NCLEX-RN Passpoint - Basic Care and
Comfort, Pharmacological and Parenteral
Therapies, Reduction of Risk Potential,
Physiological Adaptation STUDY GUIDE
After teaching the multiparous mother about hemolytic disease of the newborn and Rh sensitization, the
nurse determines that the client understands why she was not sensitized during her other pregnancy
when she makes which statement? - ✔✔Antibodies are not usually formed until after exposure to an
antigen.
Twenty-four hours after giving birth to a term neonate, a primipara receives acetaminophen with
codeine for perineal pain. One hour after administering the medication, which finding should alert the
nurse to the development of a possible side effect? - ✔✔dizziness
A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with
this client? - ✔✔by supplying a magic slate or similar device
A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue,
the nurse should tell the client to - ✔✔rest in an air-conditioned room. Fatigue is a common symptom in
clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve
fatigue; however, extreme cold should be avoided.
A nurse is preparing for the discharge of a neonate born 7 weeks premature. The neonate has had
several apneic episodes and will need a home apnea monitor but will require no other specialized care.
Which nursing diagnosis is most appropriate for the neonate's parents? - ✔✔Deficient knowledge
related to lack of exposure to apnea monitor.
A client with lung cancer has developed an intractable, nonproductive cough that is unrelieved by
nonopioid antitussive agents. The physician orders codeine, 10 mg P.O. every 4 hours. Which statement
accurately describes codeine? - ✔✔It's a centrally-acting antitussive and can cause dependence.
The nurse is reviewing the chart information for a client with increased ascites. The data include the
following: temperature 98.9°F (37.2°C), heart rate 118 bpm, shallow respirations 26 breaths/min, blood
, pressure 128/76 mm Hg, and SpO2 89% on room air. What should the nurse do first? - ✔✔Raise the
head of the bed
A client with suspected gastric cancer undergoes an endoscopy of the stomach. Which assessment made
after the procedure would indicate the development of a potential complication? - ✔✔The client
experiences a sudden increase in temperature
What actions should the nurse take for a 4-year-old girl who has just had a lumbar puncture? -
✔✔Encourage the parents to hold the child.
A client takes prednisone for an acute exacerbation of rheumatoid arthritis. The nurse determines the
client understands how to take the prednisone when the client says: - ✔✔"It is best if I take this
medication with some food.
A client with diabetes mellitus develops sinusitis and otitis media accompanied by a temperature of
100.8° F (38.2° C). What should the nurse anticipate in this client's plan of care? - ✔✔An increased need
for insulin and blood glucose monitoring
Which assessment finding puts a client at increased risk for epistaxis? - ✔✔cocaine use; Using nasally
inhaled illicit drugs, such as cocaine, increases the risk of epistaxis (nosebleed) because of the increased
vascularity of the nasal passages.
A client with depression states, "I'm still feeling nauseous after I take venlafaxine. Maybe I need
something else." What should the nurse should tell the client to do? - ✔✔Take the medication at
mealtime;
Nausea is a common adverse effect of venlafaxine; it should be taken at mealtime to minimize
gastrointestinal discomfort.Venlafaxine, unless prescribed in the extended release form, is given in
divided doses throughout the day. The amount should not be taken in one dose because of the drug's 3-
to 7-hour half-life in adults. The dosage should not be halved unless warranted by the client's
psychological condition.
When a client returns from a magnetic resonance imaging (MRI) exam with contrast, which action is
appropriate? - ✔✔administering fluids to the client
Comfort, Pharmacological and Parenteral
Therapies, Reduction of Risk Potential,
Physiological Adaptation STUDY GUIDE
After teaching the multiparous mother about hemolytic disease of the newborn and Rh sensitization, the
nurse determines that the client understands why she was not sensitized during her other pregnancy
when she makes which statement? - ✔✔Antibodies are not usually formed until after exposure to an
antigen.
Twenty-four hours after giving birth to a term neonate, a primipara receives acetaminophen with
codeine for perineal pain. One hour after administering the medication, which finding should alert the
nurse to the development of a possible side effect? - ✔✔dizziness
A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with
this client? - ✔✔by supplying a magic slate or similar device
A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue,
the nurse should tell the client to - ✔✔rest in an air-conditioned room. Fatigue is a common symptom in
clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve
fatigue; however, extreme cold should be avoided.
A nurse is preparing for the discharge of a neonate born 7 weeks premature. The neonate has had
several apneic episodes and will need a home apnea monitor but will require no other specialized care.
Which nursing diagnosis is most appropriate for the neonate's parents? - ✔✔Deficient knowledge
related to lack of exposure to apnea monitor.
A client with lung cancer has developed an intractable, nonproductive cough that is unrelieved by
nonopioid antitussive agents. The physician orders codeine, 10 mg P.O. every 4 hours. Which statement
accurately describes codeine? - ✔✔It's a centrally-acting antitussive and can cause dependence.
The nurse is reviewing the chart information for a client with increased ascites. The data include the
following: temperature 98.9°F (37.2°C), heart rate 118 bpm, shallow respirations 26 breaths/min, blood
, pressure 128/76 mm Hg, and SpO2 89% on room air. What should the nurse do first? - ✔✔Raise the
head of the bed
A client with suspected gastric cancer undergoes an endoscopy of the stomach. Which assessment made
after the procedure would indicate the development of a potential complication? - ✔✔The client
experiences a sudden increase in temperature
What actions should the nurse take for a 4-year-old girl who has just had a lumbar puncture? -
✔✔Encourage the parents to hold the child.
A client takes prednisone for an acute exacerbation of rheumatoid arthritis. The nurse determines the
client understands how to take the prednisone when the client says: - ✔✔"It is best if I take this
medication with some food.
A client with diabetes mellitus develops sinusitis and otitis media accompanied by a temperature of
100.8° F (38.2° C). What should the nurse anticipate in this client's plan of care? - ✔✔An increased need
for insulin and blood glucose monitoring
Which assessment finding puts a client at increased risk for epistaxis? - ✔✔cocaine use; Using nasally
inhaled illicit drugs, such as cocaine, increases the risk of epistaxis (nosebleed) because of the increased
vascularity of the nasal passages.
A client with depression states, "I'm still feeling nauseous after I take venlafaxine. Maybe I need
something else." What should the nurse should tell the client to do? - ✔✔Take the medication at
mealtime;
Nausea is a common adverse effect of venlafaxine; it should be taken at mealtime to minimize
gastrointestinal discomfort.Venlafaxine, unless prescribed in the extended release form, is given in
divided doses throughout the day. The amount should not be taken in one dose because of the drug's 3-
to 7-hour half-life in adults. The dosage should not be halved unless warranted by the client's
psychological condition.
When a client returns from a magnetic resonance imaging (MRI) exam with contrast, which action is
appropriate? - ✔✔administering fluids to the client
