PASS POINT NCLEX EXAM 2025
QUESTIONS AND ANSWERS
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? - ANS 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 - ANS 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: - ANS 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.
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,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? -
ANS 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? -
ANS 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. - ANS 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? - ANS 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
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, 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? - ANS 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? - ANS Ask the client if they have trouble breathing;
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.
A charge nurse is making client care assignments for the day. Which client would be most
appropriate to assign a licensed practical nurse (LPN)? - ANS 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? - ANS 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
Copyright ©2025 BRIGHTSTARS ALL RIGHTS RESERVED 3
QUESTIONS AND ANSWERS
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? - ANS 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 - ANS 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: - ANS 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.
Copyright ©2025 BRIGHTSTARS ALL RIGHTS RESERVED 1
,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? -
ANS 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? -
ANS 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. - ANS 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? - ANS 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
Copyright ©2025 BRIGHTSTARS ALL RIGHTS RESERVED 2
, 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? - ANS 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? - ANS Ask the client if they have trouble breathing;
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.
A charge nurse is making client care assignments for the day. Which client would be most
appropriate to assign a licensed practical nurse (LPN)? - ANS 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? - ANS 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
Copyright ©2025 BRIGHTSTARS ALL RIGHTS RESERVED 3
