Passpoint NCLEX Actual Exam Questions 100% Correct Answers Verified 2024 Version
6 views 0 purchase
Course
Academic Avengers Verified Papers
Institution
Academic Avengers Verified Papers
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 con...
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
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)? - ✔✔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 benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller hov. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $8.49. You're not tied to anything after your purchase.
