NCLEX RN-PassPoint Pracetice Exam Case Study Questions
The nurse is deciding what actions to take. Which intervention(s) are appropriate for the nurse to perform? Select all that apply. Inspect room and remove door hooks and call light cords. Go through the clients belongings. Increase the level of observation on the client. Notify the provider. Reassure the client that everything will be ok. Give the client an additional dose of citalopram. Tell the client firmly that you will not let them harm themselves.
Inspect room and remove door hooks and call light cords. Go through the clients belongings. Increase the level of observation on the client. Notify the provider.
A 10-year-old with a history of recent respiratory infection has swelling around the eyes in the morning and dark urine. What question should the nurse ask first?
"Has the child had a sore throat?" In conjunction with the child's history of recent respiratory infection and report of dark urine, swelling around the eyes should lead the nurse to suspect acute glomerulonephritis. Therefore, the nurse should ask about a recent sore throat because a child with glomerulonephritis typically would have had a sore throat in the past 10 days. Asking about rash and fever are not as specific as asking about sore throats when assessing a child for glomerulonephritis. Allergies are unrelated to ark urine. Drinking lots of liquids is unrelated to periorbital edema.
The nurse has given report to the receiving facility. Select the three (3) statements by the receiving nurse that indicate a need for additional follow-up. "The client is being transferred because of a bad stomach infection." "The client is having chest pain." "I will ensure that the client is continued on oxygen upon arrival." "The client has not received any medication while at your facility." "I will have a translator device ready when the client arrives." "I understand the client should receive a gluten-free diet when appropriate."
"The client is being transferred because of a bad stomach infection." "The client has not received any medication while at your facility." "I will have a translator device ready when the client arrives."
The nurse is performing an assessment. Which finding(s) should the nurse be concerned about? Select all that apply. Chest pain 9/10 Client took antacid tablets last night Elevated troponin levels Family history of heart disease History of celiac disease EKG results Clammy, diaphoretic skin
Chest pain 9/10 Elevated troponin levels Family history of heart disease EKG results Clammy, diaphoretic skin
The nurse caring for a postterm client scheduled for an induction of labor has completed the necessary assessments. The client has been placed on electronic fetal monitoring, and venous access has been established. After reviewing a titrated prescription for oxytocin (see graphic), the nurse should perform what action next?
Contact the health care provider to clarify the prescription. Titration prescriptions must include the medication name, route, starting rate of infusion (dose/min), incremental units the rate can be increased or decreased, frequency for incremental doses (how often the dose [rate] can be increased or decreased), maximum rate (dose) of infusion, and an objective clinical endpoint. This prescription does not contain a maximum rate and therefore must be clarified before administering the medication. The nurse cannot begin the infusion without clarification. Oxytocin infusions are not associated with respiratory or cardiac arrests to require the placement of adult resuscitation equipment in the room. Oxytocin is a high-alert medication that should be verified by two nurses, but only after the prescription is clarified.
The nurse is preparing to transfer the client. Select five (5) potential actions the nurse should take to transfer the client. Give report to the receiving facility. Secure the client's IV and oxygen tubing. Ensure the client has all personal belongings. Educate the client on reasons for the transfer and the process. Verify that a transfer order is in place. Remove the client's identification armband. Attach defibrillation pads to the client's chest. Cleanse the client with a chlorhexidine scrub.
Give report to the receiving facility. Secure the client's IV and oxygen tubing. Ensure the client has all personal belongings. Educate the client on reasons for the transfer and the process. Verify that a transfer order is in place.
The unlicensed assistive personnel (UAP) asks what they can do to help. Select the three (3) tasks that would be appropriate to delegate to the UAP. Obtaining vital signs. Providing diapers and assist with change. Helping the client eat while the parent takes a shower. Documenting the results of the assessment. Calling the provider to obtain pain medication. Changing the client's normal saline bag.
Obtaining vital signs. Providing diapers and assist with change. Helping the client eat while the parent takes a shower.
The nurse is assessing the client. Which clinical finding(s) require follow-up by the nurse? Select all that apply. Restless and crying Elevated heart rate Wet diaper Abdomen soft IV to right forearm Mucous membranes pink and moist
Restless and crying Elevated heart rate Wet diaper Restlessness and crying indicate that something is upsetting the child; it could be as simple as a wet diaper or a change in circumstance, or it could indicate the child is in pain. An elevated heart rate can indicate client distress or pain and should be evaluated further. A wet diaper would require follow-up in order to provide the client comfort. A soft abdomen is considered a normal finding. An IV to the right forearm is part of the client's treatment and does not require additional follow-up at this time. Mucous membranes should be pink and moist. This is a normal finding and indicates that the child is well-hydrated.
A client in labor is receiving oxytocin to augment her labor. The nurse notes a change in her contraction pattern. The fetal heart monitor indicates that her contractions are lasting 2 minutes, with a notable rise in the baseline. Based on this finding, what action is the priority?
Turn oxytocin to the lowest level. The first action must be to lower the oxytocin to prevent fetal hypoxia or possible rupture of the uterus. The client would then be placed on her left side and given oxygen to prevent fetal hypoxia. The provider would be notified.
A client comes to the emergency department complaining of a fast and irregular heartbeat. After examining the client, a physician gives a verbal order for digoxin, 1 mg I.V. in four divided doses over the next 24 hours, with the first dose administered stat. How should the nurse respond to this order?
Write and sign the order as dictated; then repeat it aloud for the physician's verification. In urgent situations, such as the one described here, the nurse should write and sign a verbal order as dictated by the prescriber and then repeat the order aloud for the prescriber's verification. The nurse should ask the prescriber to spell the drug name if necessary. Although verbally repeating the order for verification is appropriate, the nurse must write the order to prevent errors. In an urgent situation, insisting that the physician write the order would take valuable time away from crucial interventions and client evaluation. Refusing to carry out the order would be appropriate only if the nurse felt the order was unsafe.
The nurse is caring for a 19-year-old male client with Duchenne muscular dystrophy whose symptoms are getting progressively worse. 0900 Client's parent reports that client's muscles are getting progressively weaker and muscle contractions are developing despite daily physical and occupational therapy. Client is no longer walking and uses wheelchair for mobility. Able to lift arms, but not against resistance. Hyporeflexia in arms. No purposeful movement of legs. Absent leg reflexes in legs and significant atrophy of legs. Vital signs: temperature, 98.2°F (36.8°C); heart rate, 76 beats/min; respiratory rate, 16 breaths/min; blood pressure, 122/60 mm Hg. Lungs clear with decreased chest expansion. Per orders in medical record, discussed new drug with parent and client, including dose, frequency, side effects, when to seek urgent medical attention, and to not abruptly stop medication. 1 month later, 1000 Parent report
hypokalemia irregular heart rhythm anorexia serum electrolyte levels
The nurse is comparing the Nurse's Notes of 1000 today with 0900 of 1 month ago. Complete the following sentence by choosing from the lists of options. The nurse suspects that the client is experiencing
hypokalemia irregular heart rhythm anorexia serum electrolyte levels
The nurse is determining how to delegate tasks to the UAP. Complete the following sentence(s) by choosing from the lists of options. When delegating tasks to the UAP, the nurse should include instructions on ___ and ___.
notification of abnormalities appropriate documentation
An 18-month-old child is experiencing supraventricular tachycardia (SVT). What should be the nurse's first intervention?
placement of a bag of ice over the child's face Vagal maneuvers, such as placing a bag of ice over the face for 15 to 30 seconds, or immersing the hands in cold water are commonly the first mechanism used to decrease the heart rate. Other vagal maneuvers include breath-holding, carotid massage, gagging, and placing the head lower than the rest of the body. Synchronized cardioversion may be required if vagal maneuvers and drugs are ineffective. If a child has low cardiac output, cardioversion may be used instead of drugs. Adenosine is the drug of choice for medical conversion of SVT. Verapamil isn't recommended in children under two years of age. Digoxin has a narrow therapeutic margin, has a risk of toxicity, and can delay the attainment of therapeutic levels.
The nurse is deciding the best way to communicate with the receiving facility. Complete the following sentence(s) by choosing from the lists of options. The nurse should
speak directly with the receiving nurse use the SBAR (situation, background, assessment, recommendation) communication technique