NCLEX Passpoint Review
Standards of care
-criteria that serve as a basis for evaluating the quality of nursing practice -are established by federal organizations, accreditation organizations, state organizations, and professional organizations.
Buspirone
-is not habit forming, is administered on a schedule, and does not work immediately -may have side effects such as chest pain, dizziness, headache, drowsiness, or nausea
Clonidine
-s used as adjunctive therapy in opioid withdrawal -It is mainly used for the treatment of blood pressure, however with treatment for alcohol withdrawal, a priority assessment should be for hypotension
vestibulocochlear nerve
-the eighth cranial nerve -is responsible for hearing and equilibrium -Streptomycin can damage this nerve (ototoxicity)
Discuss the procedure with the parents. Act out the procedure using a doll and biopsy kit. Explain the discomforts the child will feel. Assure the child that the pain will go away. Check the biopsy site for hemorrhage and infection.
A 5-year-old preschooler suspected of having leukemia is admitted to the hospital for diagnosis and treatment. The physician orders a bone marrow aspiration. Place the interventions below in ascending chronological order according to their importance.
high-protein
A ______ diet is not recommended for renal clients
Screen the client for new, worsened, or increased depression
A client attends a follow-up visit to a clinic after being diagnosed with atypical depression. The practitioner prescribed tranylcypromine sulfate, 10 mg by mouth twice a day during the last visit 14 days ago. Which would be the priority action by the nurse for this client?
IgE
A client develops a facial rash and urticaria after receiving penicillin. Which laboratory value does the nurse expect to be elevated?
hypoventilation
A client had posterior packing inserted to control a severe nosebleed. After insertion of the packing, the nurse should observe the client for which finding?
hypopituitarism
A client has had an hypophysectomy. What signs of a potential complication should the nurse teach the client to report?
at about 28 weeks' gestation and again within 72 hours after birth
A client is Rh(D)-negative and D-negative and hasn't formed Rh antibodies. When should the client receive RHO(D) immune globulin (RhoGAM) to prevent isoimmunization?
coarctation of the aorta.
A client is admitted with a tentative diagnosis of congenital heart disease. When assessment reveals a bounding radial pulse coupled with a weak femoral pulse, the nurse suspects that the client has:
decreased platelet count and white blood cell count with changes in the CBC differential
A client is taking methotrexate for severe rheumatoid arthritis. This client should be monitored for blood dyscrasias, evidenced by:
akathisia
A client receiving phenothiazine has become restless and fidgety and is anxiously pacing the hallway. What adverse effect of phenothiazine would the nurse suspect, based on this behavior?
using a cooling mist humidifier and administering dextromethorphan
A client reports having a dry, hacking cough that disturbs sleep at night. Which antitussive agent and intervention are most appropriate for this client?
phenytoin
A client taking ________ to control seizures must undergo routine blood testing to monitor for therapeutic levels. Typically, the client takes the medication for 1 year after the original seizure, then is reevaluated for continued therapy. During the therapy, the client may drive and operate machinery. This drug may cause a decreased heart rate and hypotension.
Offer the client frequent oral hygiene care.
A client who is on nothing-by-mouth status is constantly asking for a drink. Which nursing intervention is the most appropriate?
DIC
A client with ______ is at risk for Impaired skin integrity related to bleeding or ischemia. The nurse should place the client on a pressure-reducing mattress and perform skin care every 2 hours. The nurse should avoid administering any medication that decreases platelet function, such as aspirin. The nurse should perform mouth care using sponge swabs and baking soda solution, not lemon-glycerin swabs, because lemon-glycerin swabs can dry the oral mucosa, which may lead to bleeding. I.M. injections should be avoided in because of the potential for bleeding
Dissolved emboli
A client with a cerebral embolus is receiving IV recombinant tissue-type plasminogen activator (rt-PA). The nurse should evaluate the client for which expected therapeutic outcomes of this drug therapy?
Offer the client proportioned fluids in the day and less during the night.
A client with acute kidney failure is placed on fluid restriction of 1000 mL of fluid over a 24-hour period. What is the priority nursing action?
The pouch faceplate doesn't fit the stoma.
A client with bladder cancer had the bladder removed and an ileal conduit created for urine diversion. While changing this client's pouch, the nurse observes that the area around the stoma is red, weeping, and painful. What should the nurse conclude?
follow a low-fiber diet to help minimize bulk in the stools
A client with diverticulitis needs to modify fiber intake to effectively manage the disease. During episodes of diverticulitis, the client should:
Initiate fluid replacement therapy
A client with type 1 diabetes is admitted to an acute care facility with diabetic ketoacidosis. To correct this acute diabetic emergency, which measure should the healthcare team take first?
monitor the patency of an indwelling urinary catheter to prevent its occlusion
A full bladder can precipitate autonomic dysreflexia. The nurse should _______, which could result in a full bladder.
The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance.
A medical nurse educator is reviewing a client's recent episode of metabolic acidosis with members of the nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis?
current medications
A multigravida prenatal client with a history of postpartum depression tells the nurse that she is taking measures to make sure that she does not suffer that complication, including taking St. John's wort. What is the most important assessment for the nurse to make?
review the unit's procedure manual
A new nurse is asked to start an I.V. on an antepartum client. The new nurse has performed the procedure only once and isn't familiar with the I.V. pumps used in this facility. The new nurse should:
liquid or semiliquid stools
A nurse caring for a client with a fecal impaction should watch for
The client reports having a dry mouth
A nurse is administering atropine sulfate to a client about to undergo electroconvulsive therapy (ECT). Which assessment indicates that the medication is effective?
haloperidol
A nurse is caring for a client admitted with arching of the back, extension and rotation of the neck, and slow involuntary contractions of the arms and neck. After review of the client's medication list, the nurse would be correct in associating these symptoms with which medication?
encouraging intake of at least 2 L of fluid daily
A nurse is caring for a client who had a stroke. Which nursing intervention promotes urinary continence?
Place the client in knee-chest or Trendelenburg position.
A nurse is examining a client in active labor, who has had spontaneous rupture of the amniotic membrane, and notes a protruding umbilical cord. What is the priority nursing action?
The client's bladder does not become over distended.
A nurse is preparing the plan of care for a client with neurogenic flaccid bladder. Which outcome is appropriate for this client?
Write "T.O." after the order and write out the physician's and nurse's names.
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?
elevating the affected limb, applying warm compresses, and administering phentolamine as ordered
A nurse regularly inspects a client's I.V. site to ensure patency and prevent extravasation during dopamine therapy. What is the treatment for dopamine extravasation?
blue
A nurse uses Nitrazine paper to determine whether a pregnant client's membranes have ruptured. If the membranes have ruptured, the paper will turn which color?
Continue to assess the client, allowing the officer to assume responsibility for the handcuffs.
A nurse working in the emergency department is concerned that a client, who is in police custody, is handcuffed to the stretcher. The nurse asks the police officer to remove the cuffs, but the officer refuses. What should be the next action by the nurse?
narcissistic
A person with a _____ personality has an exaggerated sense of self-worth
dependent
A person with a _______ personality is submissive and frequently apologizes and backs down when confronted.
danger signs during pregnancy
A pregnant client comes to the facility for her first prenatal visit. When providing teaching, the nurse should be sure to cover which topic?
glucocorticoid and mineralocorticoid dosages are increased
Adrenal crisis can occur with physical stress, such as surgery, dental work, infection, flu, trauma, and pregnancy. In these situations,:
Gradually reduce the rate of the TPN per health care provider order.
An order has been written to discontinue an infusion of total parenteral nutrition (TPN) for a child. What is the priority nursing action?
stomachaches, nausea, headaches, and dizziness
Children with school phobia commonly complain of vague symptoms, such as ________, to avoid going to school.
one nostril per day.
Clarify with the physician that the spray should be given in only:
passive-aggressive
Clients who are ______ won't confront or discuss issues with others but will go to great lengths to "get even."
initial insult, oliguric phase, diuretic phase, and recovery phase
Clients with acute renal failure pass through the phases in the following order:
correcting nutritional deficits
Clients with gastric cancer commonly have nutritional deficits and may have cachexia. Therefore, _____ is a top priority.
having the client tilt the head back and look up to protect the cornea; holding the dropper over the eye and pulling the lower eyelid down to release the drops in the conjunctival sac
Correct technique for instilling eyedrops includes:
"I will eat five or six small meals each day and have some protein with each meal."
During a prenatal visit, a pregnant client with cardiac disease and slight functional limitations reports increased fatigue. The nurse knows that the client understands the management of the disorder when the client says:
benzodiazepines (lorazepam)
During detoxification from alcohol, changes in the client's physiological status, especially an increase in blood pressure, may indicate a possible seizure. Clients are treated with ________ to prevent this.
whole grains, meats, dairy products, and seafood
Good sources of zinc include:
Assess the client's vital signs.
Immediately after receiving an injection of bupivacaine, the client becomes restless and nervous and reports a feeling of impending doom. What should the nurse do next?
refuse medications
In involuntary admissions, clients are still competent and have the right to:
sitting or a left side-lying position with shoulders parallel and legs slightly flexed
Lumbar epidural anesthesia is usually administered with the client in a:
protect the stomach's lining when a client has a peptic ulcer
Misoprostol is used to:
lower
Older adult clients are typically on _____ dosages of antipsychotic medications because of the metabolic changes of aging
perineal hematoma
On the first postpartum day, the primiparous client reports perineal pain of 5 on a scale of 1 to 10 that was unrelieved by ibuprofen 800 mg given 2 hours ago. The nurse should further assess the client for which complication?
50 years old
People over ____ should receive the shingles vaccine.
void
Saw palmetto is used to relieve symptoms of benign prostatic hypertrophy. It would be important to assess about the client's ability to:
alcohol withdrawal
Signs of _______ include diaphoresis, tremors, nervousness, nausea, vomiting, malaise, increased blood pressure and pulse rate, sleep disturbance, and irritability.
wearing gloves when handling the client's urine disposing of chemotherapy waste as hazardous material wearing a long-sleeved gown when administering chemotherapy
The RN is administering intravenous chemotherapy to a client with cancer. Which precautions are necessary when administering chemotherapy?
annual intraocular pressure measurements for people older than 40 years.
The most effective health-promotion measure related to glaucoma that the nurse could teach clients is:
edrophonium test
The most useful and reliable diagnostic test for myasthenia gravis is the:
signs of exhaustion and dehydration
The normal length of the latent stage of labor in a primigravid client is 6 hours. If the client is having prolonged labor, the nurse should monitor the client for:
less difficulty breathing
The nurse administers theophylline to a client. When evaluating the effectiveness of this medication, what is an expected outcome?
a high-backed chair with armrests
The nurse advises the client who has had a femoral head prosthesis placement on the type of chair to sit in during the first 6 to 8 weeks after surgery. Which chair would be the correct type to recommend?
to open the client's airway
The nurse has already called for help and established unresponsiveness so the first action is _______; this may result in spontaneous breathing and will help the nurse determine whether or not further intervention is required.
Explain to the client that the health care provider (HCP) will write a prescription for the eye drops to be used at the hospital.
The nurse is admitting a client with glaucoma. The client brings prescribed eye drops from home and insists on using them in the hospital. What should the nurse do?
Order two different sizes of stockings and use one from each package.
The nurse is caring for a client who has a prescription for thigh high antiembolism stockings. The client's left thigh measures 3 in (7.5 cm) larger than the client's right thigh. What is the next action by the nurse?
Wear a mask at all times when entering the room
The nurse is developing a care plan for a client with tuberculosis. Which measures would be implemented for staff prior to entering the room?
"Relax your neck and shoulder muscles." "Breathe in normally through your nose for two counts (while counting to yourself, one, two)." "Pucker your lips as if you were going to whistle." "Breathe out slowly through pursed lips for four counts (while counting to yourself, one, two, three, four)."
The nurse is instructing a client with chronic obstructive pulmonary disease how to do pursed-lip breathing. In which order from first to last should the nurse explain the steps to the client?
Draw 0.5 ml medication into a syringe, draw the remaining 0.5 ml into another syringe, and ask another nurse to witness the waste of 0.5 ml into the sink.
The nurse is preparing the prescribed fentanyl 25 mcg I.V. After obtaining a fentanyl 50 mcg/ml vial, what is the priority action by the nurse?
arranging for respite care to watch her child and give herself a regular break
The nurse meets with the mother of a child diagnosed with attention deficit hyperactivity disorder. The mother states, "I feel so guilty that he has this disease, like I did something wrong. I feel like I need to be with him constantly in order for him to get better. But still sometimes I feel like I'm going to lose control and hurt him." The nurse should suggest which intervention to the mother?
has a plan for self-harm
The nurse should establish if the client _______ that would warrant suicide precautions prior to initiating these precautions
naloxone
The nurse should monitor the client who has received _____ for side effects such as restlessness, agitation, and potential cardiac arrhythmias
dietary fiber
The nurse teaches the client with type 1 diabetes mellitus about the importance of maintaining stable blood glucose levels. The nurse should suggest the client include which type of food to minimize the rise in blood glucose level after meals?
Wernicke's encephalopathy
Thiamine specifically prevents the development of ___________, a reversible amnestic disorder caused by a diet deficient in thiamine secondary to poor nutritional intake that commonly accompanies chronic alcoholism. It is characterized by nystagmus, ataxia, and mental status changes.
eye discomfort
Timolol can cause some:
spend brief intervals with the client each day
To promote a therapeutic relationship with a suspicious client, it is best to ________ to develop trust, respect, and rapport.
200; 100; 40; 50; 45; 55
Total cholesterol greater than ______, LDL greater than _______, HDL less than _______ in men, HDL less than _______ in women, men ___ years and older, women ____ years and older, smoking and obesity increase the risk of CAD.
deep red
Typically, the stoma should remain _____ in color as long as the infant has the colostomy
increasing fluid intake
Urinary stasis is a major cause of UTIs, and can be partially prevented by:
"Morphine decreases the heart's need for oxygen and also makes your heart not work as hard."
What is the best nursing response to a client who is experiencing an acute myocardial infarction (MI) and asks why the nurse is administering intravenous morphine?
Block radiant, convective, conductive, and evaporative losses.
What is the nurse's priority to regulate the temperature of a neonate?
clear liquids
When a child is ready to take fluids by mouth postoperatively, ____ are given initially
10 to 20 mm Hg
When assessing the pressure of the anterior chamber of the eye, a nurse normally expects to find a pressure of:
selective serotonin reuptake inhibitors (SSRIs) (citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline)
When comparing the safety profiles of the various classes of antidepressants used in the control of panic disorder, _______ are considered first line.
meeting the child's nutritional needs for optimal growth
When developing the plan of care for a child diagnosed with phenylketonuria (PKU), the nurse should establish which goal?
may not cause symptoms until serious complications occur
When educating a female client with gonorrhea, what should the nurse emphasize? In women, gonorrhea:
gloves
When leaving the room of a client in strict isolation, the nurse should remove which protective equipment first?
prone with hips in abduction
When positioning a neonate with an unrepaired myelomeningocele, which position is most appropriate?
Maintain an adequate sodium intake.
When preparing the teaching plan for a client about lithium therapy, the nurse should provide which instruction to the client concerning sodium?
3-4 months
When teaching a primaparous client about neonatal reflexes the nurse determines that teaching about the rooting reflex has been effective when the mother identifies what as the age at which the rooting reflex disappears?
altering the usual method of feeding
When the nurse is developing the plan of care for an infant with a cleft lip before corrective surgery is performed, what should be a priority?
2 to 3 cups (500 to 750 mL)
Which amount of daily milk intake should the nurse include in the plan of care for a 15-month-old?
excessive growth of gum tissue
Which clinical manifestation is a typical reaction to long-term phenytoin sodium therapy?
minimal pain
Which finding is expected when the nurse is assessing a child who has sustained full-thickness burns?
"Drink 6 to 8 glasses of fluid daily while taking this medication."
Which instruction should a nurse give a client with prostatitis who is receiving co-trimoxazole double strength?
Encourage a high fluid intake.
Which intervention should the nurse perform for a child who is receiving chemotherapy and allopurinol?
the severity of withdrawal symptoms
While admitting a client to the alcohol treatment program, the nurse asks the client how long she has been drinking, how much she has been drinking, and when she had her last drink. The client replies that she has been drinking about a liter of vodka a day for the past week and her last drink was about an hour ago. This information helps the nurse to determine which factor?
melanoma
While assessing the skin of a 45-year-old, fair-skinned female client, the nurse notes a lesion on the medial aspect of her lower leg. It has irregular borders, with various shades of black and brown. The client states that the lesion itches occasionally and bled slightly a few weeks ago. She also reveals a history of sunburns. Based on these signs and symptoms, the nurse suspects
Assess for a pulse deficit.
While auscultating the apical heart rate, the nurse notes an irregular heart rhythm at a rate of 120 beats/min. What is the nurse's next action?
To keep gastric pH at 3.0 to 3.5
Why are antacids administered regularly, rather than as needed, in peptic ulcer disease?
CD4+
_____ levels in the blood of an individual with HIV infection determine the extent of damage to the individual's immune system.
Dystonia
a common extrapyramidal reaction to fluphenazine decanoate, manifests as muscle spasms in the tongue, face, neck, back, and sometimes the legs
Increased blood glucose, increased appetite, increased risk of infection, and increased hair growth
adverse effects of prednisone
Thioridazine
affects the neurotransmitter norepinephrine, which causes hypotension and other cardiovascular effects.
Advanced directives or a "living will"
allow clients to convey their wishes for treatment, alternative decision makers, and end of life treatment, but do not specifically address issues of placement in a long-term care facility
Hypotension and tachycardia
are common adverse effects of droperidol and should be monitored closely by the nurse.
frequent early feedings with formula
can prevent hypoglycemia during the first 24 hrs of life in a neonate of mother with gestational diabetes
vesicle
circumscribed skin elevation filled with serous fluid
stridor
indicates partial airway obstruction, and requires immediate intervention
laryngeal cancer
one the most preventable types of cancer
dyspareunia
painful intercourse
goggles, gown, and respirator mask
protective personnel equipment appropriate for suctioning the client
patching one eye at a time
relieves diplopia
Nurse practice act
set educational requirements for the nurse, distinguish between nursing practice and medical practice, and define the scope of nursing practice in that state.
fresh-frozen plasma or blood administration
treatment of DIC includes:
