passpoint nclex RN review
When teaching the mother of an infant who has received a temporary colostomy for treatment of Hirschsprung's disease about how the stoma should normally appear, the nurse should include which description about the stoma's appearance in the teaching?
staying deep red in color
Which statement by a client taking trazodone as prescribed by the health care provider indicates to the nurse that further teaching about the medication is needed?
"My depression will be gone in about 5 to 7 days."
A client is brought to the emergency department with a painful swollen ankle. What is the nurse's most appropriate action?
Elevate the ankle.
A nurse should question an order for a heating pad for a client who has
active bleeding.
The nurse is reviewing the interventions listed in the plan of care for a child in vaso-occlusive crisis. Which intervention should the nurse implement first?
administering analgesics
A client reports abdominal pain. Which action allows the nurse to investigate this complaint?
assessing the painful area last
A nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which finding requires immediate intervention?
urine retention or incontinence
The risk for injury during an attack of Ménière's disease is high. The nurse should instruct the client to take which immediate action when experiencing vertigo?
"Assume a reclining or flat position."
The nurse is assessing the pain level in a client who typically gives a stoic response to describing the pain. Which comment from this client is expected?
"Enduring pain is a part of God's will."
A hospital employee asks the nurse if another hospital employee is a client on the medical unit. What statements made by the nurse protect client privacy? Select all that apply.
"I am not able to provide that information." "Client privacy is part of the hospital code of conduct."
The nurse reviews information about how to take the prescribed tetracycline. Which statement by the client allows the nurse to determine that the client understands the information?
"I can take tetracycline 1 hour before or 2 hours after meals with plenty of water."
A nurse is caring for a client who is receiving chemotherapy and has a platelet count of 30,000/mm3. Which statement by the client indicates a need for additional teaching?
"I floss my teeth every morning."
A client is taking fluphenazine. The nurse understands that teaching and discharge instructions are understood when the client states
"I need to stay out of the sun."
A client hospitalized with Crohn's disease is experiencing a migraine aura. The client requests that the client's chiropractor be allowed to visit even though it is after visiting hours. What is the nurse's best response?
"Tell me what helps your migraines outside of the hospital."
A client with pernicious anemia asks why she must take vitamin B12 injections forever. Which is the nurse's best response?
"The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient amounts of a factor that allows the vitamin to be absorbed."
The parent of a child who is taking an antibiotic for bilateral otitis media tells the nurse that he has stopped the medicine since the child is better and is saving the rest of the medication to use the next time the child gets sick. What should the nurse tell the parent?
"Your child needs all of the medicine so that the infection clears."
A nurse in a well-child clinic is assessing children for scoliosis. Which child is most at risk for scoliosis?
10-year-old girl
nurse is assigned to four clients. Which client should the nurse see first?
A client who is being prepared for a major surgery receiving clopidogrel
Following surgery for removal of a brain tumor, a client is coughing, short of breath, and has a "bad" feeling. The nurse obtains the following vital signs: blood pressure of 80/60 mm Hg; pulse rate of 120 bpm; and respiratory rate of 30 shallow breaths/min. What should the nurse do first?
Activate the Rapid Response Team (RRT).
A client states, "If my heart stops beating, I do not want to be resuscitated." Which action would the nurse take?
Ask if the client discussed this with the healthcare provider.
The unlicensed assistive personnel (UAP) reports to the nurse that the client with an abdominal hysterectomy who returned from the recovery room 1 hour earlier has saturated the blue pad with bright red blood. What should the nurse do?
Ask the UAP to obtain vital signs while the nurse calls the surgeon.
A client has been admitted with severe burns. Lactated Ringer's has been ordered to infuse via a pump. Why is this solution being used?
to prevent signs of hypovolemic shock and restore circulation
A preschool-age child has just been admitted to the pediatric unit with a diagnosis of bacterial meningitis. What is the nurse's priority intervention?
Decrease environmental stimulation.
A parent calls the health clinic and tells the nurse that the toddler was found with an open and empty bottle of acetaminophen. The parent asks the nurse what to do. What is the nurse's priorityintervention?
Give the parent instructions on how to call poison control.
While making rounds, a nurse observes that a client's primary bag of intravenous (IV) solution is light yellow. The label on the IV bag says the solution is D5W. What should the nurse do first?
Hang a new bag of D5W, and complete an incident report.
A nurse is teaching a client with bipolar disorder about the drug carbamazepine. The nurse determines teaching was effective when the client states
I need to have my blood counts checked periodically."
A client with a history of Addison's disease is experiencing weakness and headache. The vital signs are blood pressure of 100/60 and heart rate of 80. Laboratory values are Na 130, potassium 4.8, and blood glucose 70. Which solution would the nurse expect to administer?
I.V. normal saline and glucocorticoids
Which nursing strategy would be effective in managing a client who has Alzheimer's disease and wanders?
Involve the client in activities that promote walking.
A child with asthma states, "I want to play some sports like my friends. What can I do?" The nurse responds to the child based on the understanding of what information?
Most children with asthma can participate in sports if the asthma is controlled.
Upon review of a client's phenytoin levels, a nurse notes a value of 16 mcg/ml. What should the nurse do next?
No action is needed at this time because the drug level is normal.
A nurse is teaching a client with diabetes mellitus about self-management. Which statement would be correct about the administration of lispro insulin?
Take the insulin at around the same time each day at a meal.
One day after an appendectomy, a 9-year-old rates pain at 4 out of 5 on the pain scale but is playing video games and laughing with a friend. What should the nurse document on the child's chart?
The child rates pain at 4 out of 5. Administered pain medication as ordered.
A school-age child is being discharged with a diagnosis of rheumatic fever. Which instructions should be included in the teaching plan for the family?
The child should stay on penicillin and return for a follow-up appointment.
Why are antacids administered regularly, rather than as needed, in peptic ulcer disease?
To keep gastric pH at 3.0 to 3.5
The nurse is preparing to administer the initial dose of digoxin PO to a client. What is the nurse's priority assessment before administering this medication?
apical heart rate
Which meal would be appropriate for the child with osteomyelitis to choose?
beef and bean burrito with cheese, carrot and celery sticks, and a glass of milk
The nurse is caring for an 8-year-old child who arrived at the emergency department with chemical burns to both legs. What is the priority intervention for this child?
diluting the chemicals
A 22-year-old client reports substernal chest pain and states that their heart feels like "it's racing out of my chest." The client reports no history of cardiac disorders. The nurse attaches the client to a cardiac monitor and notes sinus tachycardia with a rate of 136 beats/minute. Breath sounds are clear, and the respiratory rate is 26 breaths/minute. When a cardiorespiratory basis is eliminated, which drug would the nurse question about usage?
cocaine
The client was admitted to the hospital with the diagnosis of iron overload. Over time, an excess of iron can damage the liver and cause heart problems. Which medication does the nurse anticipate the healthcare provider to order?
deferoxamine
The nurse is aware that antihypertensives should be used cautiously in clients already taking
thioridazine.
When planning care for a client with a small-bowel obstruction, which should the nurse consider to be the primary goal?
maintaining fluid balance
Which nursing intervention is the highest priority when a client is placed in restraints?
monitoring the client every 15 minutes
A 7-year-old child is admitted to the hospital with acute rheumatic fever. During the acute phase of the illness, which diversional activity would the nurse most discourage?
playing checkers with a roommate
The nurse is caring for a 5-year-old child who had a hernia repair 1 day ago. The child is vomiting, has a nasogastric (NG) tube to low intermittent suction, and has diarrhea. Which of the following laboratory results would be the immediate priority for the nurse to assess?
potassium level
A high-carbohydrate, low-protein diet is prescribed for the client with acute renal failure. What should the nurse tell the client to expect when following this diet?
prevent the development of ketosis.
The nurse is caring for a primigravid client at about 9 weeks' gestation. After explaining self-care measures for common discomforts of pregnancy, the nurse determines that the client understands the instructions when she makes which statement?
"Nausea and vomiting can be decreased if I eat a few crackers before arising."
The nurse is coaching a diabetic client using an empowerment approach. The nurse should initiate teaching by asking which question?
"What activities are most important for you to be able to maintain control of your diabetes?"
A client diagnosed with thyroid cancer signed a living will that states the client doesn't want ventilatory support if the condition deteriorates. As the client's condition worsens, the client states, "I changed my mind. I want everything done for me." Which response by the nurse is best?
"What exactly do you mean by wanting 'everything' done for you?"
The nurse is notifying the health care provider via telephone of a change in condition of a client diagnosed with an exacerbation of asthma. Arrange the nursing statements in order as they would be communicated using the SBAR method. All options must be used.
1.Hello. My name is Nurse Jones from Unit D. 2. I am notifying you because Bob Smith has become increasingly short of breath with audible wheezing this afternoon. 3. Mr. Smith was admitted yesterday with an exacerbation of asthma. He typically controls his asthma with oral medication and inhalers at home. He is ordered albuterol treatments twice daily. Oxygen is prescribed at 2 liters. 4. Respirations are now 32 breaths/minute. The pulse oximeter is 89%. Lungs reveal wheezing in all lung fields. Slight nasal flaring is noted. 5.I recommend that we increase his oxygen dose and prescribe an extra albuterol treatment
A nurse is caring for a neonate with congenital clubfoot. The child has a cast to correct the defect. Before discharge, what should the nurse tell the parents?
A new cast is needed every 1 to 2 weeks.
A staff nurse receives a phone call and is told there is a bomb in a client's room. What is the nurse's priority action?
Ask the caller for details about the bomb placement.
A client with a suspected brain tumor is scheduled for a computed tomography (CT) scan. What should the nurse do when preparing the client for this test?
Determine whether the client is allergic to iodine, contrast dyes, or shellfish.
The nurse is giving care to an infant with a brain tumor. The nurse observes the infant arches the back (see figure). What action should the nurse take first?
Notify the health care provider (HCP).
To evaluate a client's atrial depolarization, the nurse observes which part of the electrocardiogram waveform?
P wave
A female client who has diagnosis of borderline personality disorder is manipulative and very disruptive on the hospital unit. She is not dangerous to herself or others, but is clearly not making any therapeutic progress. She consistently refuses any medications. The nurse realizes that legally this client has which option?
Refuse treatment.
The nurse is caring for an older adult with mild dementia admitted with heart failure. What nursing care will be helpful for this client in reducing potential confusion related to hospitalization and change in routine? Select all that apply.
Reorient frequently to time, place and situation. Arrange for familiar pictures or special items at bedside. Spend time with the client, establishing a trusting relationship.
Which action should the nurse do first when noting clear drainage on the child's dressing and bed linen after a craniotomy for a brain tumor?
Test the fluid for glucose.
A client diagnosed with seminomatous testicular cancer expresses fear and questions the nurse about his prognosis. Which information should the nurse give the client about the prognosis for testicular cancer?
Testicular cancer has a cure rate of 90% when diagnosed early.
A client is to be discharged from same-day surgery 7 hours after his inguinal hernia repair. Which nursing observation indicates this client is ready to be discharged?
The client voids 500 mL of urine.
A client underwent insertion of a nasogastric (NG) tube for partial bowel obstruction the previous evening. The nurse notes that the tube is not secured to the client's face. How will the nurse proceed?
Verify placement of the tube.
The triage nurse in the emergency department must prioritize the care of children waiting to be seen. Which child is in the greatest need of emergency medical treatment?
a 6-year-old with a fever of 104° F (40° C), a muffled voice, no spontaneous cough, and drooling
The nurse should use which type of precautions for a client being admitted to the hospital with suspected tuberculosis?
airborne precautions
Which risk factor would most likely contribute to the development of a client's hiatal hernia?
being 5 feet, 3 inches (160 cm) tall and weighing 190 lb (86.2 kg)
A nurse is assessing a client using light palpation. How does a nurse perform light palpation?
by indenting the client's skin ½″ to ¾″ (1.3 to 1.9 cm)
A nurse is caring for a client who's had surgery to repair a hip fracture. The client says their left hand and arm are numb and they can't move the extremity. The nurse contacts the physician, who suspects brachioplexus nerve damage. What additional priority assessment does the nurse need?
function of the client's left hand before the operation
The nurse is giving preoperative instructions to a client who will be undergoing rhinoplasty. What should the nurse tell the client? You Selected:
"Do not take aspirin-containing medications for 2 weeks before surgery."
Which statement, made by a client with a hiatal hernia, indicates that the client understands the treatment plan?
"I will sit in a chair for several hours after I eat."
A client has been taking imipramine for depression for 2 days. His sister asks the nurse, "Why is he still so depressed?" Which response by the nurse is most appropriate?
"It takes 2 to 4 weeks for the drug to reach its full effect."
The nurse is caring for a group of clients on a medical-surgical nursing unit. Which task(s) could the nurse delegate to unlicensed assistive personnel (UAP)? Select all that apply.
Perform vital signs and oxygen saturation on a client returning from the catheterization lab. Obtain intake and outputs on a client experiencing heart failure.
When caring for a client with a 3-cm stage I pressure ulcer on the coccyx, which action may the nurse institute independently?
Using normal saline solution to clean the ulcer and applying a protective dressing as necessary
Which child most needs a screening for scoliosis?
a preadolescent client at the beginning of a growth spurt
A major role in crisis intervention is getting a client's family and friends involved in helping with the immediate crisis as soon as possible. The nurse should determine that the support persons are prepared to help when they verbalize what information?
emergency resources and when to use them
A nurse should encourage a client with a wound to consume foods high in vitamin C because this vitamin
enhances protein synthesis.
The client is in the emergency department with her boyfriend. She is just recovering from a temporary drug-induced psychosis from lysergic acid diethylamide (LSD). She is still frightened and a little suspicious. Which nursing action is most appropriate?
having an unlicensed assistive personnel (UAP) stay with the client to decrease her fear
Which is an expected outcome when a client is receiving an IV administration of furosemide?
increased urine output
A client is admitted with increased ascites related to cirrhosis. The client has a large round and firm abdomen. The client is not able to lie flat in bed and requests to be placed in a high Fowler's position to sleep. Which nursing diagnosis should receive top priority?
ineffective breathing pattern
A 3-month-old infant with meningococcal meningitis has just been admitted to the pediatric unit. Which nursing intervention has the highest priority?
instituting droplet precautions
A nurse is assessing a client with bipolar disorder. The client tells the nurse that the family health care provider prescribed lithium. Which symptom would indicate that the client is developing lithium toxicity?
lethargy
Which philosophy should the nurse integrate into the plan of care for a client and family to help them best cope during the final stages of the client's illness?
living each day as it comes as fully as possible
A nurse is working within the managed care delivery model. Which is true regarding managed care?
ll systems reflect the values of efficiency and effectiveness.
A mother brings her child to the emergency department after the child has taken "some white pills just a short while ago." When assessing the child, what should lead the nurse to determine that the pills taken were most probably acetaminophen?
nausea and vomiting
A client is admitted to an acute care facility with a tentative diagnosis of hypoparathyroidism. The nurse should monitor the client closely for the related problem of
profound neuromuscular irritability.
Which is an advantage of using biologic burn grafts such as porcine (pigskin) grafts? Porcine grafts:
promote the growth of epithelial tissue.
The client sustained a tibia fracture and a cast was applied. The client is reporting increasing pain when flexing toes. Which symptoms does the nurse assess as associated with compartment syndrome? Select all that apply.
pulselessness paresthesia pain
A nurse is caring for a client with human immunodeficiency virus (HIV). To determine the effectiveness of treatment the nurse expects the physician to order:
quantification of T-lymphocytes.
A nurse notes the following laboratory values for a client receiving chemotherapy: white blood cell count 6000/µL, red blood cell count (RBC) 3.7 million cells/cm3, hematocrit 35%, platelet count 80,000 mm3. Which order would the nurse question?
rectal temperatures every 4 hours
During the emergent (resuscitative) phase of burn injury, which finding indicates that the client requires additional volume with fluid resuscitation?
serum creatinine level of 2.5 mg/dL (221 µmol/L)
A client has had a cast applied to the arm. When discharging the client, the nurse should tell the client to:
smell the cast for foul odors.
A nurse is assigned to care for a postoperative client with diabetes mellitus. During the assessment interview, the client reports that he's impotent and says he's concerned about the effect on his marriage. In planning this client's care, the most appropriate intervention would be to
suggest referral to a sex counselor or other appropriate professional.
During a routine physical examination to assess a client's deep tendon reflexes, a nurse should make sure to
support the joint where the tendon is being tested.
A 34-year-old primigravid client at 39 weeks' gestation admitted to the hospital in active labor has type B Rh-negative blood. The nurse should instruct the client that if the neonate is Rh positive, the client will receive an Rh immune globulin injection for what reason?
to prevent Rh-positive sensitization with the next pregnancy
The nurse is preparing to take a meal tray to the client. The nurse understands that the client follows a kosher diet. Which foods noted on the tray would be of a concern to the nurse?
turkey and cheese sandwich
A nurse is caring for a client with diabetes insipidus. The nurse should anticipate administering
vasopressin.
A nurse is providing care for a client who underwent mitral valve replacement. The best example of a measurable client outcome goal is for the client to
walk from their room to the end of the hall and back before discharge.
After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when the nurse notes tidal movements or fluctuations in which compartment of the system as the client breathes?
water-seal chamber
A client with peptic ulcer disease is ordered aluminum-magnesium complex. When teaching about this antacid preparation, the nurse should instruct the client to take it with
water.
The parent of an 18-year-old with chronic renal disease states, "My son has so many problems. I'm really worried that he won't get the right care if he gets sick at college." What is the nurse's best response?
"Your son can make an electronic history to facilitate his care if he gets sick away from home."
A psychiatric treatment team is planning care for a client who was involuntarily admitted for treatment of depression and suicide ideation. When planning the client's care, what legal parameters of care should the nurse be aware of?
The client is able to refuse medications.
