NCLEX PassPoint Exam 1 | Actual Exam
Questions | 100% Correct Answers |
Verified 2024 Version
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:
Questions | 100% Correct Answers |
Verified 2024 Version
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:
