passpoint review nclex 2022
Question 1 See full question
What is the nurse’s most important intervention for a client having a tonic-clonic seizure?
You Selected:
• Protect the client from further injury
Correct response:
• Protect the client from further injury
Explanation:
The p...
passpoint review nclex 2022 question 1 see full question what is the nurse’s most important intervention for a client having a tonic clonic seizure you selected • protect the client from further i
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passpoint review nclex 2022
Question 1 See full question
What is the nurse’s most important intervention for a client having a tonic-clonic seizure?
You 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
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