NCLEX Challenge 2

a nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy via a nasal cannula. which of the following should the nurse include in the teaching ( select all of the following)

- check the cannula position on a regular basis - check the top of the ears for skin breakdown - post "no smoking" signs in a prominent location in the home

a nurse is preparing to provide tracheostomy care for a client who has a nondisposable tracheostomy tube. Which of the following equipment should the nurse plan to use

- clean gloves - sterile cotton- tipped applicators is correct - sterile base

a nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect?

- increased heart rate - increased blood pressure - increased respiratory rate

A nurse is providing discharge teaching for a client who requires home oxygen therapy. Which of the following statements should the nurse identify as an indication that the client needs further teaching

" I will wear synthetic clothing and woolen socks when using my oxygen"

a nurse is leading a group therapy session for clients who are newly diagnosed with cancer. Which of the following statements should the nurse take

" Let's discuss what you mean why you say that you cannot ever return to work"

a nurse is caring for a client who has hypertension and develops epistaxis. which of the following actions should the nurse take

- apply pressure to the nares - place ice to the bridge of the client's nose - move the client into high-fowler's position

a nurse is caring for a client who has metabolic alkalosis. For which of the following clinical manifestations should the nurse monitor?

- bicarbonate excess - Circumoral paresthesia

a nurse is teaching a client who has chronic kidney disease about limiting foods that are high in potassium. Which of the following foods should the nurse instruct the client to avoid ( select all that apply)

- tomatoes - bananas - raisins

a nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. which of the following solutions should the nurse prepare to infuse for this client

0.45% sodium chloride

a nurse is instructing a group of clients regarding calcium rich foods. which of the following foods should the nurse include in the teaching as the best source of calcium

1 cup milk

a nurse is preparing to suction a client who has a tracheostomy. Identify the sequence of actions the nurse should take ?

1. adjust the suction 2. don sterile gloves 3. check the function of the suction catheter 4. hyperoxygenate the client 5. insert the suction catheter without catheter 6. apply suction while rotating the catheter 7. assess for secretion clearance

a nurse is caring for a client who had IV fluids initiated at 0330. the IV fluids are infusing at 120ml/hr. The nurse should record how many mL of IV fluids on the intake record at 0600

300 mL

a nurse is caring for a client who is receiving oxygen therapy via a nasal cannula. the nurse explains to the client that this method of oxygen delivery does which of the following

delivers a low concentration of oxygen

a nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?

Cheyne-Stokes respirations

a nurse is reviewing the medical record of a client who has a potassium level of 3.0 mEq/L. which of the following findings should the nurse recognize as a potential causative factor

Client has a NG tube to gastric suction

a nurse is caring for a client who has the following arterial blood gas results: HCO3 18mEq, PaCO2 28 mm Hg and pH 7.30. The nurse recognizes the client is experiencing which of the following acid base imbalances?

Metabolic ACIDosis

a nurse is reviewing the laboratory values of a client who has respiratory acidosis. which of the following findings should the nurse expect

PaCO2 50 mm Hg

a client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take

Preoxygenate the client with 100% oxygen for up to 3 min

a client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? - pH 7.22 - PaCO2 68mm Hg - Base excess -2 - PaO2 78 mm Hg - Saturation 80% - Bicarbonate 26 mEq/L

Respiratory ACIDosis

a nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mmHg. The nurse should identify that the client is experiencing which of the following acid base imbalances

Respiratory acidosis

a nurse is reviewing the laboratory report of a client and identifies a serum potassium level of 6.8mEq/L. Which of the following medications should the nurse plan to administer

Sodium Polystyrene

a nurse is reviewing the medical records of four clients who have an acid-base imbalance. The nurse should recognized that which of the following clients is at risk for metabolic acidosis

a client who has diarrhea

a nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate 40/min.............

administer oxygen via face mask

a nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse prepare for first

airway patency

a nurse on a medical-surgical unit is preparing to contact a provider about a client's condition. The client is 6hr postoperative from a total hysterectomy. The nurse notes the client's postoperative oxygen saturation is 94% and her apical heart rate is 110.............

assessment

a nurse is providing dietary teaching for a client who takes furosemide. The nurse should recommend which of the following foods as the best source of potassium

bananas

a nurse is caring for a client who has a prescription for potassium chloride (KCL) 20 mEq PO daily. The nurse reviews the client's most recent lab results and finds the client's potassium level is 5.2 mEq/L. which of the following actions should the nurse take?

call the prescribing physician and inform her of the client's serum potassium level results

a nurse is assessing a client who has chronic respiratory insufficiency. which of the following findings should the nurse expect as result of the long term inadequate oxygenation

clubbing of the fingers

a nurse in the emergency department is caring for a client who collapsed after playing football on a hot day. after reviewing the admission laboratory findings, the nurse recognizes.....

dehydration

a nurse is reviewing a client's lab report of blood gas findings: HCO3- 18mEq/L and PaCO2 28mmHg. Which of the following pH values and conditions should the nurse expect when interpreting these findings ?

decreased pH and metabolic ACIDosis

a nurse is caring for a client who has preclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep tendon reflexes are absent. Which of the following actions should the nurse take?

discontinue the medication infusion

a nurse is caring for a client scheduled to receive external radiation to the neck for cancer of the larynx. During a pre-treatment exam, the nurse explains to the client that the most likely side effect would be

dysphagia

a nurse is assessing a child who is postoperative following a tonsillectomy. which of the following findings is a manifestation of hemorrhage

frequent swallowing

a nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. the nurse should anticipate that the client will report that her earliest manifestation was

hoarseness

a nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. Which of the following client statements indicates an understanding of the teaching ?

if i could lose about 50lbs, i might stop having so many apneic episodes

a nurse is assessing a client who has fluid volume deficit. The nurse should expect which of the following findings?

increased BUN

a nurse is teaching a client who needs to increase their daily fluid intake. which of the following foods has the highest percentage of water by weight

lettuce

a nurse is admitting a client who has influenza and is reporting numbness and tingling of the toes and fingers. The nurses should recognize the client is experiencing which of the following acid-base imbalances

metabolic ALKALOSIS

a nurse is assessing a client who has a sodium level of 116mEq/L. Which of the following findings should the nurse expect ?

nausea and vomiting

a nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. which of the following results should the nurse expect to see

pH below 7.35

a nurse is caring for a client with a tracheostomy. The client's partner has been taught to perform suctioning. which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge?

performing the procedure independently

a nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/mins and becomes irregular. Which of the following actions should the nurse take

preform pre-oxygenation prior to suctioning

A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first?

raise the head of the bed

a nurse is caring for a client who is postoperative and whose respirations are shallow and 9/min. which of the following acid-based imbalances should the nurse identify the client as being at risk for developing initially

respiratory ACIDosis

a nurse is planning the discharge of a client who has sleep apnea and requires bi-level positive airway pressure (BiPAP) at night. The nurse should plan to consult with which of the following health care team members to help educate the client?

respiratory therapist

a nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?

suction two or three times with a 60 sec pause between passes

a nurse is caring for four hospitalized clients. which of the following clients should the nurse identify as being at risk for fluid volume deficit

the client who has gastroenteritis and is febrile

a nurse is observing a client's nonverbal behavior. When evaluating this behavior, the nurse should factor in which of the following principles influencing nonverbal communication

the client's sociocultural background influences nonverbal communication

a nurse is caring for a client who had total thyroidectomy and a serum calcium level of 7.6mg/dL. Which of the following findings should the nurse expect?

tingling of the extremities

a nurse in the PACU is admitting a client who is postoperative following a tonsillectomy. which of the following actions should the nurse plan to take to prevent aspiration

withhold fluids until the client demonstrates a gag reflex