Passpoint Prioritization | Several hours into a shift, a nurse on a very busy medical-surgical unit privately asks the charge nurse to change her assignment. She is frustrated because she has had to devote so much time and energy to helping a newly licensed nurse provide discharge teaching for clients with diabetes mellitus.

Passpoint Prioritization Question 1 See full question

Several hours into a shift, a nurse on a very busy medical-surgical unit privately asks

the charge nurse to change her assignment. She is frustrated because she has had to

devote so much time and energy to helping a newly licensed nurse provide discharge

teaching for clients with diabetes mellitus. The charge nurse should:

Correct response:

 offer to assist with the discharge teaching needs.

Explanation:

Staff members need to know the charge nurse is a supportive leader who respects their

honesty and stands behind them. By offering to help with discharge teaching, the

charge nurse is actively engaging with her staff at a time of need. Changing all the

assignments on this extremely busy floor would be counterproductive. Insisting that the

staff member follow through with her assignment disrespects her request and genuine

need. Providing a float nurse could help, but there are no guarantees a float nurse is

available.

Remediation:

 Discharge

Question 2 See full question

During chemotherapy, an oncology client has a nursing diagnosis of Impaired oral

mucous membrane related to decreased nutrition and immunosuppression secondary

to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to

decrease the pain of stomatitis

Correct response:

 Providing a solution of viscous lidocaine for use as a mouth rinse

Explanation:

To decrease the pain of stomatitis, the nurse should provide a solution of hydrogen

viscous lidocaine for the client to use as a mouth rinse. (Commercially prepared

mouthwashes contain alcohol and may cause dryness and irritation of the oral mucosa.)

The nurse also may administer systemic analgesics as ordered. Stomatitis occurs 7 to

10 days after chemotherapy begins; thus, stopping chemotherapy wouldn't be helpful or

practical. Instead, the nurse should stay alert for this potential problem to ensure prompt

treatment. Monitoring platelet and leukocyte counts may help prevent bleeding and

infection but wouldn't decrease pain in this highly susceptible client. Checking for signs

and symptoms of stomatitis also wouldn't decrease the pain.

Remediation:

 Impaired Oral Membrane

Question 3 See full question

A nurse has been caring for an adolescent client in a residential facility. The child has

been through a series of foster placements since infancy with no success in any

placement until the age of 7 when placed with a middle-aged single woman. The client

thrived there until the woman was killed in a car accident. The client attempted suicide

after her foster mother died in response to the loss and the child was placed in the

residential facility. The nurse has become close to this client and wants to help her

address her issues and move on with her life. Which comment to the manager

demonstrates that the nurse understands the client’s issues and is able to respond

appropriately to the client’s needs?

You Selected:

 "It is difficult for her to love and trust again after her losses. In this facility, she

can learn to deal with her loss in a less emotionally charged environment than a

foster home."

Explanation:

The severe emotional trauma the girl has experienced will likely make it difficult for her

to be successful in an adoptive placement at the present time, whether that placement

is with someone she knows (the nurse) or another adoptive family. Additionally, adoption

by the nurse is inappropriate because it blurs the lines between her professional and

personal life and is likely to confuse the client. It is clear that the client has many issues

and that love alone is not likely to solve all her problems. Treatment at the residential

facility will allow her to work through emotional issues in a more therapeutic

environment. Though not currently ready for adoption, she may be ready for adoption in

the future after sufficient treatment.

Question 4 See full question

A client is about to undergo cardiac catheterization for which he signed an informed

consent. As the nurse enters the room to administer sedation for the procedure, the

client states, "I'm really worried about having this open heart surgery." Based on this

statement, how should the nurse proceed?

Correct response:

 Withhold the medication and notify the physician immediately.

Explanation:

The nurse should withhold the medication and notify the physician that the client does

not understand the procedure. The physician then has the obligation to explain the

procedure better to the client and determine whether or not the client understands. If the

client does not understand, he cannot give a true informed consent. If the medication is

administered before the physician explains the procedure, the sedation may interfere

with the client's ability to clearly understand the procedure. The nurse may not just

medicate the client and document the finding; the physician must be notified. The

procedure does not need to be cancelled, only postponed until the client receives more

education and is able to give informed consent.

Remediation:

 Decisional Conflict

Question 5 See full question

Which action associated with restraint use on a confused client can be delegated to an

unlicensed healthcare worker/nursing assistant?

 Completion of range of motion on limbs restrained

Question 1 See full question

Four clients have been admitted to the cardiac intensive care unit after experiencing

acute myocardial infarctions. Each client has sustained a percentage of cardiac

damage. Which client is most in need of interventions to prevent the development of

cardiogenic shock?

Correct response:

 The client with 40% damage

Explanation:

At least 40% of the heart muscle must be involved for cardiogenic shock to develop. In

most circumstances, the heart can compensate for up to 25% damage. An infarction

involving 70% of the heart would have likely already caused cardiogenic shock.

Question 2 See full question

The nurse is providing postoperative care to a client with sickle cell anemia. What is the

most important intervention for the nurse to include in the plan of care?

Correct response:

 Increasing fluids

Explanation:

The main surgical risk of anesthesia is hypoxia. Emotional stress, demands of wound

healing, and the potential for infection can each increase the sickling phenomenon.

Increased fluids are encouraged because hydration promotes hemodilution, and

decreases sickling. Preparing the child psychologically to decrease fear will minimize

undue emotional stress, but is not a priority. Deep coughing is encouraged to promote

pulmonary hygiene and prevent respiratory tract infection. Analgesics are used to

control wound pain and to prevent abdominal splinting and decreased ventilation.

Remediation:

A hospitalized client, with a productive cough, chills, and night sweats is suspected of

having active tuberculosis (TB). What is the nurse’s most important intervention?

You Selected:

 Maintain the client on respiratory isolation

Correct response:

 Maintain the client on respiratory isolation

Explanation:

This client is showing signs and symptoms of active TB and, because of the productive

cough, is highly contagious. He should be admitted to the hospital and placed in

respiratory isolation. Three sputum cultures should be obtained to confirm the

diagnosis.

Question 4 See full question

The nurse is caring for a client with type 1 diabetes mellitus. At 3:00 AM, the nurse finds

the client disoriented to time and place, diaphoretic, and complaining of palpitations.

What is the nurse’s priority intervention?

You Selected:

 Check blood glucose level

Correct response:

 Check blood glucose level

Explanation:

Check the blood glucose level first when symptoms arise, then proceed with treatment

according to the results. If the client is hypoglycemic, administration of a simple

carbohydrate is appropriate. If the client is conscious, the carbohydrate may be given

orally. If consciousness is altered, subcutaneous or intramuscular glucagon is

appropriate. This client is showing symptoms of hypoglycemia, additional insulin would

further lower the blood glucose.

Remediation:

 Diabetes Mellitus (Type 1), Long-Term Care

Question 5 See full question

A two-month-old infant arrives with a heart rate of 180 bpm and a temperature of 103.1°

F (39.5° C) rectally. What is the most appropriate initial nursing intervention?

You Selected:

 Give acetaminophen

Correct response:

 Give acetaminophen

Explanation:

Acetaminophen should be given to decrease the temperature. A heart rate of 180/bpm

is normal in an infant with a fever. A tepid sponge bath may be given to help decrease

the temperature and calm the infant. Carotid massage, and placing the infant’s hands in

cold water are attempts to decrease the heart rate through vagal maneuvers. This will

not work because the source of the increased heart rate is fever. Fluid intake is

encouraged after the acetaminophen is given to help replace insensible fluid losses.

Remediation:

 Acetaminophen

Question 6 See full question

A 19-month-old child with croup is crying as a nurse tries to auscultate breath sounds.

What is the nurse’s most appropriate intervention?

You Selected:

 Hand the stethoscope to the child to examine before auscultating his lungs

Correct response:

 Hand the stethoscope to the child to examine before auscultating his lungs

Explanation:

Children at this age are very curious. Encouraging the child to play with the stethoscope

will distract him and help gain trust so that the nurse will be able to auscultate the lungs.

Ignoring the child’s crying may only upset him more, and will not help the nurse gain his

trust. The nurse should ask the parents to help quiet and comfort the child. Asking the

parents to leave may only upset the child more. The nurse should speak to the child in a

soft, comforting tone of voice.

Question 7 See full question

A client in early labor tells the nurse that she has a thick, yellow discharge from both of

her breasts. What is the nurse’s most appropriate intervention?

You Selected:

 Inform the client that the discharge is colostrum, and a normal finding