NCLEX PassPoint Exam 1

NCLEX PassPoint Exam 1 Leave the first rating Students also studied Terms in this set (70) Science MedicineNursing Save PassPoint practice exam 1 75 terms helorynah_hendrikus Preview RN Pharmacology Online Practice 2...60 terms arandy_Preview nur 111 - Davis - Left and Right Heart...30 terms matthew_jupp1 Preview Chronic 36 terms sara A client diagnosed with obsessive-compulsive disorder arrives late for an appointment with the nurse at the outpatient clinic. During the interview, he fidgets restlessly, has trouble remembering what topic is being discussed, and says he thinks he is going crazy. Which statement by the nurse best deals with the client's feelings of "going crazy?"

• "What do you mean when you say you think you're

going crazy?"

• "Most people feel that way occasionally."

-"I don't know you well enough to judge your mental state."

• "I haven't heard you make a crazy statement."

"What do you mean when you say you think you're going crazy?" When the client says he thinks he is "going crazy," it is best for the nurse to ask him what "crazy" means to him. The nurse must have a clear idea of what the client means by his words and actions. Using an open-ended question facilitates client description to help the nurse assess his meaning. The other statements minimize and dismiss the client's concern and do not give him the opportunity to openly discuss his feelings, possibly leading to increased anxiety.

A nurse administers cefazolin instead of ceftriaxone to an 8-year-old with pneumonia. The client has suffered no adverse effects. The nurse tells the charge nurse of the incident but fears disciplinary action from reporting the error. What should the charge nurse should tell the nurse?

• "If you do not report the error, I will have to."
• "Reporting the error helps to identify system problems

to improve client safety."

• "Notify the client's health care provider to see if she

wants this reported."

• "This is not a serious mistake, so reporting it will not

affect your position." "Reporting the error helps to identify system problems to improve client safety." Client safety is enhanced when the emphasis on medication errors is to determine the root cause. All errors should be reported so systems can identify patterns that contribute to errors. Here, the similar names probably contributed to the error.The nurse who commits the error knows all the relevant information and is in the best position to report it. While the health care provider (HCP) should be notified, it is a nursing responsibility to report errors, not a HCP's choice. Relating mistakes to a nurse's position focuses on personal blame.While making rounds, the nurse enters a client's room and finds the client on the floor between the bed and the

bathroom. The nurse should first:

-assist the client back to bed.-ask what the client was doing out of bed.-assess the client's current condition and vital signs.-activate the "Emergency Response" button.assess the client's current condition and vital signs.The nurse's first priority is to complete an assessment of the client including assessment of airway, breathing, circulation, and vital signs as well as any change in level of consciousness or obvious injury.The nurse should not move the client or assist the client back to bed until after an assessment has been completed to prevent further injury.While it may be helpful to know what the client was doing out of bed in order to assess for potential confusion, the client's immediate safety is first priority.The nurse would not activate the "Emergency Response" button until an initial assessment was done to determine the need.A client is receiving a bowel preparation of magnesium citrate the evening before a scheduled colonoscopy.Which factor should the nurse consider when providing care for this client?-Antidiarrheal medication should be given if the client has more than two loose stools.-Eating large meals should be encouraged to prevent weight loss.-The client may require fluid and electrolyte replacement.-Side rails should be raised at all times.The client may require fluid and electrolyte replacement.Bowel preparation, which usually involves laxatives and sometimes enemas, may cause severe fluid and electrolyte loss. The nurse should monitor the client for dehydration and electrolyte loss. Diarrhea is expected after bowel preparation and shouldn't be treated. Most clients eat a light meal the evening before the procedure or are ordered a clear liquid diet. Raising the side rails may increase the risk of fall for a client with frequent diarrhea.

A client with schizophrenia has been stable for some time. What action is most important for preventing relapse?-attending group therapy sessions -participating in family support meetings

• going to social skills training sessions
• taking prescribed medications consistently

taking prescribed medications consistently Although all of the choices are important for preventing relapse, compliance with the medication regimen is the priority in the treatment of schizophrenia.A client with a modified radical mastectomy is being discharged. The client has been very reluctant to discuss the surgery or her situation. The nurse making

assignments should delegate the client's care to the:

-unlicensed assistive personnel (UAP) because the client is stable and being discharged.-same nurse who has cared for her the past 3 days, for continuity of care.-nurse in orientation who needs experience in discharge instructions.-nurse with the most bed baths, because this client will not need a bath.same nurse who has cared for her the past 3 days, for continuity of care.Continuity of care is crucial for this client to feel more comfortable about asking questions and discussing her care at home.A UAP does not have the educational preparation (registered nursing license) to provide discharge instructions.It is not appropriate to assign this client to a nurse in orientation or one who needs assistance; the priority need is continuity of care.The nurse is assessing a neonate born to a mother with type 1 diabetes. Which finding is expected?-hypertonia -hyperactivity -large size -scaly skin large size Women with diabetes mellitus generally have neonates who are large but physically immature. Other common findings in these infants are hypoglycemia, hypocalcemia, hyperbilirubinemia, polycythemia, renal thrombosis, and congestive anomalies. The neonates do not exhibit hypertonia, hyperactivity, or scaly skin.The nurse is assessing a client who has a history of peripheral artery disease. The nurse observes that the left great toe is black. The nurse determines that the black color is caused by which factor?-atrophy -contraction -gangrene -rubor gangrene The term gangrene refers to blackened, decomposing tissue that is devoid of circulation. Chronic ischemia and death of the tissue can lead to gangrene in the affected extremity. Injury, edema, and decreased circulation lead to infection, gangrene, and tissue death. Atrophy is the shrinking of tissue, and contraction is joint stiffening secondary to disuse. The term rubor denotes a reddish color of the skin.A client is receiving epoetin alfa. Which findings indicate the effectiveness of the drug?-increase in white blood cells -decrease in blood glucose -increase in red blood cells -decrease in blood coagulation increase in red blood cells Epoetin alfa is a man-made form of the protein human erythropoietin used to lessen the need for red blood cell transfusions. It stimulates the bone marrow to produce more red blood cells. The drug is used to treat anemia caused by chronic kidney disease, chemotherapy, and zidovudine, which is a drug used to treat HIV infection. The drug does not affect white blood cells or coagulation, nor does it cause blood glucose to decrease.

A nurse is conducting a physical examination on a 2- month-old infant at the well-child examination. When measuring chest circumference, what is the standard anatomical landmark used?(Image Question) Around the nipple line Head circumference and chest size measurements are often taken on newborns and infants to measure growth levels and development. These growth milestones reveal healthy brain growth and development. Chest circumference is most accurately measured by placing the measuring tape around the infant's nipples.Measuring above or below the nipples will yield a false measurement. The measurement would be taken after exhalation.Which clinical signs would indicate to a nurse caring for a terminally ill client that death may be imminent?-diminished urine output and Cheyne-Stokes respirations -Narrow pulse pressure and a body temperature of

98.6°F (37°C)

-swallowing reflex and bowel sounds present -respirations regular at 18 breaths/min and weak pedal pulses diminished urine output and Cheyne-Stokes respirations A client diagnosed with idiopathic thrombocytopenia purpura needs a peripherally inserted central catheter (PICC) placed. When explaining the catheter to the client, the nurse explains that one advantage of a catheter is that it can be used

• to administer only blood products and I.V. fluids.
• in clients with infections in the blood.
• to provide long-term access to central veins.
• for 2 weeks without being replaced.

The nurse caring for a client on the cardiac unit notices that the client's cardiac monitor shows ventricular fibrillation. What is the priority action by the nurse?-administration of digoxin -insertion of an I.V. line -immediate defibrillation -scheduling a pacemaker insertion A nurse is providing health teaching on female sexuality and provides an illustration for education on the female anatomy. When discussing problems with sexual excitation, the nurse is correct to indicate which site as the area of sexual stimulation?(Image Question) Clitoris Sexual excitement causes various physiological changes in the female body. The area associated with sexual stimulation is located near the vaginal entrance and behind the labia minora. The clitoris is directly associated with engorgement and climax.