Passpoint NCLEX Actual Exam Questions | 100% Correct Answers | Verified 2024 Version

An adolescent is brought to the emergency department (ED) after accidentally taking an overdose of heroin. The adolescent is semiconscious, unable to respond appropriately to questions, slurs words, and has constricted pupils; the client's vital signs are blood pressure 60/50 mm Hg, pulse 50 beats/min, and respirations 8 breaths/min. Naloxone is administered to temporarily reverse the effects of the heroin. Which finding would first indicate that the naloxone administration has been effective? - The client's respirations improve to 12/min; Decreased respirations and coma are the two most dangerous effects of heroin overdose, so an increase in respirations after administration of the naloxone demonstrates initial effectiveness of the medication. Changes in cognition and psychomotor activity will take more time to become apparent. The client's blood opioid level may not drop to a nontoxic level for a few days. The third stage of labor ends - after the delivery of the placenta; The definition of the third stage of labor is the delivery of the placenta. The first stage of labor ends with complete cervical dilation and effacement. The second stage of labor ends with the birth of the neonate. The fourth stage of labor includes the first 4 hours after birth. The client with a nasogastric (NG) tube has abdominal distention. What should the nurse do first? You Selected: - Check the function of the suction equipment; When a client with a NG tube exhibits abdominal distention, the nurse should first check the suction machine. If the suction equipment is functioning properly, then the nurse should take other steps, such as repositioning the tube or checking tube patency by irrigating it. If these steps are not effective, then the HCP should be called. A public health nurse has been asked to teach the importance of hand washing to elderly clients. Which statement by a client indicates that the teaching has been effective? - Friction while washing hands decreases transmission of bacteria; Soap helps by reducing surface tension of water, but friction is necessary for the removal of microorganisms. The use of warm water still needs friction. Use of other products besides soap can reduce infection. Fifteen seconds is an insufficient length of time for hand washing. A client develops hepatic encephalopathy 1 week after portal caval shunt surgery. The client's physician orders neomycin, 4 g by mouth daily in four divided doses. The client's partner asks how neomycin decreases the serum ammonia concentration. How should the nurse respond? - Neomycin decreases the amount of ammonia-producing bacteria in the GI tract; Neomycin lowers the blood ammonia level by reducing the quantity of ammonia-producing bacteria in the GI tract. The drug also exerts its antibacterial activity directly on the ribosomes of susceptible organisms, among them E. coli, by inhibiting protein synthesis via direct action on ribosomal subunits. When present, these bacteria convert urea to ammonia. Neomycin is bactericidal in high concentrations and bacteriostatic in low concentrations. Thus, it doesn't trap or bind with ammonia in the GI tract. A hospital safety officer is evaluating nurses' responses to potential safety hazards. Which employee actions are appropriate for the situation? Select all that apply. - 1. taking small steps with feet shoulder length apart when walking on wet surfaces 2. removing clients from the area where a fire is reported 3. using tongs to place a dislodged radioactive device in a lead container A client with chronic obstructive pulmonary disease presents with respiratory acidosis and hypoxemia. The client tells the nurse that they don't want to be placed on a ventilator. What action should the nurse take? - Notify the physician immediately to have the physician determine client competency; Three requirements are necessary for informed decision-making: the decision must be given voluntarily; the client making the decision must have the capacity and competence to understand; and the client must be given adequate information to make the decision. In light of the client's respiratory acidosis and hypoxemia, the client might not be competent to make this decision. The physician should be notified immediately so the physician can determine client competency. The physician, not the nurse, is responsible for discussing the implications of a DNR order with the client. The Patient's Bill of Rights entitles the client to make decisions about the care plan, including the right to refuse recommended treatment. The client's family may oppose the client's decision. Consulting the palliative care group isn't appropriate at this time and must be initiated by a physician order. A client in the emergency department reported vomiting and diarrhea for the previous 24 hours. The client's blood pressure is 90/60 mm Hg, respiration is 20 breaths per minute, heart rate is 92 beats per minute, and temperature is 37.5° C (99.5° F). Which intervention will the nurse perform first? - Assess for dehydration; The priority for this client is assessing the problem. Then the nurse should treat the fluid volume deficit, then the temperature. This client has hypotension, and the nurse would raise the legs, not the head, of the bed first to improve perfusion to the brain, as it is the least restrictive intervention. A nurse is caring for a client who has returned to their room after a carotid endarterectomy. Which action should the nurse take first? - Ask the client if they have trouble breathing; The nurse should f irst assess the client's breathing. A complication of a carotid endarterectomy is an incisional hematoma, which could compress the trachea causing breathing difficulty for the client. Although the other measures are important actions, they aren't the nurse's top priority. A charge nurse is making client care assignments for the day. Which client would be most appropriate to assign a licensed practical nurse (LPN)? - 6-year-old child 2-day post-op appendectomy with a surgical drain; The 6-year-old child who is post-appendectomy would be the most stable child to assign to the LVN/LPN. The skill set of an LVN/LPN includes care of surgical drains. A 6-month-old infant with pneumonia requiring oxygen might be the next choice, depending on the infant's vital signs. Being that the child is very young, the condition could change rapidly. This infant will require frequent respiratory assessments. The infant with a respiratory rate of 60 is not stable and is in respiratory distress. The child with nephrotic syndrome and 4+ protein is very ill and needs many nursing interventions and assessments best done by the registered nurse. The parents of a child with occasional generalized seizures want to send the child to summer camp. The parents contact the nurse for advice on planning for the camping experience. Which type of activity should the nurse and family decide the child should most avoid? - Rock climbing; A child who has generalized seizures should not participate in activities that are potentially hazardous. Even if accompanied by a responsible adult, the child could be seriously injured if a seizure were to occur during rock climbing. Someone also should accompany the child during activities in the water. At summer camps, hiking and swimming would occur most commonly as group activities, so someone should be with the child. Tennis would be considered an appropriate, nonhazardous activity for a child with generalized seizures. Which toxic adverse reaction should the nurse monitor in a toddler taking digoxin? - nausea and vomiting; Digoxin toxicity in infants and children may present with nausea, vomiting, anorexia, or a slow, irregular heart rate. Weight gain, tachycardia, and seizures are not findings in digoxin toxicity. A client has been in an automobile accident, and the nurse is assessing the client for possible pneumothorax. What finding should the nurse immediately report to the health care provider? - Sudden, sharp chest pain; Pneumothorax signs and symptoms include sudden, sharp chest pain, tachypnea, and tachycardia. The nurse should report these to the health care provider (HCP). Other signs and symptoms include diminished or absent breath sounds over the affected lung, anxiety, and restlessness. Hemoptysis and cyanosis are not typically present with a pneumothorax. The nurse is caring for a client admitted with Addisonian crisis. Which outcome is the priority? - Preventing irreversible shock; A client in Addisonian crisis has an uncontrolled loss of sodium in the urine, and impaired mineralocorticoid function, which results in a loss of extracellular fluid, low blood volume, and possible irreversible shock. Preventing infection isn't an appropriate goal in this life threatening situation. Relieving anxiety is appropriate after the client is stabilized. The client in Addisonian crisis is hypotensive, and blood pressure should be raised not lowered. The nurse who cared for a client in the home environment for several months learns that the client has died. What should the nurse do to support the family at this time? - Attend the funeral; It is appropriate for the nurse who took care of a client for a prolonged period to attend the funeral. It also is appropriate for the nurse to make a follow-up personal or phone call to the client's family after the funeral or memorial service to offer both concern and care for the family's well-being. Follow-up visits are important to give support to the family. Flowers may not be desired by the family. The nurse needs to do more than just remove the client's name from the care list. The nurse conducts the health assessment of a client who is a primigravida in the prenatal clinic. Which presumptive signs of pregnancy should the nurse expect to assess? - amenorrhea and quickening; Presumptive signs, such as amenorrhea and quickening, are mostly subjective and may be indicative of other conditions or illnesses. Probable signs are objective, but nonconclusive indicators — for example, Chadwick's sign, Hegar's sign, a positive pregnancy test, uterine enlargement, and Braxton Hicks contractions. Positive signs and objective indicators, such as fetal outline on ultrasound confirm pregnancy. Which client's care may a registered nurse (RN) safely delegate to the nursing assistant? - a client requiring assistance ambulating, who was admitted with a history of seizures; The RN may safely delegate assistance ambulating for the client with a history of seizures to a nursing assistant. The RN should provide direct care to the client who requires continuous pulse oximetry monitoring because pulse oximetry interpretation requires assessment skills. Care of the clients requiring suctioning and patient-controlled analgesia can be safely delegated to a licensed practical nurse. When planning care for a client with schizophrenia, who lacks motivation to shower and dress, which outcome should the nurse expect the client to achieve by the end of 4 days? - Perform showering and dressing for herself; By the end of 4 days, the client should be able to perform showering and dressing for herself. The client with schizophrenia commonly appears to be apathetic and lack initiative. Therefore, demonstrating the ability to complete the tasks indicates improvement. Although the client may be able to recognize, verbalize, or explain the need to shower and dress herself, she may be unable to do so because of the ambivalence associated with schizophrenia that impedes the client's ability to initiate and complete self-care. Therefore, evidence of improvement would be lacking. Which health education topic is the priority when teaching parents ways to prevent urinary tract infections (UTIs) in their children? - Teach parents to promote adequate fluid intake; Urinary stasis is a major cause of UTIs, and can be partially prevented by increasing fluid intake. Baths and hand hygiene are less significant factors in the development of UTIs. Urinary tract infections are increased in uncircumcised male infants under 1 year of age, but unaffected thereafter. A client has been unable to void since having abdominal surgery 7 hours ago. What should the nurse do f irst? - Assist the client up to the toilet to attempt to void; Urinary retention is common following abdominal surgery. The nurse should first assist the client to an anatomically comfortable position to void prior to resorting to other strategies such as cauterization. If the client is unable to void, the nurse can use a bladder scanner to determine the volume of retained urine, and then, if necessary, use an intermittent urinary catheter. While increasing fluid intake is important, it will not help the client void now. An 8-year-old has a body mass index (BMI) for age at the 90th percentile but has no other risk factors. What should the nurse do? - Refer the family to a dietician; Children aged 2 to 20 years with a BMI for-age at the 90th percentile are considered overweight. If no other risk factors are present, the family should receive dietary counseling to slow the child's weight gain until an appropriate height for weight is attained. Without intervention, the child may become obese. An HCP who specializes in pediatric weight loss should be considered when the child is obese and has complicating factors. Commercial diet programs alone do not include the necessary monitoring for children, thus are rarely appropriate. The health care provider prescribes raloxifene hydrochloride for a 60-year-old woman. The drug is effective if the client does not develop: - Osteoporosis; Raloxifene hydrochloride, an estrogen receptor modulator, increases bone mineral density without stimulating the endometrium. The drug is useful in preventing osteoporosis in postmenopausal women. This drug is co