passpoint review nclex
Question 1 See full question
What is the nurse’s most important intervention for a client having a tonic-clonic seizure?
You
... [Show More] Selected:
Protect the client from further injury
Correct response:
Protect the client from further injury
Explanation:
The priority during and after a seizure is to protect the person from injury by keeping them from falling
to the floor. Furniture or other objects that be a source of injury during the seizure should be moved out
of the client’s way. Timing the seizure, and noting the origin of the seizure are important, but are not the
priority. Nothing should be placed in the client’s mouth during a seizure because teeth may be dislodged
or the tongue pushed back, further obstructing the airway.
Remediation:
Seizure management
Question 2 See full question
The nurse is caring for a neonate weighing 4,536 g (10 lb) who was born via cesarean section 1 hour ago
to a mother with insulin-dependent diabetes. She asks the nurse, “Why is my baby in the neonatal
intensive care unit?” The nurse bases a response on the understanding that neonates of mothers with
diabetes commonly develop which condition?
You Selected:
hypoglycemia
Correct response:
hypoglycemia
Explanation:
Hypoglycemia is caused by the rapid depletion of glucose stores. In addition, neonates born to class
women with insulin dependent diabetes are about seven times more likely to suffer from respiratory
distress syndrome than neonates born to nondiabetic women. This neonate should be closely monitored
for symptoms of hypoglycemia and respiratory distress. Neonates of diabetic mothers commonly have
polycythemia, not anemia. Anemia and hemolytic disease are associated with erythroblastosis fetalis.
Persistent pulmonary hypertension is associated with meconium aspiration syndrome.
Remediation:
Glucose management, neonatal
Question 3 See full question
After knee replacement surgery, a client is being discharged with acetaminophen with codeine 30 mg
tablets for pain. During discharge preparation, the nurse should include which instruction?
You Selected:
"Avoid driving a car while taking this medication."
Correct response:
"Avoid driving a car while taking this medication."
Explanation:
Clients taking codeine should avoid driving because the medication can impair mental alertness. Fluid
restriction isn't indicated, especially after surgery. To prevent adverse GI effects such as nausea,
vomiting, anorexia, and constipation, the client shouldn't take codeine on an empty stomach. Codeine
may cause dizziness, drowsiness, and seizures but doesn't cause fine motor tremors.
Remediation:
Codeine phosphate–acetaminophen
Question 4 See full question
The nurse manager has noticed a sharp increase in medication errors associated with IV antibiotic
administration over the past 2 months. The nurse manager should discuss the situation with each nurse
involved and then:
You Selected:
ask them to attend in-service training for administration of IV medications.
Correct response:
ask them to attend in-service training for administration of IV medications.
Explanation:
Identification of causes of medication errors requires in-service education to inform the staff of
strategies to decrease these errors. Errors are frequently the result of systemic problems that can be
identified and rectified through problem-solving techniques and changes in procedures.
Documenting or reporting the situation would not directly assist the nurses in eliminating errors.
Reporting the incidents to the hospital attorney is unnecessary.
Remediation:
Safe medication administration practices
Question 5 See full question
Clients receiving a monoamine oxidase inhibitor must avoid tyramine, a compound found in which
foods?
You Selected:
Aged cheese and Chianti wine
Correct response:
Aged cheese and Chianti wine
Explanation:
Aged cheese and Chianti wine contain high concentrations of tyramine. Green, leafy or yellow
vegetables, figs, cream cheese, and fruit are low in tyramine.
Remediation:
Tranylcypromine
Question 6 See full question
A client with a diagnosis of schizophrenia and who is paranoid asks the nurse, "How do I know what is
really in those pills?" The best response is to:
You Selected:
allow the client to open the individual medication wrappers.
Correct response:
allow the client to open the individual medication wrappers.
Explanation:
Allowing a paranoid client to open his medication can help reduce his suspiciousness. Telling the client
that he should know the pills are his medicine is incorrect because the client doesn't know this
information for sure; he's obviously suspicious that it isn't. Telling the client not to worry or ignoring his
comment isn't supportive and doesn't reassure him.
Remediation:
Oral drug administration, psychiatric patient
Question 7 See full question
When instilling erythromycin ointment into the eyes of a neonate 1 hour old, the nurse would explain to
the parents that the medication is used to prevent which problem?
You Selected:
cataracts from beta-hemolytic streptococcus
Correct response:
blindness secondary to gonorrhea
Explanation:
The instillation of erythromycin into the neonate’s eyes provides prophylaxis for ophthalmia
neonatorum, or neonatal blindness caused by gonorrhea in the mother. Erythromycin is also effective in
the prevention of infection and conjunctivitis from Chlamydia trachomatis. The medication may result in
redness of the neonate’s eyes, but this redness will eventually disappear. Erythromycin ointment is not
effective in treating neonatal chorioretinitis from cytomegalovirus. No effective treatment is available for
a mother with cytomegalovirus. Erythromycin ointment is not effective in preventing cataracts.
Additionally, neonatal infection with beta-hemolytic streptococcus results in pneumonia, bacterial
meningitis, or death. Cataracts in the neonate may be congenital or may result from maternal exposure
to rubella. Erythromycin ointment is also not effective for preventing and treating strabismus (crossed
eyes). Infants may exhibit intermittent strabismus until 6 months of age.
Remediation:
Neonatal eye prophylaxis
Question 8 See full question
For the client who has difficulty falling asleep at night because of withdrawal symptoms from alcohol,
which are abating, which nursing intervention is likely to be most effective?
You Selected:
teaching the client relaxation exercises to use before bedtime
Correct response:
teaching the client relaxation exercises to use before bedtime
Explanation:
The best action by the nurse to help a client who has difficulty falling asleep would be to teach the client
relaxation exercises to use before bedtime to reduce anxiety and promote relaxation. This activity will
also be useful for the client when out of the hospital. Inviting the client to play a board game is
inappropriate because this activity can be competitive and thus stimulate the client. Allowing the client
to sit in the community room until she feels sleepy is inappropriate because it does nothing to help the
client relax. Taking frequent naps can worsen the ability to fall asleep at night.
Remediation:
Relaxation and stress management techniques
Alcoholism
Question 9 See full question
An 18-year-old is highly dependent on her parents and fears leaving home to attend college. Shortly
before the fall semester starts, she complains that her legs are paralyzed and is rushed to the emergency
department. When physical examination rules out a physical cause for her paralysis, the physician admits
the woman to the psychiatric unit, where she is diagnosed with functional neurologic symptom disorder.
She asks the nurse, "Why has this happened to me?" What is the nurse's best response?
You Selected:
"Your problem is real but, there is no physical basis for it. We'll work on what is going on in your
life to find out why it's happened."
Correct response:
"Your problem is real but, there is no physical basis for it. We'll work on what is going on in your
life to find out why it's happened."
Explanation:
The nurse must be honest by telling the client that her paralysis has no physiologic cause while also
conveying empathy and acknowledging that her symptoms are real. The client will benefit from
psychiatric treatment, which will help her understand the underlying cause of her symptoms. After her
psychological conflict is resolved, her symptoms will disappear. Telling the client that being unable to
move her legs must be awful wouldn't answer the client's question; knowing that the cause is
psychological rather than physical wouldn't necessarily make her feel better. Telling the client that she
has developed paralysis to avoid leaving her parents or that her personality caused her disorder wouldn't
help her understand and resolve the underlying conflict.
Remediation:
Conversion disorder patient care
Psychiatric nursing assessment
Question 10 See full question
A client periodically has acute panic attacks. These attacks are unpredictable and have no apparent
association with a specific object or situation. During an acute panic attack, the client may experience:
You Selected:
a decreased perceptual field.
Correct response:
a decreased perceptual field.
Explanation:
Panic is the most severe level of anxiety. During a panic attack, a client's perceptual field, narrows. He
becomes more focused on himself, less aware of surroundings, and unable to process information from
his environment. His decreased perceptual field impairs his attention and ability to concentrate. During
an acute panic attack, the client may experience an increase, not a decrease, in heart and respiratory
rates, resulting from stimulation of the sympathetic nervous system.
Remediation:
Panic disorder
Question 11 See full question
A nurse obtained a client’s fasting blood sugar (FBS) at 0700, which was 144 mg/dL (8 mmol/L). The
client has an order for regular insulin 8 units every morning. What should the nurse do next?
You Selected:
Administer the insulin as ordered.
Correct response:
Administer the insulin as ordered.
Explanation:
The nurse should know that a normal fasting blood sugar is between 72 and 108 mg/dL (4 and 6
mmol/L). The result of 144 mg/dL indicates that the client requires insulin to lower the blood glucose
level. The other options are incorrect because they do not reflect the nurse's understanding of diabetes
and its treatment.
Remediation:
Blood glucose monitoring
Insulins (short-acting)
Hormonal Control of Blood Glucose
Question 12 See full question
A nurse is providing discharge teaching to a client who is immunosuppressed. Which statement by the
client indicates the need for additional teaching?
You Selected:
"I can eat whatever I want as long as it's low in fat."
Correct response:
"I can eat whatever I want as long as it's low in fat."
Explanation:
The client requires additional teaching if he states that he can eat whatever he wants.
Immunosuppressed clients should avoid raw fruit and vegetables because they may contain bacteria that
could increase the risk of infection; foods must be thoroughly cooked. Avoiding people who are sick,
products containing alcohol, and people who have just received vaccines are appropriate actions for an
immunosuppressed client.
Remediation:
Neutropenia
Question 13 See full question
The client with acute renal failure is recovering and asks the nurse, "Will my kidneys ever function
normally again?" The nurse's response is based on knowledge that the client's renal status will most
likely:
You Selected:
continue to improve over a period of weeks.
Correct response:
continue to improve over a period of weeks.
Explanation:
The kidneys have a remarkable ability to recover from serious insult. Recovery may take 3 to 12 months.
The client should be taught how to recognize the signs and symptoms of decreasing renal function and
to notify the health care provider (HCP) if such problems occur. In a client who is recovering from acute
renal failure, there is no need for renal transplantation or permanent hemodialysis. Chronic renal failure
develops before end-stage renal failure.
Remediation:
Renal failure, acute
Urinary: Renal Function
Question 14 See full question
Which is the most important initial postprocedure nursing assessment for a client who has had a cardiac
catheterization? [Show Less]