Physiological Adaptation Passpoint
A student nurse requires additional teaching when identifying what factor as contributing to a client's increased risk for infection?
proper nutrient intake
The nurse is assessing a client with Parkinson disease. Which is an initial sign of Parkinson disease?
tremor
A newly admitted client reports taking digoxin and warfarin. Which statement would the nurse include in the discharge instructions?
"Notify your healthcare provider if you experiences visual changes."
A client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct?
"OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints."
A client with diabetes who just gave birth plans to breastfeed. The nurse determines that the client's understanding of breastfeeding instructions is sufficient when the client makes which statement?
"Breastfeeding will assist in lowering maternal blood glucose."
In discharge planning after scleral buckling for a detached retina, the nurse should teach the client to avoid which activity during the early recovery period?
reading
The nurse in the emergency department is admitting a client with cholecystitis who is experiencing pain and nausea. Which action should the nurse take first?
Administer pain medication.
The nurse teaches the child with scoliosis being treated with a Boston brace about exercises. The nurse explains that the exercises are performed primarily for what reason?
to strengthen the back and abdominal muscles
What is a priority nursing goal for an infant with intussusception?
Manage acute pain.
The nurse explains to the client that a biopsy of the enlarged lymph node is important because, if Hodgkin's disease is present, the histologic examination will reveal which of the following?
Reed-Sternberg cells.
A client is seeking infertility treatment after attempting pregnancy for 2 years. Of the data from the client's history, which has the greatest impact on infertility?
The client is a gymnast weighing 105 lb (47.6 kg).
A client with quadriplegia is in spinal shock. What finding should the nurse expect?
absence of reflexes along with flaccid extremities
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?
being an infant
To assess the effectiveness of cardiac compressions during adult cardiopulmonary resuscitation (CPR), a nurse should palpate which pulse site?
carotid
The client sustained an open fracture of the femur from an automobile accident. The nurse should assess the client for which type of shock?
hypovolemic
A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem?
urine output of 20 ml/hour
On a visit to the family physician, a client is diagnosed with a bunion on the lateral side of the great toe, at the metatarsophalangeal joint. Which statement should the nurse include in the teaching session?
"Some bunions are congenital; others are caused by wearing shoes that are too short or narrow."
A nurse is teaching the parents of an infant with clubfeet about cast care. Which statement by the parent indicates the need for further teaching?
"Immunizations will have to be delayed until the casts come off."
The nurse teaches a child's parent about sickle cell disease. Which statement by the parent would indicate the need for additional teaching?
"My child is going to be playing on a soccer team when they're feeling better."
Parents bring their infant to the emergency department because the child has stopped breathing. A nurse obtains a brief history of events occurring before and after the parents found the infant not breathing. Which question should the nurse ask the parents first?
"What did the infant look like when you found the child?"
Three days after surgery, a client continues to take hydrocodone 7.5 mg and acetaminophen 500 mg for postoperative pain. What should the nurse ask the client before administering the pain medication?
"When did you last have a bowel movement?"
A nurse in a prenatal clinic is assessing a client who is 28 weeks' pregnant. Which findings lead the nurse to suspect that the client has mild preeclampsia?
1+ protein, blood pressure 142/92 mmHg
Which client is most likely to exhibit dehydration?
8-month-old infant with persistent diarrhea for 24 hours
A client has a sucking stab wound to the chest. Which action should the nurse take first?
Apply a dressing over the wound and tape it on three sides.
A client is admitted to the telemetry unit following a ST segment-elevation myocardial infarction (STEMI). The electrocardiogram (EKG) tracing shows a run of sustained ventricular tachycardia. What is the first action that the nurse should take?
Assess the client's airway, breathing, pulses, and level of conciseness.
A nurse is caring for a client that received a colostomy 2 days ago. Which is the priorityintervention?
Assess the drainage from the stoma.
A client who underwent a mastectomy has been admitted to the surgical care unit after discharge from the postanesthesia care unit. What is the nurse's priority assessment?
Assess the vital signs and oxygen saturation levels.
A parent calls the clinic after their 4-year-old choked on a peanut. The parent reports performing abdominal thrusts and the child is breathing normally now. What should the nurse tell the parent to do?
Bring the child to the emergency department to check for airway obstruction.
A toddler is receiving an infusion of total parenteral nutrition via a Broviac catheter. As the child plays, the I.V. tubing becomes disconnected from the catheter. What should the nurse do first?
Clamp the catheter.
A nurse is caring for a client at 30 weeks' gestation who has tested positive for the human immunodeficiency virus (HIV). What should the nurse tell the client when the client says that she wants to breast-feed her neonate?
Discourage
A pregnant client arrives in the emergency department and states, "My baby is coming." The nurse sees a portion of the umbilical cord protruding from the vagina. What should the nurse do first?
Hold pressure on the fetal head.
Which nursing intervention is most important postoperatively for an infant who has received a ventriculoperitoneal shunt?
Monitor head circumference.
A client has chest pain rated at 8 on a 10-point visual analog scale and is receiving intravenous nitroglycerin. The 12-lead electrocardiogram reveals ST elevation in the inferior leads, and troponin levels are elevated. What should the nurse do first?
Notify the health care provider.
An adult client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the midepigastric region along with a rigid, boardlike abdomen. After obtaining the client's vital signs, the nurse should do what next?
Notify the health care provider.
At 0300 the parent of a 3-year-old child calls the telehealth nurse and reports the child has a temperature of 101°F (38°C), a runny nose, and a barky cough that "gets going and will not stop." The parent states that they just gave the child acetaminophen. What should the nurse recommend next?
Sit with the child in a steamy, warm bathroom.
Which finding is an example of a variance in the critical pathway of a client 3 days after an above-the-knee amputation?
Temperature of 102° F (38.9°C)
A client arrives in the emergency department reporting intense pain in the abdomen and tells the nurse that it feels like a heartbeat in the abdomen. Which nursing assessment would indicate potential rupture of an aortic aneurysm?
The client reports increasing severe back pain.
A nurse is providing care for a client who has a sacral pressure ulcer with a wet-to-damp dressing. Which guideline is appropriate for a wet-to-damp dressing?
The dressing should keep the wound moist.
The nurse assesses an infant with a suspected inguinal hernia. Which finding would be mostconcerning?
The inguinal swelling is reddened, and the abdomen is distended.
A client has a nursing diagnosis of fluid volume deficit. Which nursing assessment finding would support this diagnosis?
orthostatic blood pressure changes
A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?
The system has an air leak.
When assessing a client during a routine checkup, the nurse reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. Aphthous stomatitis is best described as
a canker sore of the oral soft tissues.
During the admission assessment of a female neonate, a nurse notes a large lump on the neonate's head. Concerned about making the correct assessment, the nurse differentiates between caput succedaneum and a cephalohematoma based on the knowledge that
a cephalohematoma doesn't cross the suture lines.
The charge nurse is working on a medical-surgical unit and must rearrange room assignments for several clients. Which clients should the nurse put in the same room? Select all that apply.
a client with pain related to pancreatitis a client who underwent cholecystectomy today
A client with a clamped chest tube in place has become increasingly short of breath throughout the shift and reports pain to the right chest wall. The nurse understands that the most likely cause is:
a tension pneumothorax.
A client diagnosed with acute pancreatitis 5 days ago is experiencing respiratory distress. Which finding should the nurse report to the health care provider (HCP)?
arterial oxygen level of 46 mm Hg (6.1 kPa)
After total hip replacement, a client is receiving epidural analgesia to relieve pain. Which action is a nursing priority for this client?
assessing for sensation in the legs
Which class of medication protects the ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation?
beta-adrenergic blockers
A client is admitted to the emergency department after intentionally taking an overdose of amitriptyline hydrochloride. A nurse knows that giving the client activated charcoal will
bind with the ingested drug.
The nurse is assessing a client at risk for acute disseminated intravascular coagulation (DIC). Which finding indicates the client is showing an early sign of DIC?
bleeding without history or cause
A client's blood glucose level is 45 mg/dl (2.5 mmol/L). The nurse should be alert for which signs and symptoms?
coma, anxiety, confusion, headache, and cool, moist skin
The nurse is assessing a client with a known history of chronic heart failure. Which finding indicates poor perfusion to the tissues?
cool, pale extremities
A 36-year-old multigravid client is admitted to the hospital with a possible ruptured ectopic pregnancy. When the nurse is obtaining the client's history, which finding would be mostimportant to identify as a predisposing factor?
episodes of pelvic inflammatory disease
A young adult has been diagnosed with hypertrophic cardiomyopathy. The nurse should further assess the client for which complication?
fatigue and shortness of breath
When caring for a multigravid client admitted to the hospital with vaginal bleeding at 38 weeks' gestation, the nurse would anticipate administering intravenously which therapeutic agent if the client develops disseminated intravascular coagulation (DIC)?
fresh frozen platelets
The nurse is caring for a client on the urinary unit. When providing report to the next shift, it is noted that the client has osteopenia and history of renal calculi. Which disorder would the nurse suspect?
hyperparathyroidism
A 19-year-old primigravida at 38 weeks' gestation, in active labor for the past 8 hours, is admitted to the hospital accompanied by their parent. On admission, the client's cervix is 5 cm dilated, blood pressure is 120/84 mm Hg, and they are breathing rapidly and feeling dizzy and light-headed. The nurse determines that the client is most likely experiencing the effects of which condition?
hyperventilation
How does the nurse describe the movements of a child with spastic cerebral palsy?
increased muscle tone and stretch reflexes
A nurse notes that a client has kyphosis and generalized muscle atrophy. Which problem is a priority when the nurse develops a nursing plan of care?
ineffective coughing and deep breathing
A nurse is assessing a client and obtains the following findings: abdominal discomfort, mild diarrhea, and a temperature of 100°F (37.8°C). The nurse questions the client about a past diagnosis of what condition?
inflammatory bowel disease (IBD)
The parents of an 8-month-old infant have brought the child to the emergency department after falling from the high chair. The nurse takes immediate actions for increased intracranial pressure (ICP) based on what assessment finding?
lethargy and sluggish pupils
A client with cancer is being evaluated for possible metastasis. What is one of the mostcommon metastasis sites for cancer cells?
liver
The nurse is caring for a client with multiple organ failure who is in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation?
lungs and kidneys
A nurse assesses a 1-day-old neonate. Which finding indicates respiratory distress?
nasal flaring
An infant requires tracheal suctioning after the nurse assesses airway congestion. Which is the priority initial action when performing the procedure?
oxygenation prior to the procedure
A nurse at a community event is called to an unresponsive 3-year-old. The parent states the child was eating a hot dog. The nurse determines the child has an obstructed airway. After instructing an observer to call 911, what intervention should happen first?
performing chest compressions with the heel of one hand 30 times
During a follow-up visit to the physician, a client with hyperparathyroidism asks the nurse to explain the physiology of the parathyroid glands. The nurse states that these glands produce parathyroid hormone (PTH). PTH maintains the balance between calcium and
phosphorus.
Which nursing action addresses the primary concern for a client with Guillain-Barré syndrome?
preparing for mechanical ventilation
The nurse teaches a parent about caring for a 12-month-old child newly diagnosed with celiac disease. Which food would be most appropriate to include in the child's diet?
rice cereal
On a client's second postpartum visit, a health care provider reviews the chart. What's the best term for the lochia described?
rubra
A nurse is caring for a young client with tetralogy of Fallot (TOF). The client is upset and crying. The nurse observes that the client is dyspneic and cyanotic. Which position would help relieve the client's dyspnea and cyanosis?
squatting
The nurse is caring for a toddler who has been diagnosed with pernicious anemia. Which of the following should the nurse include in the health teaching about pernicious anemia for the parents?
the need to comply with lifelong injections of vitamin B12
A nurse is caring for a client after evacuation of a hydatidiform mole. The nurse should tell the client to:
use birth control for at least 1 year.
The nurse interprets the rhythm strip (see figure) from a client's bedside monitor as which rhythm? 200 bpm
ventricular tachycardia
The health care team determines that the family of an infant with failure to thrive who is to be discharged will need follow-up care. Which approach would be the most effective method of follow-up?
weekly visits by a community health nurse
A client has obtained levonorgestrel as emergency contraception. After unprotected intercourse, the client calls the clinic to ask questions about taking this contraceptive. The nurse realizes the client needs further explanation when they make which statement?
"I can wait up to 4 days after intercourse to start taking these to prevent pregnancy."
A client is induced with oxytocin. The fetal heart rate is showing accelerations lasting 15 seconds and exceeding the baseline with fetal movement. What action associated with this finding should the nurse take?
Document fetal well-being.
A nurse is instructing a client with newly diagnosed hypoparathyroidism about the regimen used to treat this disorder. The nurse should state that the physician probably will order daily supplements of calcium and
vitamin D
The nurse is assessing a client who has a chest tube connected to a water-seal chest tube drainage system. According to the illustration shown, what should the nurse do?
Lower the drainage system to maintain gravity flow.
A client has a C7 spinal cord injury. Which would be the most important nursing intervention during the acute stage of the injury?
Maintain a patent airway.
The nurse is teaching a client with peripheral arterial disease about how to promote circulation. Which instruction will be most helpful?
walking slowly but steadily for 30 minutes twice a day
The nurse is teaching a client with multiple sclerosis (MS) who has slurred speech how to improve verbal communication. Which is the most effective strategy for the nurse to suggest to the client?
Speak slowly.
A child with a tracheostomy suddenly becomes diaphoretic and has an increased heart rate, an increased work of breath, and a decreased oxygen saturation level. What should the nurse do first?
Suction the tracheostomy.
A client arrives at a public health clinic worried that she has breast cancer after finding a lump in her breast. When assessing the breast, which assessment finding provides an indication that the lump is more typical of fibrocystic breast disease?
The lump is round and movable.
What is a priority for the nurse developing a plan with a client admitted to the hospital with an acute exacerbation of rheumatoid arthritis?
achieving a controlled level of pain and fatigue throughout the day.
An adult recently diagnosed with Hodgkin's disease is admitted for staging by undergoing a bone marrow aspiration and biopsy. To obtain more information about the client's nutritional status, the nurse should review the results of which test?
albumin levels
When assessing a client with a chest tube inserted for a hemothorax, the nurse would expect which findings? Select all that apply. use of accessory muscles during respirations subcutaneous emphysema at the chest wall insertion site. fluid drainage into the first chamber of the drainage system a dry dressing at the chest wall insertion site tidaling in the water-seal chamber during respirations
fluid drainage into the first chamber of the drainage system a dry dressing at the chest wall insertion site tidaling in the water-seal chamber during respirations
After teaching a parent about tests performed to monitor the success of their infant's treatment for congenital hypothyroidism, the nurse should determine that the teaching was effective when the parent states that the child will need frequent blood tests and regular assessment of what?
bone age
A client who has been treated for chronic open-angle glaucoma (COAG) for 5 years asks the nurse, "How does glaucoma damage my eyesight?" What should the nurse tell the client? "Your glaucoma:
causes increased intraocular pressure."
The nurse notes serous discharge when an abdominal dressing is changed. How would the nurse would document this drainage?
clear, watery, yellow-tinged drainage
The nurse is conducting an initial nursing history of a client who is experiencing pain related to bone cancer. What information is most important for the nurse to obtain?
client's self-reporting of the pain experience
A client is recovering from abdominal surgery and has a nasogastric (NG) tube inserted. Which is the expected outcome of inserting the NG tube in the client's gastrointestinal tract?
decompression
A client has sustained a head injury and is to receive mannitol by I.V. push. In evaluating the effectiveness of the drug, the nurse should expect to find:
decreased cerebral edema
For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the care plan?
inspecting the skin for petechiae once every shift
The client is being discharged today after having an above-the-knee amputation a week ago. Which complications should the nurse include in the discharge directions? Select all that apply.
new openings in wound or skin around the wound pulling away worsening pain not controlled by medication skin around the stump or wound dark or turning black
When assessing a client who has been diagnosed with hepatic cirrhosis, the nurse should obtain which information when conducting a focused assessment? Select all that apply.
nutritional status. mental status current use of alcohol
Which assessment is most supportive of the nursing diagnosis, impaired skin integrity related to purulent inflammation of dermal layers as evidenced by purulent drainage and erythema?
oral temperature of 101° F (38.3° C)
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
