PassPoint Fail
The nurse is caring for a child experiencing a sickle cell crisis. What priority nursing intervention should the nurse perform?
provide oral and IV fluids
The charge nurse in an acute care setting assigns a client, who is on one-to-one suicide precautions, to a psychiatric aide. This assignment is considered:
reasonable nursing practice because one-to-one requires the total attention of a staff member.
A nurse is caring for 10-year-old child with sickle cell anemia admitted for vaso-occlusive crisis. Which would be the most appropriate activity for the nurse to provide for the child?
reading
A pregnant client at 26 weeks' gestation undergoes a glucose tolerance test. The nurse identifies the need for further action based on which results?
a 1-hour glucose level of 160 mg/dL (8.88 mmol/L) during a 3-hour glucose tolerance test
A toddler is brought to the emergency department with sudden onset of abdominal pain, vomiting, and stools that look like red currant jelly. To confirm intussusception, the suspected cause of these findings, the nurse expects the physician to order:
a barium enema.
Which finding would indicate the neonate was adapting normally to extrauterine life without difficulty? Select all that apply.
respiratory rate of 40 to 60 breaths/minute heart rate of 130 to 140 beats/minute
Continual assessment is an important component in cardiopulmonary resuscitation (CPR). Before initiating CPR, the nurse should always assess for:
responsiveness
A client with a diagnosis of respiratory acidosis is experiencing renal compensation. What function does the kidney perform to assist in restoring acid-base balance?
returning bicarbonate to the body's circulation
The nurse is caring for a child suspected of having roseola. Which finding is consistent with a roseola rash?
rose pink macules that blanch on pressure
Which reason best accounts for the physical symptoms in a client with a somatic symptom disorder?
to prevent or relieve symptoms of anxiety
The nurse is gathering data regarding the physical development of a 33-month-old who is playing. Which activity does the nurse anticipate the toddler being able to complete with minimal assistance? Select all that apply.
washing and drying hands removing his or her jacket using a spoon for eating
A client with peptic ulcer disease is prescribed aluminum-magnesium complex. When teaching about this antacid preparation, the nurse should instruct the client to take it with:
water
A nurse discovers that a stat dose of potassium chloride that was prescribed by the physician was never administered. Which action should the nurse take?
Notify the charge nurse so she can notify the physician of the missed dose.
A nurse is caring for a client who has been administered digoxin 0.125 mg by mouth daily. The client develops sinus bradycardia with a heart rate of 50 beats/minute, and other vital signs are stable. Which action should the nurse take first?
Notify the physician
An older adult client who underwent total hip replacement exhibits a red, painful area on the calf of the affected leg. Based on these signs and symptoms, which intervention should the nurse perform?
Notify the physician
While in a skilled nursing facility, a client contracted scabies, which is diagnosed the day after discharge. The client is living at her daughter's home, where six other family members are living. During her visit to the clinic, she asks a staff nurse, "What should my family do?" The most accurate response from the nurse is:
"All family members will need to be treated."
During a client-teaching session, the nurse includes which instruction to a client receiving kaolin and pectin for treatment of diarrhea?
"Drink 8 to 13 8-oz glasses (2 to 3 L) of fluid daily."
The nurse is teaching the parents of a child with hemophilia about how to provide a safe home environment throughout the child's life. Which nursing instruction is most appropriate?
"Establish a written emergency plan that includes what to do in specific situations and the names and phone numbers of emergency contacts."
On admission to the inpatient psychiatric unit, a client's facial expression indicates severe panic. The client repeatedly states, "I know the police are going to shoot me. They found out that I'm the child of the devil." What is the nurse's best response to initiate a therapeutic relationship with the client?
"Hello, my name is ___. I'm a nurse, and I'll care for you when I'm on duty. Should I call you ___, or do you prefer something else?"
A client is given triazolam for a sleep disorder. The nurse is reinforcing some teaching precautions concerning the medication. Which statements by the client indicate an understanding of the information provided?
"I shouldn't confuse this medication with Haldol."
A 78-year-old client with type 2 diabetes needs a kidney transplant. The client's daughter volunteers to donate a kidney, but the client voices concerns about her daughter's health to the nurse. Which response by the nurse is appropriate?
"I'll notify your physician of your concerns and see if he can discuss the procedures with you."
The nurse is teaching a breast-feeding client how to care for her engorged breasts. Which statement by the client indicates the need for further teaching?
"If my breasts are uncomfortable, I'll limit the time I spend breast-feeding."
The nurse is reinforcing education with an infant's parents about diabetes insipidus. When explaining the diagnostic test that's used, the nurse knows that which comment by the parents indicates an understanding of the diagnostic test?
"My infant's fluid intake will be restricted."
A child with pauciarticular juvenile rheumatoid arthritis (JRA) is being seen for an annual physical examination. The child's parent reports not understanding why the child will need to have an annual eye examination if there are no visual problems. Which statement by the nurse is most appropriate?
"Painless iritis (inflammation of the iris) is commonly seen with the disease."
A client is admitted to the inpatient unit of a mental health center with a diagnosis of schizophrenia, shouting, "The government of France is trying to assassinate me!" Which response by the nurse would be most appropriate?
"This is unlikely. You are safe here, but you must feel frightened by this."
A client who's 37 weeks pregnant comes to the clinic for a prenatal checkup. To evaluate the client's preparation for parenting, the nurse might ask which question?
"What changes have you made at home to get ready for the baby?"
A client who sustained a closed head injury in a motor vehicle accident is diagnosed as brain dead by a neurosurgeon. The physician has scheduled a meeting with the client's family about discontinuing life support. Before the meeting, a family member asks the nurse her opinion about life support. Which response by the nurse is appropriate?
"What has the physician explained about the client's prognosis?"
A nurse is caring for a client who is placed in traction to treat a fractured femur. Which nursing intervention has the highest priority?
Evaluate the extremity for paleness and edema.
The nurse is gathering vital signs on a client. Blood pressure reading is 180/100 mm Hg by electronic blood pressure cuff. Place in order the steps that should be taken.
Wait 5 minutes. Perform a manual blood pressure. Notify the RN. Notify the health care provider.
Criteria for rheumatic fever are being discussed with parents. The nurse realizes that the parents understand chorea when they make which statement?
My child might have difficulty in school
Which of the following is the most numerous type of white blood cell (WBC)?
Neutrophil
Before a cancer client receiving total parenteral nutrition (TPN) resumes a normal diet, the nurse teaches him about dietary sources of minerals. Which foods are good sources of zinc?
Whole grains and meats
The physician prescribes acetaminophen elixir, 160 mg every 4 hours, for a 14- month-old child who weighs 20 lb (9.08 kg). This drug, supplied in a bottle labeled 160 mg/tsp, has a safe dosage of 10 mg/kg/dose. The nurse should administer how many milliliters?
None because this isn't a safe dose
A nurse is caring for a client diagnosed with pneumonia, a urinary tract infection, dehydration, and temperature of 101.4°F (38.6°C). The physician orders 1,000 mL of D5W to infuse over 8 hours. The available drop factor is 20 gtt/mL. The nurse should regulate the I.V. flow rate to deliver how many drops per minute? Round your answer to the nearest whole number.
42 - Calculate the flow rate using the formula below: Total volume ordered/Number of hours = Flow rate. 1,000 mL/8 hours = 125 mL/hour. Change from mL/hour to drops/minute using the provided drop factor. 125 mL/60 min X 20 gtt/1 mL = 41.66. Rounded off, this is 42 gtt/min.
When explaining to the parents the optimal time for repair of hypospadias, the nurse should indicate which as the age of choice?
6 to 18 months
Which neonate is at greatest risk for the nursing diagnosis Imbalanced nutrition: Less than body requirements related to poor sucking?
A bottle-fed, 7-lb, 2-oz (3.2-kg) neonate who produces two stools and wets four diapers per day
During the insertion of a rigid scope for bronchoscopy, a client experiences a vasovagal response. Which physiological response should the nurse monitor this client for?
A drop in the client's heart rate
An adolescent who is depressed and whose parents report as having difficulty in school is brought to the community mental health center to be evaluated. Which additional problem would the nurse expect the client to have?
Behavioral difficulties
When measuring the radial pulse of a client with known aortic insufficiency, the nurse detects a "water-hammer" or Corrigan's pulse. What are the characteristics of this pulse?
Bounding, with a rapid rise and fall
The nurse is reinforcing education to a client that is demonstrating considerable anxiety about an impending surgical procedure. Which nursing intervention is most appropriate?
Calmly ask the client to describe the procedure that is to be done.
If a central venous catheter becomes disconnected accidentally, what should the nurse do immediately?
Clamp the catheter
The nurse is caring for a dying client who's receiving comfort measures. Which intervention by the nurse is most effective in promoting comfort?
Comb the client's hair
The nurse is aware that Standard Precautions represent the first tier of Centers for Disease Control guidelines for isolation precautions. Which is the nurse's primary responsibility when following Standard Precautions?
Consider all body substances potentially infectious.
After undergoing a right lower lobectomy for treatment of lung cancer, a 75-year-old client returns to his room with a chest tube in place. Several hours later a nurse finds the client out of bed barely able to speak, with the chest tube removed. Which action should the nurse take immediately?
Cover the insertion site with an occlusive dressing, call for assistance, and remain with the client.
A client with chronic schizophrenia receives 20 mg of fluphenazine decanoate by I.M. injection. Three days later, the client has muscle contractions that contort his neck. This client is exhibiting which extrapyramidal reaction?
Dystonia
The nurse is teaching parents about otitis media. When discussing why children are predisposed to this disorder, the nurse should mention the significance of which anatomical feature?
Eustachian tubes
A nurse is explaining how to measure blood pressure in a client who has lymphedema in both arms and requires blood pressure measurement using a thigh cuff. In reference to the client's baseline arm blood pressure, what information would the nurse expect to find when utilizing the thigh?
Higher systolic blood pressure reading
A client is admitted to the emergency department with an acute asthma attack. The physician prescribes ephedrine sulfate, 25 mg subcutaneously (subQ). After administration, how soon should the nurse expect ephedrine take effect?
Immediately
A client with pneumococcal pneumonia is admitted to an acute care facility. The client in the next room is being treated for mycoplasma pneumonia. Despite the different causes of the various types of pneumonia, the nurse recognizes that all of them share which feature?
Inflamed lung tissue
Which of the following would be appropriate for a client with arterial blood gas (ABG) values of pH 7.5, PaCO2 26 mm Hg, O2 saturation 96%, HCO3- 24 mEq/L, and PaO2 94 mm Hg?
Instruct the client to breathe into a paper bag.
When a client with a halo vest is discharged from the hospital, which instruction should the nurse reinforce to the client and family?
Keep the wrench that opens the vest attached to the client at all times.
A client is receiving a cleansing enema. During the procedure, the client reports abdominal cramping. What should the nurse do?
Lower the fluid bag so that the instillation slows.
A client has sustained a severe burn to the face and neck. What is the priority intervention in the immediate burn phase?
Maintain a patent airway.
A client is diagnosed with an unruptured ectopic pregnancy. Which medication does the nurse expect to administer to the client?
Methotrexate
An infant goes into cardiac arrest. When delivering chest compressions as part of cardiopulmonary resuscitation (CPR), where should the rescuer place her fingers?
One fingerbreadth below the nipple line, directly over the sternum
A nurse administers etanercept by subcutaneous injection to a client with ankylosing spondylitis. Which action should the nurse take to prevent a needle-stick injury?
Place the uncapped needle in the designated puncture-resistant container.
A nurse is assisting with the development of a plan of care for a client at 34 weeks' gestation experiencing preterm labor. Which intervention would the nurse expect to be included to assist in halting the client's preterm labor?
Promoting adequate hydration
The nurse is caring for a client who is in the panic level of anxiety. Which action is the nurse's highest priority?
Provide for the client's safety needs.
A nurse observes that an alternate personality (a child) of an adult client with dissociative identity disorder (DID) is in control. The client is sitting in the dayroom, interacting with others. Which action would be most appropriate?
Remove the client from the dayroom and reorient in a safe place.
A nurse is caring for a confused client with a fractured hip who is trying to get out of bed. Which action should the nurse take first?
Reorient the client to the surroundings.
A client states, "I can't eat because my bowels have turned against me." The nurse determines that the client is exhibiting which behavior?
Somatic delusion
A nurse is caring for an older adult client who is about to undergo paracentesis. Which intervention should the nurse perform to prepare the client for the procedure?
Tell the client to void before the procedure.
A nurse is caring for a 25-year-old client with end-stage testicular cancer who has been referred to hospice care. Which of the following criteria excludes the client from hospice care?
The client entered a clinical trial through the National Cancer Institute.
The nurse is observing the parents of a 4-year-old child who has been admitted to the hospital. Which actions indicate that the parents understand how to best minimize anxiety during their child's hospitalization? Select all that apply.
The parents bring the child's favorite toy to the hospital. The parents remain at the child's side during the hospitalization. The parents bring the child's siblings for a brief visit.
The plan of care for a client with anorexia includes the parents of the client in therapy sessions alongside their child. Which fact would be most important to incorporate about the parents when implementing this plan?
They have a tendency to overprotect their children.
A client with acne vulgaris is seeking treatment. The nurse will reinforce education on nightly apply of which medication?
Tretinoin
When developing a plan of care for a child, the nurse identifies which Eriksonian stage as corresponding to Freud's oral stage of psychosexual development?
Trust versus mistrust
A client with advanced breast cancer is prescribed tamoxifen. When teaching the client about this drug, the nurse should emphasize the importance of reporting which adverse reaction immediately?
Vision changes
A client with a history of hypertension is 15 weeks' pregnant. For which condition should the nurse closely monitor this client?
abruptio placentae
A client, who is newly prescribed metoprolol, has a headache and asks the nurse what medication to take. The nurse should reinforce the health care provider's instructions to take which of the following medications?
acetaminophen
An adult who has never had mumps reports that he was just notified that a child of a family with whom he stayed recently has been diagnosed with mumps. Which treatment should the man receive?
administration of gamma globulin
One hour after receiving pyridostigmine, a client reports difficulty swallowing and excessive respiratory secretions. The nurse notifies the health care provider and prepares to administer which medication?
atropine
Which finding observed in a client taking finasteride should the nurse immediately report to the health care provider?
azotemia
A client reports excessive flatulence. Which food, reported by the client as consumed regularly, may be responsible for this?
cauliflower
A client undergoes rhinoplasty to repair a nasal fracture. Postoperatively, the client swallows frequently and requires frequent changes of the mustache dressing, which is soiled with bright-red blood. Which is the best action for the licensed practical nurse (LPN) to take?
check the pharynx with a penlight for bleeding, and confer with the registered nurse (RN)
The nurse is caring for a teenage client involved in a motor vehicle accident. The client has a chest tube in place. If the chest tube is accidentally removed, the nurse should immediately:
cover the opening with sterile petroleum gauze.
While obtaining a health history, the nurse learns that the client is allergic to bee stings. When obtaining this client's medication history, the nurse should determine if the client keeps which medication on hand?
diphenhydramine hydrochloride
A client with major depression begins to improve and participates in treatment programs on the unit. Which client behavior would best indicate to the team that the client is ready for discharge?
discusses plans to return home and continue outpatient treatment
A pregnant woman arrives at the emergency department with abruptio placentae at 34 weeks gestation. Which blood dyscrasia should the nurse closely monitor for?
disseminated intravascular coagulation (DIC)
During a prenatal visit, a pregnant client with cardiac disease and slight functional limitations reports increased fatigue. To help combat this problem, the nurse should advise her to:
divide daily food intake into five or six meals.
Which short-term goal is appropriate for a client with an antisocial personality disorder who acts out when distressed?
educating the client about expressing feelings in a nondestructive manner
A client is admitted to the emergency department with chest discomfort, diaphoresis, and nausea. Suspecting possible myocardial infarction (MI), the nurse would anticipate that the health care provider will prescribe which diagnostic test to quickly determine myocardial damage?
electrocardiogram
A nurse is assisting in monitoring a client in labor. Which data obtained by the nurse is indicative of fetal well-being?
fetal heart rate of 145 to 155 beats/minute with 15-second accelerations to 160
The nurse is caring for a client with acute renal failure. Rank in chronological order the phases of acute renal failure. Use all the options.
initial insult oliguric phase diuretic phase recovery phase
The nurse is caring for a client with an acute bleeding cerebral aneurysm. The nurse should take all of the following steps except:
keep the client in one position to decrease bleeding.
The nurse is caring for a toddler with right lower lobe pneumonia. In order to improve gas exchange, which position should the child be placed in?
left side-lying
The nurse is caring for a client in the immediate postoperative phase after undergoing gastric surgery. Which is the priority action by the nurse?
monitoring for symptoms of hemorrhage
A neonate born 8 weeks preterm has no spontaneous respirations but is successfully resuscitated. Within several hours, the neonate develops respiratory grunting, cyanosis, tachypnea, nasal flaring, and retractions and is diagnosed with respiratory distress syndrome, intubated, and placed on a ventilator. When implementing the neonate's plan of care, which intervention would be most appropriate to assist in preventing retinopathy of prematurity?
monitoring partial pressure of oxygen (PaO2) levels
A 2-year-old child is being treated with rifampin for tuberculosis. Which expected finding does the nurse anticipate?
orange body secretions
A nurse is assisting with the development of a plan of care for a client at 34 weeks' gestation experiencing preterm labor. Which intervention would the nurse expect to be included to assist in halting the client's preterm labor?
promoting adequate hydration
A female client with human immunodeficiency virus (HIV) receives family-planning counseling. Which statement about safe sex practices for persons with HIV is accurate?
A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse.
The nurse is meeting with a 17 year-old client who has recently tested positive for human immunodeficiency virus (HIV). The client states, "What information will be disclosed to others." What information should be provided by the nurse?
"In some jurisdictions laws may require you share this information with future sexual partners."
A client approaches the nurse and points at the sky, showing the nurse where the scary men would be coming from to get them. Which response is most therapeutic?
"It seems like the world is pretty scary for you, but you're safe here."
A client is brought to the emergency department after wandering on the street. The client is confused, verbalizes double vision, headache, and shakiness. Laboratory data reveal a serum blood glucose of 52 mg/dL. Which questions, asked by the nurse, may reveal more data related to the client's condition? Select all that apply.
"What have you eaten today?" "Do you take insulin or oral antidiabetic medication?" "Have you ever felt this way before?"
A 2-year-old child is being discharged from the hospital after treatment for croup. The parent asks, "What should we do if the child gets croup again?" What is the best response by the nurse who is reinforcing the discharge instructions?
"If the child gets another cold, watch for croup. Keep a cool-mist humidifier running in the room, and give the child lots of clear liquids."
While being escorted to an operating room, a client is extremely anxious and says, "I really don't know what they're going to do to me today. The physician said I have a lump in my breast and that's all I know." Which action is appropriate for the nurse to take?
Notify the physician upon arrival at the operating room.
Which finding is common when gathering data from a child with a total anomalous pulmonary venous return defect?
frequent respiratory infections
A client is taking salicylates for osteoarthritis. What should the nurse carefully monitor the client for?
hearing loss
A client with diabetes delivers a 9-lb, 6-oz (4,250 g) neonate. The nurse should be alert for which condition in the neonate?
hypoglycemia
The nurse is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to:
identify anxiety-causing situations.
