP reports to the nurse that the blood glucose was incorrect. What actions should the nurse take? Select all that apply. Obtain a current blood glucose level. Observe the client for hypoglycemia. Reprimand the UAP for the incorrect blood glucose. Report the incident to the healthcare provider. Complete an incident report.
Obtain a current blood glucose level. Observe the client for hypoglycemia. Report the incident to the healthcare provider. Complete an incident report. The nurse should obtain a current blood glucose level to ascertain whether the blood glucose level is higher or lower than the amount stated, and this will guide the nurse in correcting the error. Observe for hypoglycemia because the nurse administered insulin to the client and the client's blood glucose may drop drastically. Report the incident to the healthcare provider so an order can be given, and complete an incident report recounting the incident. Reprimanding the UAP for the incorrect blood glucose will not correct the incident.
A registered nurse caring for a client with generalized anxiety disorder identifies a nursing diagnosis of Anxiety. A short-term goal is established as follows: "The client will identify physical, emotional, and behavioral responses to anxiety." Which nursing interventions will help the client achieve this goal? Select all that apply. -Avoid talking about the client's sources of stress. -Advise the client that consuming one glass of red wine per day may lessen anxiety. -Explain to the client that expressing feelings through journal writing may increase anxiety. -Observe the client for overt signs of anxiety. -Help the client connect anxiety with uncomfortable physical, emotional, or behavioral responses. -Introduce the client to new strategies for coping with anxiety, such as relaxation techniques and exercise.
Observe the client for overt signs of anxiety. Help the client connect anxiety with uncomfortable physical, emotional, or behavioral responses. Introduce the client to new strategies for coping with anxiety, such as relaxation techniques and exercise. The nurse should observe the client for overt signs of anxiety to assess anxiety and establish care priorities. The nurse should also help the client connect anxiety with uncomfortable physical, emotional, or behavioral responses. To modify the automatic response to stress, the client needs to connect the anxiety experience with the unpleasant symptoms. The nurse should also introduce new coping strategies, such as relaxation techniques and exercise, which can enable the client to take personal responsibility for making changes. The nurse should work with the client to identify sources of stress. The nurse should advise the client to avoid using caffeine, nicotine, and alcohol to cope with anxiety. Nicotine and caffeine are stimulants; alcohol acts as a depressant but, over time, requires increased use to achieve the desired effect, which may lead to alcohol abuse. The nurse should encourage the client to use a journal to record feelings, behaviors, stressful events, and coping strategies used to address anxiety. Documentation may help the client become aware of anxiety and the ways in which it affects overall functioning.
