PassPoint NCLEX Study Guide | Actual
Exam Questions | 100% Correct Answers
| Verified 2024 Version
After a lengthy labor, a primigravid client gives birth to a healthy newborn boy with a moderate amount
of skull molding. What information would the nurse include when explaining to the parents about this
condition?
a)It is typically seen with breech births.
b)It usually lasts a day or two before resolving.
c)It is unusual when the brow is the presenting part.
d)Surgical intervention may be necessary to alleviate pressure. - ✔✔b)it usually lasts a day or two before
resolving
Explanation: Molding occurs with vaginal births and is commonly seen in newborns. This is especially
true with primigravid clients experiencing a lengthy labor process. Parents need to be reassured that it is
not permanent and that it typically lasts a day or two before resolving. Molding rarely is present if the
fetus is in a breech or brow presentation. Surgical intervention is not necessary.
A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping,
abdominal pain, and weight loss. The nurse should review the client's laboratory reports to determine
which potential complication of the client's symptoms?
a)hyperalbuminemia
b)thrombocytopenia
c)hypokalemia
d)hypercalcemia - ✔✔c)hypokalemia
Explanation: Hypokalemia is the most expected laboratory finding owing to the diarrhea.
Hypoalbuminemia can also occur in Crohn's disease; however, the client's potassium level is of greater
importance at this time because a low potassium level can cause cardiac arrest. Anemia is an expected
development, but thrombocytopenia is not. Calcium levels are not affected.
,A client admitted in an acute psychotic state hears terrible voices in the head and thinks a neighbor is
upset with the client. What is the nurse's best response?
a)"What has your neighbor been doing that bothers you?"
b)"How long have you been hearing these terrible voices?"
c)"We won't let your neighbor visit, so you'll be safe."
d)"What exactly are these terrible voices saying to you?" - ✔✔d)"What exactly are these terrible voices
saying to you?"
Explanation: The nurse needs to collect additional information about the client's report about hearing
voices. Assessing the content of hallucinations is essential to determine whether they are command
hallucinations that the client might act on. Asking about what the neighbor has been doing or telling the
client that the neighbor will not visit indirectly reinforces the delusion about the neighbor. Although
determining the onset and duration of the voices is important, the nurse needs to assess the content of
the hallucinations first.
Following an education session on proper hand hygiene, the nurse educator observes a nurse washing
hands before entering a client's room. Which observation would alert the nurse educator to the need for
further education?
a)The nurse dries from finger tips down toward elbows.
b)The nurse dries from forearms up toward fingers.
c)The nurse keeps hands lower than elbows while washing.
d)The nurse uses at least 3 to 5 mL of liquid soap. - ✔✔b)The nurse dries from forearms up toward
fingers.
Explanation: Hand hygiene procedures involve drying from the fingers toward the forearm and discarding
the paper towel. The other options should be included in hand hygiene practices.
Which fetal presentation is most favorable for birth?
,a)vertex presentation
b)transverse lie
c)frank breech presentation
d)posterior position of the fetal head - ✔✔a)vertex presentation
Explanation: Vertex presentation (flexion of the fetal head) is the optimal presentation for passage
through the birth canal. Transverse lie presentation (when the neonate is in a horizontal position across
the birth canal) requires a cesarean birth. Frank breech presentation, in which the buttocks present first,
can make for a difficult vaginal delivery. Posterior positioning of the fetal head can make it difficult for
the fetal head to pass under the maternal symphysis pubis bone.
A client enters the crisis unit complaining of increased stress from studies as a medical student. The
client reports increasing anxiety for the past month. The physician orders alprazolam, 0.25 mg by mouth
three times per day, along with professional counseling. Before administering alprazolam, the nurse
reviews the client's medication history. Which drug can produce additive effects when taken
concomitantly with alprazolam?
a)levodopa
b)famotidine
c)diphenhydramine
d)norgestrel - ✔✔c)diphenhydramine
Explanation: Using benzodiazepines with other central nervous system depressants such as
diphenhydramine produces additive effects. Alprazolam doesn't cause clinically significant drug
interactions with levodopa, famotidine, or hormonal contraceptives such as norgestrel.
A 10-week pregnant client tells the nurse she is worried about the fatigue that is causing difficulty with
functioning at work. How can the nurse best instruct this client about the relief of fatigue?
a)Explain that fatigue will improve during the second trimester.
b)Instruct the client to take at least two rest breaks during the workday.
c)Instruct the client to get at least 9 hours of sleep each night.
, d)Instruct the client to modify work hours during the first trimester. - ✔✔b)Instruct the client to take at
least two rest breaks during the workday.
Explanation: Fatigue and frequent urination are early signs and symptoms of pregnancy that may
continue through the first trimester. For the working pregnant client, it is advisable to take two 10- to 15-
minute breaks within an 8-hour workday. While at home the client should nap or rest if she feels sleepy
or tired. People need different amounts of sleep to help them feel rested. Telling the client to get 9 hours
is a good suggestion, but it isn't helpful or practical if the client needs normally needs significantly more
or less than that. In general, 7-8 hours is adequate. Modifying work hours can be suggested, but many
times this is not something within the client's control. Fatigue will most likely improve during the second
trimester, but that does not address the client's immediate concerns.
Which statement about a fetal biophysical profile would be incorporated into the teaching plan for a
primigravid client with insulin-dependent diabetes?
a)It determines fetal lung maturity.
b)It is noninvasive using real-time ultrasound.
c)It will correlate with the newborn's Apgar score.
d)It requires the client to have an empty bladder. - ✔✔b)It is noninvasive using real-time ultrasound.
Explanation: The fetal biophysical profile, a noninvasive test using real-time ultrasound, assesses five
parameters: fetal heart rate reactivity, fetal breathing movements, gross fetal body movements, fetal
tone, and amniotic fluid volume. Fetal heart rate reactivity is determined by a nonstress test; the other
four parameters are determined by ultrasound scanning. The results are available as soon as the test is
completed and interpreted. The lecithin-sphingomyelin ratio is used to determine fetal lung maturity.
Although the fetal biophysical profile is useful in predicting which fetuses may be at greater risk for
compromise, there is no correlation with the newborn's Apgar score. The biophysical score is sometimes
referred to as the fetal Apgar score. A score of 8 to 10 indicates fetal well-being. Use of an ultrasound
requires the mother to have a full bladder.
Which action should the nurse do first when noting clear drainage on the child's dressing and bed linen
after a craniotomy for a brain tumor?
a)Change the dressing.
b)Elevate the head of the bed.
Exam Questions | 100% Correct Answers
| Verified 2024 Version
After a lengthy labor, a primigravid client gives birth to a healthy newborn boy with a moderate amount
of skull molding. What information would the nurse include when explaining to the parents about this
condition?
a)It is typically seen with breech births.
b)It usually lasts a day or two before resolving.
c)It is unusual when the brow is the presenting part.
d)Surgical intervention may be necessary to alleviate pressure. - ✔✔b)it usually lasts a day or two before
resolving
Explanation: Molding occurs with vaginal births and is commonly seen in newborns. This is especially
true with primigravid clients experiencing a lengthy labor process. Parents need to be reassured that it is
not permanent and that it typically lasts a day or two before resolving. Molding rarely is present if the
fetus is in a breech or brow presentation. Surgical intervention is not necessary.
A client who has a history of Crohn's disease is admitted to the hospital with fever, diarrhea, cramping,
abdominal pain, and weight loss. The nurse should review the client's laboratory reports to determine
which potential complication of the client's symptoms?
a)hyperalbuminemia
b)thrombocytopenia
c)hypokalemia
d)hypercalcemia - ✔✔c)hypokalemia
Explanation: Hypokalemia is the most expected laboratory finding owing to the diarrhea.
Hypoalbuminemia can also occur in Crohn's disease; however, the client's potassium level is of greater
importance at this time because a low potassium level can cause cardiac arrest. Anemia is an expected
development, but thrombocytopenia is not. Calcium levels are not affected.
,A client admitted in an acute psychotic state hears terrible voices in the head and thinks a neighbor is
upset with the client. What is the nurse's best response?
a)"What has your neighbor been doing that bothers you?"
b)"How long have you been hearing these terrible voices?"
c)"We won't let your neighbor visit, so you'll be safe."
d)"What exactly are these terrible voices saying to you?" - ✔✔d)"What exactly are these terrible voices
saying to you?"
Explanation: The nurse needs to collect additional information about the client's report about hearing
voices. Assessing the content of hallucinations is essential to determine whether they are command
hallucinations that the client might act on. Asking about what the neighbor has been doing or telling the
client that the neighbor will not visit indirectly reinforces the delusion about the neighbor. Although
determining the onset and duration of the voices is important, the nurse needs to assess the content of
the hallucinations first.
Following an education session on proper hand hygiene, the nurse educator observes a nurse washing
hands before entering a client's room. Which observation would alert the nurse educator to the need for
further education?
a)The nurse dries from finger tips down toward elbows.
b)The nurse dries from forearms up toward fingers.
c)The nurse keeps hands lower than elbows while washing.
d)The nurse uses at least 3 to 5 mL of liquid soap. - ✔✔b)The nurse dries from forearms up toward
fingers.
Explanation: Hand hygiene procedures involve drying from the fingers toward the forearm and discarding
the paper towel. The other options should be included in hand hygiene practices.
Which fetal presentation is most favorable for birth?
,a)vertex presentation
b)transverse lie
c)frank breech presentation
d)posterior position of the fetal head - ✔✔a)vertex presentation
Explanation: Vertex presentation (flexion of the fetal head) is the optimal presentation for passage
through the birth canal. Transverse lie presentation (when the neonate is in a horizontal position across
the birth canal) requires a cesarean birth. Frank breech presentation, in which the buttocks present first,
can make for a difficult vaginal delivery. Posterior positioning of the fetal head can make it difficult for
the fetal head to pass under the maternal symphysis pubis bone.
A client enters the crisis unit complaining of increased stress from studies as a medical student. The
client reports increasing anxiety for the past month. The physician orders alprazolam, 0.25 mg by mouth
three times per day, along with professional counseling. Before administering alprazolam, the nurse
reviews the client's medication history. Which drug can produce additive effects when taken
concomitantly with alprazolam?
a)levodopa
b)famotidine
c)diphenhydramine
d)norgestrel - ✔✔c)diphenhydramine
Explanation: Using benzodiazepines with other central nervous system depressants such as
diphenhydramine produces additive effects. Alprazolam doesn't cause clinically significant drug
interactions with levodopa, famotidine, or hormonal contraceptives such as norgestrel.
A 10-week pregnant client tells the nurse she is worried about the fatigue that is causing difficulty with
functioning at work. How can the nurse best instruct this client about the relief of fatigue?
a)Explain that fatigue will improve during the second trimester.
b)Instruct the client to take at least two rest breaks during the workday.
c)Instruct the client to get at least 9 hours of sleep each night.
, d)Instruct the client to modify work hours during the first trimester. - ✔✔b)Instruct the client to take at
least two rest breaks during the workday.
Explanation: Fatigue and frequent urination are early signs and symptoms of pregnancy that may
continue through the first trimester. For the working pregnant client, it is advisable to take two 10- to 15-
minute breaks within an 8-hour workday. While at home the client should nap or rest if she feels sleepy
or tired. People need different amounts of sleep to help them feel rested. Telling the client to get 9 hours
is a good suggestion, but it isn't helpful or practical if the client needs normally needs significantly more
or less than that. In general, 7-8 hours is adequate. Modifying work hours can be suggested, but many
times this is not something within the client's control. Fatigue will most likely improve during the second
trimester, but that does not address the client's immediate concerns.
Which statement about a fetal biophysical profile would be incorporated into the teaching plan for a
primigravid client with insulin-dependent diabetes?
a)It determines fetal lung maturity.
b)It is noninvasive using real-time ultrasound.
c)It will correlate with the newborn's Apgar score.
d)It requires the client to have an empty bladder. - ✔✔b)It is noninvasive using real-time ultrasound.
Explanation: The fetal biophysical profile, a noninvasive test using real-time ultrasound, assesses five
parameters: fetal heart rate reactivity, fetal breathing movements, gross fetal body movements, fetal
tone, and amniotic fluid volume. Fetal heart rate reactivity is determined by a nonstress test; the other
four parameters are determined by ultrasound scanning. The results are available as soon as the test is
completed and interpreted. The lecithin-sphingomyelin ratio is used to determine fetal lung maturity.
Although the fetal biophysical profile is useful in predicting which fetuses may be at greater risk for
compromise, there is no correlation with the newborn's Apgar score. The biophysical score is sometimes
referred to as the fetal Apgar score. A score of 8 to 10 indicates fetal well-being. Use of an ultrasound
requires the mother to have a full bladder.
Which action should the nurse do first when noting clear drainage on the child's dressing and bed linen
after a craniotomy for a brain tumor?
a)Change the dressing.
b)Elevate the head of the bed.
