Nclex Passpoint Comprehensive Exam

Nclex Passpoint Comprehensive Exam 2024 Questions and Detailed Correct Answers with Rationale

The mother of an 8-year-old child with a fluid restriction of 1,000 mL/day is staying in the child's room. Which intervention would be most appropriate for the nurse to include in the child's plan of care?

Discuss the fluid restriction with the mother and child, and allow them to decide how to allocate the fluids over the 24 hours.

Explain to the mother that hospital personnel will assume the responsibility for providing fluids to the child.

Let the child eat jello if fluid limits have been met.

Tell the mother exactly how much fluid the child can have each hour, and show her examples of the amount. Correct Answer Planning the child's fluid restriction with the mother and child is most appropriate because the mother and child would best know the child's usual pattern of fluid intake. Doing so also provides the mother with a feeling of some control over her child's situation and helps to promote compliance.

A client is treated in the emergency department for acute muscle strain in the left leg caused by trying a new exercise. During discharge preparation, the nurse should provide which instruction?

"Apply ice packs for the first 12 to 18 hours." "Apply heat packs for the first 24 to 48 hours." "Apply ice packs for the first 24 to 48 hours, then apply heat packs." "Apply heat packs for the first 24 hours, then apply ice packs for the next 48 hours." Correct Answer The nurse should instruct the client to apply ice packs to the injured area for the first 24 to 48 hours to reduce swelling and then apply heat to increase comfort, promote reabsorption of blood and fluid, and speed healing. Applying ice for only 12 to 18 hours may not keep swelling from recurring. Applying heat for the first 24 to 48 hours would worsen, not ease, swelling. Applying ice 48 hours 1 / 4

after the injury would be less effective because swelling already has occurred by that time.

A nurse is providing in-home management instructions to the parents of a child who is receiving desmopressin acetate (DDAVP). What is the most important instruction the nurse to include?

Give DDAVP only when urine output begins to decrease Cleanse skin with alcohol before application of the DDAVP dermal patch Increase the DDAVP dose if polyuria occurs just before the next scheduled dose Call the healthcare provider if the child has an upper respiratory infection or allergic rhinitis Correct Answer Excessive nasal mucus, associated with upper respiratory infection or allergic rhinitis, may interfere with DDAVP absorption because it is given intranasally. Parents should be instructed to contact the health care provider for advice in altering the hormone dose during times when nasal mucus may be increased. The DDAVP dose should remain unchanged, even if the child is experiencing polyuria just before the next dose to avoid over medicating the child.

An outpatient client who has been receiving haloperidol for two days develops muscular rigidity, altered consciousness, a temperature of 103° F (39.4° C), and trouble breathing on day 3. The nurse interprets these findings as indicating which complication?

neuroleptic malignant syndrome tardive dyskinesia extrapyramidal adverse effects drug-induced parkinsonism Correct Answer The client is exhibiting hallmark signs and symptoms of life-threatening neuroleptic malignant syndrome induced by the haloperidol. Tardive dyskinesia usually occurs later in treatment, typically months to years later. Extrapyramidal adverse effects (dystonia, akathisia) and drug-induced parkinsonism, although common, are not life threatening.

The health care provider (HCP) has prescribed pseudoephedrine. The nurse should instruct the client about which possible adverse effect of this drug?

constipation bradycardia diplopia restlessness Correct Answer Adverse effects of pseudoephedrine are experienced primarily in the cardiovascular system and through sympathetic effects on the central nervous system (CNS). The most common CNS adverse effects include 2 / 4

restlessness, dizziness, tension, anxiety, insomnia, and weakness.Common cardiovascular adverse effects include tachycardia, hypertension, palpitations, and arrhythmias. Constipation and diplopia are not adverse effects of pseudoephedrine. Tachycardia, not bradycardia, is an adverse effect of pseudoephedrine.

Propylthiouracil (PTU) is prescribed for a client with Graves' disease.Which symptom should the nurse teach the client to report?

sore throat excessive menstruation constipation increased urine output Correct Answer The most serious adverse effects of PTU are leukopenia and agranulocytosis, which usually occur within the first 3 months of treatment. The client should be taught to promptly report to the health care provider (HCP) signs and symptoms of infection, such as a sore throat and fever. Clients having a sore throat and fever should have an immediate white blood cell count and differential performed, and the drug must be withheld until the results are obtained. Painful menstruation, constipation, and increased urine output are not associated with PTU therapy.

When communicating with a client who has aphasia, which approaches are helpful? Select all that apply.

Present one thought at a time.Avoid writing messages.Speak with normal volume.Make use of gestures.Encourage pointing to the needed object. Correct Answer The goal of communicating with a client with aphasia is to minimize frustration and exhaustion. The nurse should encourage the client to write messages or use alternative forms of communication to avoid frustration. Presenting one thought at a time decreases stimuli that may distract the client, as does speaking in a normal volume and tone. The nurse should ask the client to point to objects and encourage the use of gestures to assist in communicating.

The nurse is caring for a 3-month-old infant, who had a cleft palate and cleft lip surgical repair. Which assessment data would indicate a postoperative complication from the surgery?

intermittent crying Logan bar in place swollen suture line 3 / 4

suture line surrounded by erythema Correct Answer There is a risk for infection in the suture line if it is not kept clean and dry. Signs of infection would include erythema or foul drainage from the suture line and fever.Crying intermittently is a normal assessment finding and the nurse should be prepared with liquids or formula. A suture line may be swollen in the immediate postoperative period, but its appearance will improve with time. A Logan bar may be used to hold the suture line in place.

The client is discussing the client's medication history with the nurse.During the discussion, the client pulls out a list of the prescribed medications which include fish oil and St. John's Wort. Which is the nurse's understanding of why these alternative therapies are used by the client?

The client has a history of depression.The client has a history of coronary diseases.The client has a history of digestive issues.The client has a history of diabetes. Correct Answer The client has a history of depression. Fish oil and St. John's wort are alternative therapies to treat depression.

A client had a mastectomy followed by chemotherapy 6 months ago.She reports that she is now "unable to concentrate at her card game" and "it seems harder and harder to finish my errands because I am so tired." What should the nurse suggest that the client do to manage the exhaustion?

Take frequent naps. Limit activities. Increase fluid intake. Avoid contact with others. Correct Answer This client is likely experiencing fatigue and should increase her periods of rest. The fatigue may be caused by anemia from depletion of red blood cells due to the chemotherapy.Asking the client to limit her activities may cause the client to become withdrawn. The information given does not support limiting activity.Increasing fluid intake will not reduce the fatigue. The information does not indicate that the client is immunosuppressed and should avoid contact with others.

Which classification of drugs is the most potentially fatal if a client takes an overdose?

Antihistamines Dopaminergics Phenothiazine antipsychotics Tricyclic antidepressants Correct Answer Tricyclic antidepressants can create

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