Passpoint Exams
The nurse caring for a neonate observes excessive oral secretions, and suspects a tracheoesophageal atresia. Which priority intervention should the nurse perform? a. Place a nasogastric (NG) tube. b. Stop PO feedings. c. Administer oxygen. d. Suction the secretions.
My answer: Stop PO feedings. Correct answer: Suction the secretions. Explanation: Accumulated secretions are copious in neonates with this disorder because the neonate cannot swallow. This places the neonate at risk for aspiration. Maintenance of the airway and suctioning the secretions would be the first priority. PO feedings would be withheld until further evaluation and treatment are completed. A NG tube would be placed after the initial evaluation. Oxygen would only be administered if indicated.
A client with hypothyroidism (myxedema) is receiving levothyroxine, 25 mcg P.O. daily. Which finding should the nurse recognize as an adverse reaction to the drug? a. dysuria b. leg cramps c. tachycardia d. blurred vision
My answer: blurred vision Correct answer: tachycardia Explanation: Levothyroxine, a synthetic thyroid hormone, is given to a client with hypothyroidism to simulate the effects of thyroxine. Adverse reactions to this agent include tachycardia. Dysuria, leg cramps, and blurred vision aren't associated with levothyroxine.
A nurse is reviewing the healthcare provider's orders for a client admitted with systemic lupus erythematosus (SLE). Which medication would the nurse expect to find in this client's plan of care? a. morphine b. ketoconazole c. hydroxychloroquine d. dimenhydrinate
My answer: dimenhydrinate Correct answer: hydroxychloroquine Explanation: Fatigue, photosensitivity and a "butterfly" rash on the face are all signs and symptoms of SLE. Hydroxychloroquine is used in the treatment of SLE to prevent inflammation. Pharmacological treatment of SLE also involves nonsteroidal anti-inflammatory drugs, corticosteroids, and immunosuppressive agents. Morphine is an opioid analgesic, ketoconazole is an antifungal agent, and dimenhydrinate is an antiemetic.
A multiparous client who has been in labor for 2 hours states that she feels the urge to move her bowels. What would the nurse do first? a. Assist the client to get up to use the toilet. b. Allow the client to use a bedpan. c. Perform a pelvic examination. d. Check the fetal heart rate (FHR).
My answer: Check the fetal heart rate (FHR). Correct answer: Perform a pelvic examination. Explanation: A report of rectal pressure usually indicates a low presenting fetal part, and imminent birth. The nurse should perform a pelvic examination to assess the dilation of the cervix and station of the presenting fetal part. Do not let the client use the toilet or a bedpan before she's examined because she could birth on the toilet or in the bedpan. Checking the FHR is important but comes after the nurse evaluates the client's report.
A young adult woman tells the nurse she has a slight yellow vaginal discharge. The nurse should tell the client to contact her health care provider if she has which additional symptoms? Select all that apply. vaginal discharge that has a fishy odor starting her menstrual period abdominal pain a temperature above 101ºF (38.3ºC) loss of appetite
My answer: vaginal discharge that has a fishy odor abdominal pain a temperature above 101ºF (38.3ºC) loss of appetite Correct answer: vaginal discharge that has a fishy odor abdominal pain a temperature above 101ºF (38.3ºC) Explanation: The client's discharge may be a symptom of bacterial vaginosis, a clinical syndrome resulting from the replacement of the normal vaginal Lactobacillus species with overgrowth of anaerobic bacteria that cause a cluster of symptoms. Often the discharge disappears, but the nurse should instruct the client to seek care from her HCP if the discharge has a fishy odor, there is abdominal pain, or an elevated temperature. The client's menstrual cycles will continue as normal. A decreased appetite is not a sign of a vaginal infection
The parents of a pregnant adolescent are outraged that they are being refused medical information about their daughter's condition. What is the best response by the nurse to address their anger? a. "Your daughter's medical information is confidential." b. "Your daughter is not ready to share her health information." c. "If we obtain permission from her, we can include you in our discussions." d. "I understand your concerns, but she is responsible for her own health."
My answer: "Your daughter's medical information is confidential." Correct answer: "If we obtain permission from her, we can include you in our discussions." Explanation: The reality of this situation is that the parents may be included in the exchange of medical information but only with the daughter's consent. Sharing that fact with the parents clearly identifies that the decision is the daughter's to make and that she is entitled to make it. The nurse must support the client's right to privacy and confidentiality. The client is responsible for her own health, and her information is confidential, but stating these facts does not adequately address the parents' concern. The client may not be ready to share any information, but this does not help the parents understand what is occurring. It is best to simply explain that the client's permission is necessary in order to include the parents in the sharing of medical information.
After a nasogastric (NG) tube has been inserted, which finding helps the nurse determine that the tube is in the proper place? a. The client is no longer gagging or coughing. b. The pH of the aspirated fluid is measured. c. Thirty milliliters of normal saline can be injected without difficulty. d. A whooshing sound is auscultated when 10 mL of air is inserted.
My answer: A whooshing sound is auscultated when 10 mL of air is inserted. Correct answer: The pH of the aspirated fluid is measured. Explanation: Measuring the pH of the aspirated gastric fluid is the most accurate determination of the placement of the NG tube. A pH lower than 4 indicates that the tube is in the stomach. Whether or not the client is gagging or coughing is not an accurate way to determine if the tube is placed correctly. No fluids should be inserted into the tube until the placement has been determined. Inserting air into the tube and listening for the resulting whoosh can be used, but this is not as accurate as pH measurement.
The nurse is preparing to discharge a school-age child with asthma. Which intervention is most important for the nurse to perform prior to discharge? A. Obtain additional equipment and medication that can be provided at the school. B. Arrange for a thorough, deep cleaning of the home. C. Discuss limitations on the child's participation in sports activities. D. Counsel the family in making arrangements to remove the family pet.
My answer: Discuss limitations on the child's participation in sports activities. Correct answer: Obtain additional equipment and medication that can be provided at the school. Explanation: The child needs to have equipment and medication available at school to treat and prevent asthma attacks. This is the priority intervention at this time. Discussions should be held with the child and family to motivate the child to be involved in as many normal activities as possible; the emphasis is on the options rather than the limitations. The nurse should teach the parents that the house should be kept as clean as possible on an ongoing basis to prevent exacerbations due to dust and pet dander, but it is not the nurse's responsibility to arrange for this cleaning. If the child is allergic to the family pet, the nurse should provide counseling on ways to minimize the risks, but this does not necessarily mean removal of the pet.
The client who is breastfeeding asks the nurse if she should supplement breastfeeding with formula feeding. The nurse bases the response on which principle? A. Formula feeding should be avoided to prevent interfering with the breast milk supply. B. Primarily, water supplements should be used to prevent jaundice. C. Formula supplements can provide nutrients not found in breast milk. D. More vigorous sucking is needed for a bottle feeding, so supplements should be avoided.
My answer: Formula supplements can provide nutrients not found in breast milk. Correct answer: Formula feeding should be avoided to prevent interfering with the breast milk supply. Explanation: Bottle supplements tend to cause a decrease in the breast milk supply and demand for breastfeeding. Unless medically necessary, bottle supplements should be avoided until breastfeeding is well established.Bottle supplements are not appropriate to prevent jaundice, although if neonatal bilirubin level is excessive, some pediatricians recommend temporary discontinuation of breastfeeding, while others recommend increasing the frequency of breastfeeding.Breastfeeding is considered the best nutritional source for infants.Although formula supplements should be avoided, neonates suck less vigorously on a bottle than on the breast.
The nurse starts an infusion of tissue plasminogen alteplase (tPA) for a client with a cerebrovascular accident (CVA). What are the priority nursing interventions during treatment with this medication? A. Lower the head of the bed to decrease risk of a confused client falling during the transfusion. B. Conduct frequent neurologic assessments to determine whether the stroke is evolving or acute complications are developing. C. Maintain the client's blood pressure slightly below normal ranges to reduce the risk of further bleeding. D. Monitor the urine output every 8 hours.
My answer: Lower the head of the bed to decrease risk of a confused client falling during the transfusion. Conduct frequent neurologic assessments to determine whether the stroke is evolving or acute complications are developing. Explanation: Because tPA dissolves clots--clots that are anywhere in the body, not specific to the thrombosed area--neurologic checks are essential. Lowering the head of the bed is incorrect because the nurse wants slight head elevation to promote cerebral drainage of fluid. The pressure should be maintained to avoid further bleeding and/or swelling. The urine output would need frequent monitoring after administration of this medication to assess for any bleeding.
A nursery nurse performs an assessment on a 1-day-old neonate. During the assessment, the nurse notes discharge from both of the neonate's eyes. The nurse should take which step to help determine whether the neonate has ophthalmia neonatorum? A. Do nothing; discharge is a normal finding in the eyes of a 1-day-old neonate. B. Notify the physician immediately. C. Ask the physician for an order to obtain cultures of both of the neonate's eyes. D. Obtain a nasal viral culture.
My answer: Notify the physician immediately. Correct answer: Ask the physician for an order to obtain cultures of both of the neonate's eyes. Explanation: Ophthalmia neonatorum, caused by Neisseria gonorrhea, causes neonatal blindness if left untreated. The nurse should ask the physician for an order to obtain cultures of both eyes so antibiotic treatment can be initiated. Eye discharge isn't normal in a 1-day-old neonate. Neisseria gonorrhea is caused by a gram-negative bacteria, not by a virus.
A client brought to the clinic after being arrested for harassing and stalking his ex-wife denies any other symptoms or problems except anger about being arrested. The ex-wife reports to the police, "He's fine except for this irrational belief that we'll remarry." When collaborating with the health care provider about a plan of care, which intervention would be most effective for the client at this time? a. a prescription for olanzapine 10 mg daily b. a joint session with the client and his ex-wife c. a prescription for fluoxetine 20 mg every morning d. referral to an outpatient therapist
My answer: a joint session with the client and his ex-wife Correct answer: referral to an outpatient therapist Explanation: Follow-up counseling is appropriate because of the client's anger and inappropriate behaviors. The goal is to help the client deal with the end of his marriage. A joint session might have been useful before the divorce and arrest, but not after. The client is exhibiting no signs or symptoms of schizophrenia or psychosis, so olanzapine is not indicated. The client is not exhibiting signs of depression, so fluoxetine is not indicated.
A 9-month-old, well-nourished boy who lives with his extensive extended family tests positive for tuberculosis. What is a risk factor for tuberculosis in this child? a. being male b. being in the 95th percentile for height and weight c. having a mother who did not receive prenatal care until the second trimester of her pregnancy d. being an infant
My answer: being male Correct answer: being an infant Explanation: Infants are more susceptible to tuberculosis because of a diminished resistance to infection due to an immature immune system. In later childhood and adolescence, morbidity and mortality are higher in females than males. A higher-than-average weight and height would indicate that the child has had good nutrition. Poor nutrition is a risk factor for tuberculosis. Prenatal care is unrelated to tuberculosis.
A severely dehydrated adolescent admitted to the hospital with hypotension and tachycardia undergoes evaluation for electrolyte disturbances. The client's history includes anorexia nervosa and a 20-lb (9.1-kg) weight loss in the past month. She is 5′ 7″ (1.7 m) tall and weighs 80 lb (36.3 kg). Which nursing intervention takes highest priority? a. initiating caloric and nutritional therapy as ordered b. instituting behavioral modification therapy as ordered c. addressing the client's low self-esteem d. monitoring vital signs and weight regularly
My answer: monitoring vital signs and weight regularly. Correct answer: initiating caloric and nutritional therapy as ordered Explanation: A client with anorexia nervosa is at risk for death from self-starvation. Therefore, initiating caloric and nutritional therapy takes highest priority. Behavioral modification (in which client privileges depend on weight gain) and psychotherapy (which addresses the client's low self-esteem, guilt, anxiety, and feelings of hopelessness and depression) are important aspects of care but are secondary to stabilizing the client's physical condition. Monitoring vital signs and weight is important in evaluating nutritional therapy but doesn't take precedence over providing adequate caloric intake to ensure survival.
A client who had an esophageal hernia repair 4 hours ago has a pulse rate of 90 bpm, respiration rate of 16 breaths/min, blood pressure of 130/80 mm Hg, pulse oximeter of 91%, and a temperature of 100.4° F (38° C). What should the nurse do first? a. Obtain a culture of the incision. b. Notify the surgeon to obtain an antibiotic prescription. c. Offer pain medication. d. Assist the client to a sitting position to take deep breaths.
My answer: offer pain medication Correct answer: Assist the client to a sitting position to take deep breaths. Explanation: When a postoperative client has a temperature elevation to greater than 100° F (37.8° C) in the first 24 hours after surgery, the temperature elevation is usually related to atelectasis. Because this client had upper abdominal surgery with manipulation around the diaphragm, the client is more prone to guarding the operative site and shallow breathing. Encouraging the client to take deep breaths and use incentive spirometry are appropriate measures to prevent atelectasis and pulmonary infection. The nurse must assist the client in filling the alveoli in the lower posterior lobes of the lungs. An incentive spirometer is a good visual biofeedback instrument that the client had practiced with preoperatively. Changing the client's position from lying to sitting for deep breathing will expand alveoli in the lower posterior lobes. There is no indication that a surgical wound infection is occurring. An antibiotic is not indicated at this time. Pain medication will decrease respirations, and the client is not indicating pain at the moment.
A child who is of preschool age is diagnosed as having severe autism. The most effective therapy involves which intervention? a. antipsychotic medications b. group psychotherapy c. one-on-one play therapy d. social skills group
My answer: social skills group Correct answer: one-on-one play therapy Explanation: The preschool-aged child with severe autism will benefit from one-on-one play therapy. The therapist can develop a rapport with this child with nonverbal play. Antipsychotic medications are not indicated for the autism client. The child has difficulty with interpersonal relationships; therefore, group psychotherapy and social skills groups would not be effective.
The nurse is managing a pregnant client's second stage of labor. The nurse should intervene when observing which action? a. closed glottis pushing b. open glottis pushing c. "rest and descent" d. squatting while pushing
My answer: squatting while pushing Correct answer: closed glottis pushing Explanation: Closed glottis pushing, or when a woman is told to hold her breath when she pushes typically while the nurse typically counts to 10, creates the Valsalva maneuver and is associated with decreased perfusion. Open glottis pushing, on the other hand, encourages women to listen to their own body cues for when to breathe and when to bear down. "Rest and descent" and squatting have positive influences on the second stage of labor and birth.
A woman with chronic acquired immunodeficiency disorder (AIDS) tells the nurse at the women's health center that she is sexually active but has not had a gynecological exam for more than 3 years. What important information is essential to include in providing health education for the client? a. safe sex education to prevent the risk of infection b. effective partner communication to promote a healthy relationship c. important health screenings to reduce future bodily injuries d. ethical decision making to maintain appropriate moral integrity
My answer: ethical decision making to maintain appropriate moral integrity Correct answer: safe sex education to prevent the risk of infection Explanation: The essential information to address with the client is that women with HIV/AIDS have a greater risk of contracting sexually transmitted infections such as genital herpes; and they are more likely to have more severe outbreaks than women who do not have HIV/AIDS. Information on the role of effective communication in a relationship, the importance of health screenings, and acting with integrity would be topics for subsequent health teaching sessions.
A client who has just been diagnosed with mixed muscular dystrophy asks the nurse about the usual course of this disease. How should the nurse respond? a. "You should ask your physician about that." b. "The strength of your arms and pelvic muscles will decrease gradually, but this should cause only slight disability." c. "You may experience progressive deterioration in all voluntary muscles." d. "This form of muscular dystrophy is a relatively benign disease that progresses slowly."
My answer: "The strength of your arms and pelvic muscles will decrease gradually, but this should cause only slight disability." Correct answer: "You may experience progressive deterioration in all voluntary muscles." Explanation: The nurse should tell the client that muscular dystrophy causes progressive, symmetrical wasting of skeletal muscles, without neural or sensory defects. The mixed form of the disease typically strikes between ages 30 and 50 and progresses rapidly, causing deterioration of all voluntary muscles. Because the client asked the nurse this question directly, the nurse should answer and not simply refer the client to the physician. Limb-girdle muscular dystrophy causes a gradual decrease in arm and pelvic muscle strength, resulting in slight disability. Facioscapulohumeral muscular dystrophy is a slowly progressive, relatively benign form of muscular dystrophy; it usually arises before age 10.
A client with suspected abuse describes her husband as a good man who works hard and provides well for his family. She does not work outside the home and states that she is proud to be a wife and mother just like her own mother. The nurse interprets the family pattern described by the client as best illustrating which characteristic of abusive families? a. tight, impermeable boundaries b. unbalanced power ratio c. role stereotyping d. dysfunctional feeling tone
My answer: unbalanced power ratio Correct answer: role stereotyping Explanation: The traditional and rigid gender roles described by the client are examples of role stereotyping. Impermeable boundaries, unbalanced power ratio, and dysfunctional feeling tone are also common in abusive families.
