Passpoint- Fundamentals
A nurse is performing a sterile dressing change. Which action contaminates the sterile field?
Pouring solution onto a sterile field cloth.
A client has sustained a head injury and is to receive mannitol by I.V. push. In evaluating the effectiveness of the drug, the nurse should expect to find:
decreased cerebral edema.
The nurse is caring for a client with asthma. The nurse should conduct a focused assessment to detect:
inspiratory and expiratory wheezing.
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 selection of a nursing care delivery system (NCDS) is critical to the success of client care in a nursing area. Which factor is essential to the evaluation of an NCDS?
Identifying who will be responsible for making client care decisions
A client is taking paroxetine 20 mg PO every morning. The nurse should monitor the client for which adverse effect?
sexual problems
A nurse administers digoxin 0.125 mg to a client at 1400 instead of the prescribed dose of digoxin 0.25 mg. Which statement should the nurse record in the medical record?
Digoxin 0.125 mg given at 1400 instead of prescribed dose of 0.25 mg.
On entering the room of a client who has undergone a dilatation and curettage (D&C) for a spontaneous abortion, the nurse finds the client crying. Which comment by the nurse would be most appropriate?
"I am truly sorry you lost your baby."
A nurse inadvertently transcribes a client's medication order that was written as "Ampicillin 250 mg four times a day" as "Ampicillin 2500 mg four times a day." The nurse gives two doses as transcribed to the client. Another nurse gives one dose before the pharmacist questions the reorder of the medication. What should the two nurses do in this situation?
Both nurses must acknowledge making the medication error.
A nurse is developing a care plan for a client who is a single parent. The client is experiencing anxiety after the loss of a job and is verbalizing concerns regarding the ability to meet role expectations and financial obligations. Which of the following is most important for the nurse to include in the plan of care?
Determine the client's ability to cope with the job loss and family obligations.
A diabetic client with peripheral vascular disease is ordered to wear knee-high elastic compression stockings continuously until discharge. Which of the following would be the priority after the stockings are applied?
Remove elastic stockings once per day and observe lower extremities.
Delegation is the process of transferring work to subordinates. A nurse-manager may appropriately delegate which task?
Scheduling staff assignments for the next month
A nurse is faxing client information to a nursing home. Which action should the nurse take to maintain client confidentiality?
determining that the client has authorized release of the information
A client scheduled to have a surgery for a hernia the next day is anxious about the procedure. The nurse assures the client that surgery for hernias is very common and that the prognosis is very good. What skill is the nurse demonstrating?
interpersonal skills
While providing care to a client, the nurse notes multiple blue, purple, and yellow ecchymotic areas on the arms and trunk. When the nurse asks about these bruises, the client responds, "I tripped." What actions would the nurse take? Select all that apply.
-Document the client's statement and complete a body map indicating the size, color, shape, location, and type of injuries. -Assist the client in developing a safety plan for times of increased violence. -Provide the client with telephone numbers of local shelters and safe houses.
A client with asthma has been prescribed fluticasone, one puff every 12 hours per inhaler. Place in correct order the nurse's statements when teaching the client how to properly use the inhaler with a spacer.
-Take off the cap and shake the inhaler. -Attach the spacer. -Breathe out all of your air. Hold the mouthpiece of your inhaler and spacer between your teeth with your lips closed around it. -Press down on the inhaler once and breathe in slowly. -Hold your breath for at least 10 seconds, then breathe in and out slowly. -Rinse your mouth.
When planning care for a client with ulcerative colitis who is experiencing an exacerbation of symptoms, which client care activities can the nurse appropriately delegate to an unlicensed assistive personnel (UAP)? Select all that apply.
-maintaining intake and output records -obtaining the client's weight -providing skin care following bowel movements
A client has an order for a clear liquid diet. The nurse is assisting the client to complete a menu. Which item would be appropriate for the client to order?
-tea -apple juice -broth
The nurse-manager of a home health facility includes which item in the capital budget?
A $1,200 computer upgrade Capital budgets generally include items valued at more than $500. Salaries and benefits are part of the personnel budget. Office supplies and client education materials are part of the operating budget.
Which of the following is a priority nursing assessment of a reddened heel in a bed-ridden client?
Test for blanching to the affected area
An older adult with end-stage cancer needs assistance with arranging the finances for end-of-life home care. The nurse should refer the client to which person?
a social worker
For which client is the nursing assessment of pain most likely to result in undertreatment?
an older adult who grimaces and states no pain after a gastrostomy tube placement
While listening to a client's chest, the nurse notes a rub during inspiration and expiration with a grating sound. When communicating to the health care provider, what should the nurse request in the SBAR communication?
chest x-ray
A client is experiencing acute alcohol withdrawal. What complication should the nurse anticipate based on the present condition?
seizures and hallucinations
A client was admitted to the hospital 2 weeks ago following an ischemic stroke. Following the early introduction of stroke rehabilitation, the client has seen significant improvements in both medical status and activities of daily living (ADLs). This morning, however, the nurse notes that the client has been coughing since eating a minced and pureed breakfast. Auscultation of the chest reveals coarse crackles. Which practitioners should the nurse liaise with to obtain a swallowing assessment?
speech therapist
When providing care to Aboriginal clients, it may be important for the nurse to elicit help from the
spiritual healer.
The nurse should utilize SBAR communication (Situation, Background, Assessment, Recommendation) during which clinical situation?
when communicating a change in a client's condition to their physician
The son of an older adult client who has cognitive impairments approaches the nurse and says, "I'm so upset. The health care provider says I have 4 days to decide on where my dad is going to live." The nurse responds to the son's concerns, gives him a list of types of living arrangements, and discusses the needs, abilities, and limitations of the client. The nurse should intervene further if the son makes which comment?
"I want the social worker to make this decision so Dad won't blame me."
The nurse is caring for a young adult with hepatitis A. The client is crying and saying that they hate the way they look with yellow skin. Which response is most appropriate?
"If you start to get well and feel better, the skin will return to its normal color."
A client who has been prescribed chemotherapy wants to take herbal treatments instead. What should the nurse tell the client?
"Tell me about your concerns with chemotherapy."
When collecting a health history on a child, what is important for the nurse to assess regarding the child's allergies? Select all that apply.
-reaction to the allergen -severity of the allergy -allergies to items other than medications, such as foods and animals -allergies to any medications
The charge nurse on a hematology/oncology unit is reviewing the policy for using abbreviations with the staff. The charge nurse should emphasize which information about why dangerous abbreviations need to be eliminated? Select all that apply.
-to ensure efficient and accurate communication -to prevent medication errors -to ensure client safety
A nurse administers morphine sulfate to a client in the recovery room. Within 15 minutes after receiving the dose of morphine, the client is very lethargic; respiratory rate is 7 breaths per minute and shallow. What is the appropriate action of the nurse?
Administer naloxone.
Which strategy is the most effective for a nurse to use to reduce the number of children involved in automobile accidents who were not wearing seat belts?
Attend a school board meeting to advocate for classes teaching children seat belt safety.
The family members of a client who is near death from colon cancer ask the nurse what to expect if the client becomes dehydrated. What should the nurse should tell them?
Dehydration is expected during the dying process.
A nurse is assessing a client with a urinary tract infection who takes an antihypertensive drug. The nurse reviews the client's urinalysis results (see chart). What should the nurse do next?
Encourage the client to increase fluid intake. The specific gravity is high indicating that urine is very concentrated.
In preparing for a client's admission to the unit, what is the nurse's responsibility?
Ensuring the completion of room preparation responsibilities that may have been delegated to ancillary staff.
The nurse applies warm compresses to a client's leg. To determine effectiveness of the compresses, the nurse should determine if there is:
Improved circulation to the area.
The client is started on simvastatin to lower cholesterol. The nurse should explain to the client that which laboratory test will be monitored to detect potential side effects while the client is taking this drug?
Liver Function test
Which client would benefit from the application of warm moist heat?
Low Back pain
The nurse manager overhears comments made between two nurses. The first nurse repeatedly makes comments that focus on the second nurse's skin color and race. The second nurse is observably offended. Which of the following actions by the nurse manager to address the behavior of the first nurse would promote a quality practice environment?
Speak to the first nurse, pointing out that the comments constitute harassment and will not be tolerated.
A client states, "I have never taken a yellow pill before for my blood pressure. Why are you giving me this pill?" After verifying that the nurse has prepared the correct medication, which statement by the nurse would be accurate?
This is the same medication that you take at home but in generic form."
A client states, "I have abdominal pain." Which assessment question would best determine the client's need for pain medication?
What does the pain feel like?"
A client who was involved in a motor vehicle accident is admitted to the hospital. His wife arrives on the unit 6 hours after her husband's accident, explaining that she has been out of town. She is distraught because she was not with her husband when he needed her. The nurse should:
allow her to verbalize her feelings and concerns.
A client is transferred to the acute stroke unit. The nurse initiates a neurologic flow sheet to provide ongoing data about the recovery phase of care and is aware this information indicates what regarding a client's clinical status?
changes in level of consciousness or responsiveness as evidenced by movement and orientation to time, place, and person
Upon assessment, the client reports that they do not belong to an organized religion. The nurse is correct to interpret this statement as th
client is not affiliated with a specific system of belief regarding a higher power.
A client's diagnosis of pneumonia requires treatment with antibiotics. The corresponding order in the client's chart should be written as
moxifloxacin 400 mg daily
A day-shift nurse gives a client an injection of pain medication. The nurse forgets to document the injection on the medication administration record (MAR). The day-shift nurse tells the evening-shift nurse that she gave the client 4 mg of morphine at 2 p.m. for postoperative pain but didn't document the injection. The evening-shift nurse puts the day-shift nurse's initials and the date and time the dose was administered in the appropriate area of the MAR. The evening-shift nurse's action is considered to be which type of documentation error?
unauthorized entry
The nurse is administering an intradermal injection (see the accompanying figure). The nurse should:
withdraw the needle.
Before a transesophageal echocardiogram, a nurse gives a client an oral topical anesthetic spray. When the client returns from the procedure, the nurse observes that the client has no active gag reflex. In response, the nurse should
withhold food and fluids.
