Passpoint exam 2 questions and answers
with solutions
A client with a history of polysubstance abuse is admitted to the facility. He complains of nausea
and vomiting 24 hours after admission. The nurse who assesses the client notes piloerection,
pupillary dilation, and lacrimation. The nurse suspects that the client is going through
withdrawal from which substance? - ANSWER Opioids
Explanation:
Piloerection, pupillary dilation, and lacrimation are specific to opioid withdrawal. A client with
alcohol withdrawal would show elevated vital signs. There is no real withdrawal from cannabis.
Symptoms of cocaine withdrawal include depression, anxiety, and agitation.
After instructing a 20-year-old nulligravid client about adverse effects of oral contraceptives, the
nurse determines that further instruction is needed when the client states which as an adverse
effect?
weight gain
nausea
headache
ovarian cancer - ANSWER ovarian cancer
Explanation:
The nurse determines that the client needs further instruction when the client says that one of
the adverse effects of oral contraceptive use is ovarian cancer. Some studies suggest that
ovarian and endometrial cancers are reduced in women using oral contraceptives. Other
adverse effects of oral contraceptives include weight gain, nausea, headache, breakthrough
bleeding, and monilial infections. The most serious adverse effect is thrombophlebitis.
A nurse is preparing a discharge teaching plan for a client with atopic dermatitis. Which
instruction should the nurse include in her teaching plan?
,Wear only synthetic fabrics.
Use a topical skin moisturizer daily.
Bathe only three times per week.
Keep the thermostat above 75° F (23.9° C ). - ANSWER Use a topical skin moisturizer daily.
Explanation:
The nurse should instruct the client to use a topical skin moisturizer daily to help keep the skin
hydrated. Likewise, the client should be encouraged to bathe daily. To minimize irritation, the
client should wear only cotton fabrics. The client should maintain a room temperature between
68° F (20° C) and 72° F (22.2° C).
A pregnant client complains of nausea every morning and again before meals. As a result of the
nausea, she's been unable to eat enough and has lost weight. Which nonpharmacologic
intervention should the nurse recommend?
Drinking water with every meal
Keeping crackers at the bedside to eat before getting out of bed
Eating three large meals per day
Drinking liquids with dry foods - ANSWER Keeping crackers at the bedside to eat before getting
out of bed
The nurse should advise the client to keep crackers at the bedside because eating dry crackers
before getting out of bed and before the stomach becomes empty helps prevent nausea.
Drinking water with every meal does not alleviate nausea. Eating six small meals per day, rather
than three large meals, prevents nausea by preventing the stomach from becoming empty.
Drinking liquids with dry food increases nausea. The client should be instructed to wait at least
30 minutes to consume liquids after eating dry food.
A nurse is caring for a client who has returned to his room after a carotid endarterectomy.
Which action should the nurse take first? - ANSWER Ask the client if he has trouble breathing.
Explanation:
, The nurse should first 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.
The nurse is caring for a client with an exacerbation of ulcerative colitis. The nurse should
instruct the client to:
maintain a high-fiber diet.
avoid lifting more than 5 pounds (2.3 kg).
obtain frequent rest periods.
use antidiarrheal medications regularly. - ANSWER obtain frequent rest periods.
Explanation:
It is important for the client to have frequent rest periods. Repeated episodes of diarrhea
interrupt sleep patterns, and poor nutrition may also cause the client to feel weak. If the client
is experiencing a severe exacerbation of ulcerative colitis, bed rest may be prescribed.
Antidiarrheal medications can be used selectively in ulcerative colitis but are not recommended
for regular use as they can lead to colonic dilation.
The client should maintain a low-residue, high-calorie, caffeine-free diet.
It is not necessary to limit weight lifting.
A nurse completes an afternoon assessment of a client who is a nurse and who is visiting the
area on vacation. The client states that the nurse must be having a busy shift and asks about the
maximum number of clients that the nurse is allowed to care for. What is the nurse's best
response? - ANSWER "Some jurisdictions have staffing laws which allow for nurses to be
involved in staffing ratios."
Explanation:
Staffing laws exist in some jurisdiction, but not others. Staffing laws tend to fall into one of three
general approaches: The first is to require hospitals to have a nurse driven staffing committee
which create staffing plans that reflect the needs of the patient population and match the skills
with solutions
A client with a history of polysubstance abuse is admitted to the facility. He complains of nausea
and vomiting 24 hours after admission. The nurse who assesses the client notes piloerection,
pupillary dilation, and lacrimation. The nurse suspects that the client is going through
withdrawal from which substance? - ANSWER Opioids
Explanation:
Piloerection, pupillary dilation, and lacrimation are specific to opioid withdrawal. A client with
alcohol withdrawal would show elevated vital signs. There is no real withdrawal from cannabis.
Symptoms of cocaine withdrawal include depression, anxiety, and agitation.
After instructing a 20-year-old nulligravid client about adverse effects of oral contraceptives, the
nurse determines that further instruction is needed when the client states which as an adverse
effect?
weight gain
nausea
headache
ovarian cancer - ANSWER ovarian cancer
Explanation:
The nurse determines that the client needs further instruction when the client says that one of
the adverse effects of oral contraceptive use is ovarian cancer. Some studies suggest that
ovarian and endometrial cancers are reduced in women using oral contraceptives. Other
adverse effects of oral contraceptives include weight gain, nausea, headache, breakthrough
bleeding, and monilial infections. The most serious adverse effect is thrombophlebitis.
A nurse is preparing a discharge teaching plan for a client with atopic dermatitis. Which
instruction should the nurse include in her teaching plan?
,Wear only synthetic fabrics.
Use a topical skin moisturizer daily.
Bathe only three times per week.
Keep the thermostat above 75° F (23.9° C ). - ANSWER Use a topical skin moisturizer daily.
Explanation:
The nurse should instruct the client to use a topical skin moisturizer daily to help keep the skin
hydrated. Likewise, the client should be encouraged to bathe daily. To minimize irritation, the
client should wear only cotton fabrics. The client should maintain a room temperature between
68° F (20° C) and 72° F (22.2° C).
A pregnant client complains of nausea every morning and again before meals. As a result of the
nausea, she's been unable to eat enough and has lost weight. Which nonpharmacologic
intervention should the nurse recommend?
Drinking water with every meal
Keeping crackers at the bedside to eat before getting out of bed
Eating three large meals per day
Drinking liquids with dry foods - ANSWER Keeping crackers at the bedside to eat before getting
out of bed
The nurse should advise the client to keep crackers at the bedside because eating dry crackers
before getting out of bed and before the stomach becomes empty helps prevent nausea.
Drinking water with every meal does not alleviate nausea. Eating six small meals per day, rather
than three large meals, prevents nausea by preventing the stomach from becoming empty.
Drinking liquids with dry food increases nausea. The client should be instructed to wait at least
30 minutes to consume liquids after eating dry food.
A nurse is caring for a client who has returned to his room after a carotid endarterectomy.
Which action should the nurse take first? - ANSWER Ask the client if he has trouble breathing.
Explanation:
, The nurse should first 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.
The nurse is caring for a client with an exacerbation of ulcerative colitis. The nurse should
instruct the client to:
maintain a high-fiber diet.
avoid lifting more than 5 pounds (2.3 kg).
obtain frequent rest periods.
use antidiarrheal medications regularly. - ANSWER obtain frequent rest periods.
Explanation:
It is important for the client to have frequent rest periods. Repeated episodes of diarrhea
interrupt sleep patterns, and poor nutrition may also cause the client to feel weak. If the client
is experiencing a severe exacerbation of ulcerative colitis, bed rest may be prescribed.
Antidiarrheal medications can be used selectively in ulcerative colitis but are not recommended
for regular use as they can lead to colonic dilation.
The client should maintain a low-residue, high-calorie, caffeine-free diet.
It is not necessary to limit weight lifting.
A nurse completes an afternoon assessment of a client who is a nurse and who is visiting the
area on vacation. The client states that the nurse must be having a busy shift and asks about the
maximum number of clients that the nurse is allowed to care for. What is the nurse's best
response? - ANSWER "Some jurisdictions have staffing laws which allow for nurses to be
involved in staffing ratios."
Explanation:
Staffing laws exist in some jurisdiction, but not others. Staffing laws tend to fall into one of three
general approaches: The first is to require hospitals to have a nurse driven staffing committee
which create staffing plans that reflect the needs of the patient population and match the skills
