Passpoint NCLEX Exams questions with correct answers
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Passpoint NCLEX
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Passpoint NCLEX
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/...
Passpoint NCLEX Exams questions with correct
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? - Answer 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 - Answer 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: - Answer 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? - Answer 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? - Answer 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. - Answer 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? - Answer 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? - Answer 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? - Answer 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)? - Answer 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
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