NCLEX RN Passpoint - Psychosocial Integrity, Safety and Infection Control, Management of Care, Health Promotion and Maintenance

A nurse is preparing to perform a physical examination on a postpartum client. The client asks the nurse why gloves are necessary for the examination. What is the nurse's best response?

"Gloves are required for standard precautions."

A small airplane crashes in a neighborhood of 10 houses. One of the victims appears to have a cervical spine injury. What should first-aid for this victim include? Select all that apply.

1. Establish an airway with the jaw-thrust maneuver. 2. Immobilize the spine.

What should the nurse do to ensure safety for a hospitalized blind client?

Orient the client to the room environment.

A nurse determines that a client has 20/40 vision. Which action by the nurse is most appropriate?

Refer the client to a healthcare provider for possible corrective lenses.

The nurse performs a gestational age assessment on male neonate born vaginally at 37 weeks' gestation according to the mother's estimated date of delivery. Which physical finding would the nurse expect to find at 37 weeks' gestation?

Some cartilage in the ear lobes

The nurse-manager of a 20-bed coronary care unit is not on duty when a staff nurse makes a serious medication error that results in a client's overdose. The client nearly dies. Which statement accurately reflects the accountability of the nurse-manager?

The nurse-manager would receive a call at home from the on-duty nursing supervisor, apprising the nurse-manager of the problem as soon as possible.

A client with severe depression states, "My heart has stopped and my blood is black ash." The nurse interprets this statement to be evidence of which problem?

delusion; A delusion is a firm, false, fixed belief that is resistant to reason or fact. A hallucination is a false sensory perception unrelated to external stimuli. An illusion is a misinterpretation of a real sensory stimulus. Paranoia refers to suspiciousness of others and their actions.

A chronically ventilated client requests that care be withdrawn. The client is competent and understands the consequences of this decision. The client is not depressed, but does not want to continue living in this way. What should the nurse consider in this situation? Select all that apply.

1. The client has the right to refuse medical treatment. 2. The client's chart must be checked for a health care power of attorney. 3. The physician must be notified of the request.

A toddler receiving chemotherapy after surgery for a Wilms' tumor has developed neutropenia. The parent is trying to encourage the child to eat by bringing extra foods to the room. Which food would the nurse discourage for this child?

Fresh Strawberries; When a client receiving chemotherapy develops neutropenia, eating uncooked fruits and vegetables may pose a health risk due to possible bacterial contamination. All other foods are either cooked or pasteurized and would not produce a health risk.

A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority?

Impaired gas exchange; For a client with chest trauma, a diagnosis of Impaired gas exchange takes priority because adequate gas exchange is essential for survival.

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

oral mucous membranes

A nurse is caring for a client who has had paraplegia for 6 years. The client is admitted with a bleeding peptic ulcer. What would be a priority teaching concern for the nurse?

recommending foods included in a bland diet; The nurse should teach the client about consuming a bland diet. Although repositioning and retention is important for paraplegia, the client has dealt with this condition for many years. The more important concern is dealing with the new diagnosis. Increasing fluid intake will prevent constipation in a client with paraplegia, but will not treat the peptic ulcer disease.

When assessing a 13-year-old adolescent, what is an expected finding?

subjective judgments of right and wrong

The nurse has responsibility for several clients. Based on the information provided, which of these clients would be a priority for the nurse to evaluate when assuming responsibility for their care at the beginning of the evening shift?

the 70-year-old client who had a total laryngectomy the previous day; Based on the information provided, the client who is on day 1 after a total laryngectomy would be the priority client for the nurse to evaluate. This client is at risk for swelling or pressure on the trachea and should be monitored closely. Clients with acute conditions that can affect their respiratory status are a high priority for nursing care.

A daughter is concerned that her mother is in denial because when they discuss the diagnosis of breast cancer, the mother says that breast cancer is not that serious and then changes the subject. The nurse can tell the daughter that denial can be a healthy defense mechanism if it is used when?

to allow her mother to continue in her role as a mother

A nurse is attending a seminar at the local senior center. The nurse knows the presenter has a good understanding of genitourinary changes in the elderly when the presenter makes which statement?

"You should leave a light on in your bathroom at night."

Which suggestion would be most helpful to the parents of a 2-year-old child when managing separation anxiety during hospitalization?

Bring the child's favorite toys from home.

The wife of a client with alcohol dependency tells the nurse, "I'm tired of making excuses for him to his boss and coworkers when he can't make it into work. I believe him every time he says he's going to quit." The nurse recognizes the wife's statement as indicating which behavior?

enabling

A client admitted in an acute psychotic state hears terrible voices in the head and thinks a neighbor is upset with the client. What is the nurse's best response?

"What exactly are these terrible voices saying to you?"

A nurse assesses a client with psychotic symptoms and determines that the client likely poses a safety threat and needs vest restraints. The client is adamantly opposed to this. What would be the best nursing action?

Contact the physician and obtain necessary orders.

A client with schizophrenia is admitted to the psychiatric unit of a local hospital. During the next several days, the client is seen laughing, yelling, and talking out loud to no one. This behavior is characteristic of:

Hallucination

Which nursing action would be most successful in gaining a preschooler's cooperation in preparing for surgery?

Let the child choose whether to ride to the preoperative area on a stretcher or in a wagon.

The nurse is reconciling the medications with a client who is being discharged. Which information indicates there is a "discrepancy"?

There is lack of congruence between a client's home medication list and current medication prescriptions.

A client describes anxiety attacks that usually occur shortly after work when he is preparing his evening meal. Which question would be most appropriate for the nurse to ask the client first in an effort to learn how he can be helped?

"What are you thinking about before you start to prepare supper?"

The nurse cares for a client admitted to the emergency department after being found lying on the bathroom floor with several empty pill bottles around her. While waiting for a psychiatric consult, the nurse discovers that the client's boyfriend has recently broken up with her. Which response is most likely is to build and maintain a therapeutic relationship within the emergency department?

"What can I do to help while you are here?"

The nurse reads the new medication prescriptions for a 4-year-old child with nephrotic syndrome (see exhibit). What action should the nurse take?

Contact the prescriber for clarification

The nurse teaches 17-year-old girl with has a severe gonorrheal infection about her disease. The nurse realizes that the girl understands the implications of her disease when the client makes which statement?

"I could have trouble getting pregnant."

The nurse is teaching a new prenatal client about her iron-deficiency anemia during pregnancy. Which statement indicates that the client needs further instruction about her anemia?

"I may have anemia because my family is of Asian descent."

A client who has had AIDS for years is being treated for a serious episode of pneumonia. A psychiatric nurse consult was arranged after the client stated, "I'm tired of being in and out of the hospital. I'm not coming in here anymore. I have other options." The nurse would evaluate the psychiatric nurse consult as helpful if the client makes which statements?

"I realize that I really do have more time to enjoy my friends and family."

A client is admitted to a mental health unit with a diagnosis of depression and is participating in group sessions. The client asks a nurse if they are married or in a romantic relationship. What is the best response by the nurse to maintain a therapeutic relationship?

"I'm curious about your question but I want to know how you are feeling today;" Nurses must practice in a manner that is consistent with providing safe, competent, and ethical care. If the nurse shared personal information with the client, the nurse would have crossed the boundary of a therapeutic relationship and changed the focus of the discussion from a client focus to a social focus. It is very important in all areas of care, but especially in the mental health setting, that the relationship between the nurse and the client has very clear boundaries and is client focused.

The nurse is caring for a severely depressed client. Which statement by the nurse is best when talking to the client on the patient care unit?

"You're wearing a new shirt today."

The nurse cares for a client who is breathing rapidly, pacing back and forth across the room, has lips tightly closed, and with arms crossed tightly across his chest. What action should the nurse do first?

Assist client to a safe, calm environment.

A client newly admitted to a psychiatric inpatient setting demands a soda from a staff member who tells him to wait until lunch arrives in 20 minutes. The client becomes angry, pushes over a sofa, throws an end table, and dumps a potted plant. Which goal should a nurse consider to be of primary importance?

Demonstrating control over aggressive behavior

What question would the nurse ask to assess coping abilities of a family dealing with a chronic illness?

How is your condition affecting your family members and their usual roles?

The nurse is caring for a client who is confused about time and place. The client has intravenous fluid infusing. The nurse attempts to reorient the client, but the client remains unable to demonstrate appropriate use of the call light. In order to maintain client safety, what should the nurse do first?

Increase the frequency of client observation

The nurse is working in a public health clinic. Four clients present with various skin disorders. Which disorder requires disclosure to public health officials?

Picture 3 is a Rubella (German Measles) rash. Rubella is a contagious viral infection known for its distinctive red rash. Due to vaccines, it is not seen often but is still classified as a communicable disease. Titers are drawn to document immunity.

Which outcome criterion is appropriate for a child diagnosed with oppositional defiant disorder?

The child will recognize responsibility for behaviors; Children with oppositional defiant disorder frequently violate the rights of others. They are defiant, are disobedient, and blame others for their actions. Recognizing accountability for actions would demonstrate progress for the oppositional child.

A nurse notices that a client with obsessive-compulsive disorder washes the hands for long periods each day. How should the nurse respond to this compulsive behavior?

by setting aside times during which the client can focus on the behavior; The nurse should set aside times during which the client is free to focus on the compulsive behavior or obsessive thoughts. The nurse should urge the client to reduce the frequency of the compulsive behavior gradually, not rapidly.

The nurse is taking care of a client with neutropenia. Which nursing action is most important in preventing cross-contamination?

changing gloves immediately after use; Bedside rails, call bells, drug-administration controls operated by the client, and other surface areas are frequently touched by caregivers with used gloves. Changing gloves immediately after use protects the client from contamination by organisms. Cross-contamination is a break in technique of serious consequence to the severely compromised client

When assessing an elderly client, a nurse on the day shift notes redness in the sacral region. Close assessment reveals small breaks in the skin surface. The client says the area is tender and must have lost skin when a nursing assistant on the previous shift moved the client. The client tells the nurse, "The nursing assistant on the last shift was rough. I asked the nursing assitant to look at my backside, but the nursing assistant said they were too busy." What should the nurse do first?

Document the findings

An 8-year-old child, immobilized with a hip spica cast, says to the nurse, "I am so bored! Do you have any video games I can play?" What is the best nursing action?

Give child access to the unit's portable video game console and age-appropriate games.

In the hospital setting, the child of a client who is dying tells the nurse, "It is hard to just sit here for hours and not say or do anything." As the nurse responds to the child's statement, what issue is most important for the nurse to focus on during their discussion?

Know that being present with the person is important; The value of being present to a dying loved one is important, and it is often viewed as being more useful than keeping busy by doing things and having conversations. Providing background music may or may not be useful depending on the client's preference. The child will not be able to complete the client's unfinished business. Although comfort care is important, the nurse is most probably ensuring that this intervention is performed.

The treatment team plans to place a client in full leather restraints. What is the best care for this client?

Remove the leather restraints every 10-15 minutes

What is a priority to include in the plan of care for a client with Alzheimer's disease who is experiencing difficulty processing and completing complex tasks?

asking the client to do one step of the task at a time

Which is an expected finding for a client who has been treated for bacterial pneumonia?

the ability to perform activities of daily living without dyspnea; An expected outcome for a client recovering from pneumonia would be the ability to perform activities of daily living without experiencing dyspnea. A respiratory rate of 25 to 30 breaths/min indicates the client is experiencing tachypnea, which would not be expected on recovery. A weight loss of 5 to 10 lb (2 to 5 kg) is undesirable; the expected outcome would be to maintain normal weight. A client who is recovering from pneumonia should experience decreased or no chest pain

A client with a history of asthma is admitted to the emergency department. The nurse notes that the client is dyspneic, with a respiratory rate of 35 breaths/min, nasal flaring, and use of accessory muscles. Auscultation of the lung fields reveals greatly diminished breath sounds. What should the nurse do first?

Administer bronchodilators as prescribed.

A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which "related-to" phrase should the nurse add to complete the nursing diagnosis statement?

Related to impaired balance; A client with a cerebellar brain tumor may suffer injury from impaired balance as well as disturbed gait and incoordination. Visual field deficits, difficulty swallowing, and psychomotor seizures may result from dysfunction of the pituitary gland, pons, occipital lobe, parietal lobe, or temporal lobe — not from a cerebellar brain tumor. Difficulty swallowing suggests medullary dysfunction. Psychomotor seizures suggest temporal lobe dysfunction.

A nurse in a psychiatric care unit finds that a client with psychosis has become violent and has struck another client in the unit. What action should the nurse take in this case?

Restrain the client, as they are harmful to the other clients.

A nurse assesses an 82-year-old for depression. Because of the client's age, the nurse's assessment should be guided by which factor?

Sadness of mood is usually present, but it is masked by other symptoms; Older adult clients are a high-risk group for depression. The classic symptoms of depression frequently are masked, and depression presents differently in the aging population. Depression in late life is underdiagnosed because the symptoms are incorrectly attributed to aging or medical problems. Impairment of cognition in a previously healthy older adult client or psychosomatic problems may be the presenting symptom of depression. Antidepressant therapy is usually effective

When assessing a hospitalized client diagnosed with Major Depression and Borderline Personality Disorder, the nurse should ask the client about which of the following first?

Suicidal thoughts.

The nurse explains to a newly admitted primigravid client in active labor that, according to the gate-control theory of pain, a closed gate means that the client should experience what type of pain?

no pain; According to the gate-control theory of pain, a closed gate means that the client should feel no pain. The gate-control theory of pain refers to the gate-control mechanisms in the substantia gelatinosa that are capable of halting an impulse at the level of the spinal cord so the impulse is never perceived at the brain level as pain (i.e., a process similar to keeping a gate closed).

A client in a long-term care facility refuses to take oral medications. The nurse threatens to apply restraints and inject the medication if the client doesn't take it orally. The nurse's statement constitutes which legal tort?

assault

Two hours after a vaginal birth, the nurse has transferred a primipara and her term neonate to the mother-baby unit. Which observation by the nurse is a priority to be related to the nurse receiving the client on the mother-baby unit?

firm fundus when gentile massage is used

A client reports losing a job, not being able to sleep at night, and feeling upset with the client's spouse. The nurse responds, "You may want to talk about your employment situation in group today." The nurse is using which therapeutic technique?

focusing; The nurse is using focusing by suggesting that the client discuss a specific issue. The nurse didn't restate the question (restating technique) or ask further questions (exploring technique), and didn't make an observation.

The nurse observes two siblings, ages 7 and 9 years, verbally arguing over a toy. The nurse has counseled the parent before about how to handle this situation. The nurse should judge that the teaching has been effective when the parent takes what action?

ignores the arguing and continues what she is doing; The best approach by the mother is not to interfere. The children need to learn how to solve disagreements on their own. If the parent always intervenes, then the children do not learn how to do this. Siblings will disagree and argue as part of normal development. Punishment, including telling the children that they will not go out to lunch, is not warranted.

An infant undergoes surgery to correct an esophageal atresia and tracheoesophageal fistula. Which nursing diagnosis has the highest priority during the first 24 hours postoperatively?

ineffective airway clearance

One of the goals for a client with anorexia nervosa is for the client to demonstrate increased individual coping by responding to stress in constructive ways. Which intervention will the nurse discuss with the client as the best way to work toward meeting the goal?

keeping a personal journal and discussing it with the nurse

The nurse needs to pick up a large object that is sitting on the floor in a client's room. Which action most increases the nurse's risk of a back injury?

leaning forward toward the object

A healthcare provider has entered orders for a client with chronic obstructive pulmonary disease (COPD). Which order should the nurse question?

oxygen increased to 3 L/minute if oxygen saturation is less than 94% on room air; People with COPD retain CO2, which is the normal trigger for respiratory rate. In clients with COPD and high levels of CO2, oxygen levels trigger breathing. Too much oxygen and the body slows breathing. Clients with COPD may quit breathing completely when given oxygen at very high levels (greater than 2 L).

Before clients can learn, they must believe that they need to learn the information. The nurse recognizes that this is an example of which learning principle?

relevance

A nurse is caring for an elderly client in a long-term care facility. This client has a history of attempted suicide. The nurse observes the client giving away personal belongings and has heard the client express feelings of hopelessness to other residents. Which intervention should the nurse perform first?

removing items that the client could use in a suicide attempt

Which client action should the nurse judge to be a healthy coping behavior for a male adolescent after an appendectomy?

insisting on wearing a T-shirt and gym shorts rather than pajamas; Adolescents struggle for independence and identity, needing to feel in control of situations and to conform to peers. Control and conformity are often manifested in appearance, including clothing, and this carries over into the hospital experience. The adolescent feels best when he is able to look and act as he normally does, for example, wearing a T-shirt and gym shorts. Adolescents normally want to interact with peers and commonly seek every opportunity to do so. Avoiding other adolescents on the nursing unit or not taking phone calls from friends might suggest ineffective coping behavior. Refusing to fill out the menu and allowing the nurse to do so demonstrate dependent behavior, not a healthy coping mechanism.

A nurse pages a client's primary care physician in response to a low blood pressure reading. When returning the nurse's page, the physician asks the nurse to temporarily hold the client's scheduled antihypertensive and diuretic medications. How should the nurse ensure correct documentation of this telephone order?

Write "T.O." after the order and write out the physician's and nurse's names; When receiving telephone orders, the nurse should record the orders in the client's medical record, read the order back to the ordering practitioner, date and note the time the orders were issued, record T.O. (telephone orders) and the full name and title of the physician or nurse practitioner who issued the orders, and then sign the orders with name and title. It is unnecessary to obtain a confirmation from another practitioner or to have the order witnessed.