NCLEX Challenge 3
nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. which statement indicates an understanding of the teaching?
"if i could lose 50 lbs, i might stop having so many apneic episodes" laying flat on back increases apnea and sleeping pills (hypnotics) aggravate it and can also cause increased daytime somnolence
a nurse is instructing a group of clients regarding calcium rich foods. which food should the nurse include as the best source of calcium?
1 cup of milk although ice cream, swiss cheese, and cottage cheese all contain calcium, milk contains the most
nurse is preparing to suction a client who has a tracheostomy. what is 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 catheter without suction. 6. Apply suction while rotating the catheter. 7. Assess for secretion clearance.
300 mg by intermittent IV bolus over 30 min to a client with a staph infection. available is 50 mL premixed in 0.90% sodium chloride. IV pump should be set to deliver how many mL/hr?
100 mL/hr mL/hr= 50mL/30min x 60min/hr (in this case I guess 300mg = 50mL?)
nurse is calculating intake of a client during past 9 hours. client's intake includes LR IV at 150mL/hr, cefazolin 2g/100mL, two units of packed RBCs of 275mL and 250mL, two IV bolus infusions of 250mL sodium chloride, ranitidine 50mg in 50 mL of dextrose 5%. how many mL of intake should nurse record?
2525
nurse is performing trach care for a pt and suctioning to remove copious secretions. which action should nurse take?
suction two to three times with a 60-second pause between passes Copious secretions may require several passes of the suction catheter. An interval of 60 seconds should be allowed between passes to prevent hypoxia.
nurse in PACU is admitting a pt who is post op 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 to prevent aspiration, gag reflex must be present before the client is allowed to have fluids. suctioning nasopharynx can cause trauma to denuded tonsil sockets leading to hemorrhage.
a nurse is providing discharge therapy for a client who requires home oxygen therapy. which statement 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" woolen and synthetic materials can generate static electricity and oxygen is a flammable gas. pt should wear cotton clothing and use cotton bedding and blankets - A decrease in the ability to concentrate could indicate that the client is not receiving enough oxygen. The device could be malfunctioning or the client's status might require a change in his oxygen prescription.
nurse preparing 40mEq in 500mL IV to infuse 10mEq/hr. nurse should set the IV pump to deliver how many mL/hr?
125
nurse is calculating pt intake and output for an 8-hr shift. the client's intake included 1000 mL 0.9% sodium chloride IV, one 6-0z cup of coffee, 6 oz water, one 180-mL bowl of soup, 3 oz of flavored gelatin, and 3 oz of ice cream. how many mL should the nurse document as the client's total intake for the shift?
1720 1oz=30mL
nurse is preparing to administer 0.9% sodium chloride 3000 mL IV to infuse over 24 hr. drop factor on manual IV tubing is 10 gtt/mL. nurse should set the manual IV infusion to deliver how many gtt/min?
21 (20.83) gtt/min = 10gtt/mL x 3000mL/24hr x 1hr/60min
nurse is caring for a client who develops an airway obstruction from a foreign body but remains conscious. which action should nurse take first?
administer abdominal thrust maneuver The nurse should immediately begin applying abdominal thrusts to a conscious client who has an airway obstruction and should continue until the obstruction is clear or the client loses consciousness.
nurse is caring for a female client in ED who reports SOB and pain in lung area. pt started taking BC pills 3 wks ago and she smokes. HR is 110/min, RR is 40/min, BP is 140/80. ABGs are pH 7.50, PaCO2 29, PaO2 60, HCO3 20, and SaO2 86%. which is the priority nursing intervention?
administer oxygen via face mask The pH reflects alkalosis, and the low PaCO2 indicates that the lungs are involved, so the client has respiratory alkalosis. The client's oxygen saturation is low, so one priority is to administer oxygen via mask attempting to achieve an oxygen saturation of at least 95%. The greatest risk to this client is hypoxia, thus the priority is to restore oxygenation.
nurse caring for pt who is in the immediate post op period following a partial laryngectomy. which of the following parameters should nurse assess first?
airway patency When using the airway, breathing, circulation approach to client care, the nurse determines that the priority assessment is airway patency. After head and neck surgery, a major, life-threatening complication is airway obstruction. The priority actions involve airway maintenance and gas exchange.
nurse is caring for a pt who has HTN and develops epistaxis. which of the following actions should the nurse take?
apply pressure to nares, place ice on bridge of client's nose, move client into high-fowler's position - Applying direct pressure to the lateral aspects of the nose helps to clot the blood. The nurse should apply firm and consistent pressure for several minutes until coagulation occurs. - Placing an ice pack on the nose causes the blood vessels to vasoconstrict, which decreases bleeding. The nurse should use a barrier, such as a wash cloth, to avoid skin damage from the direct application of ice to the skin. Ice packs should not be left on the skin for longer than 20 min. - Sitting upright facilitates breathing and decreases the risk for aspiration.
a client who is receiving magnesium sulfate has a urine output of 20 mL/hr. which med should the nurse expect to administer?
calcium gluconate treats magnesium sulfate toxicity - flumazenil is for sedative effects of benzodiazepines - naloxone reverses opioid overdose - protamine is for heparin overdose
a nurse is caring for a pt who has a prescription for potassium chloride 20 mEq PO daily. nurse reviews pt most recent lab results and finds the pt potassium level is 5.2 mEq. which action should the nurse take?
call prescribing physician and inform her of the pt serum potassium level results As a potassium level of 5.2 mEq/L is above the expected reference range, the nurse should hold the medication and notify the provider of the client's serum potassium level.
nurse is planning care for a pt who has dehydration and is receiving a continuous IV infusion of sodium chloride. which intervention should the nurse include in plan of care?
check pt IV infusion q8h nurse should monitor pt intake and urine output q2h - offer 60-120mL of fluids q1-2hr - furosemide is a loop diuretic that will increase dehydration
nurse is reviewing med record of pt who has K level of 3.0. which should the nurse recognize as a potential causative factor?
client has an NG tube NG tube to gastric suction can put pt at risk for developing hypokalemia due to the GI loss of potassium - spironolactone is a potassium-sparing diuretic and can cause hyperkalemia - alcohol abuse disorder puts pt at risk for hypomagnesaemia - drinking 3.5-4 L of water each day can cause hyponatremia
nurse is assessing client who has fluid overload. which findings should nurse expect?
increased HR, increased BP, increased RR (as well as crackles)
nurse is completing 8hr I&O record for a client. client consumed 4 oz soda, 1 piece of toast, 12 oz water, 1 cup gelatin, 1/2 cup broth, 300 mL sodium chloride. how many mL should record?
1140 1oz=30mL 1cup=8oz
nurse is assessing four clients for fluid balance. nurse should identify which of the following pt is exhibiting manifestations of dehydration?
client has temp of 39 C (102 F) increased temp, high urine specific gravity, and elevated hematocrit are signs of dehydration. weight gain is fluid volume excess
nurse is assessing a client prior to administering a seasonal influenza vaccine. pt says he read about nasal spray and wants to receive it. nurse should recognize that which of the following findings is a contraindication for receiving the live attenuated influenza vaccine (LAIV)?
client's age is 62 must be between 2-49 to receive LAIV, must not be pregnant or immunocompromised either
nurse is caring for pt scheduled to receive external radiation to the neck for cancer of the larynx. during pre-treatment exam, the nurse explains to the client that the most likely SE would be
dysphagia radiation therapy doesn't hurt when its given, but may cause pain of discomfort later. only the area of treatment is affected. trouble swallowing, hoarsness, xerostomia (dry mouth), loss of taste, and skin redness are expected
a nurse is preparing to measure a pt oxygen saturation level and observes edema of both hands and thickened toe nails. the nurse should apply the pulse oximeter to which location?
earlobe The earlobe is rarely edematous, is the least affected by decreased blood flow, and has greater accuracy when measuring oxygen saturation.
nurse is reviewing the AGB values for a pt. pH is 7.32, PaCO2 is 48, and HCO3 is 23. which acid base imbalance is indicated?
respiratory acidosis A number of conditions can lead to respiratory acidosis, including COPD and pneumonia. In the presence of respiratory acidosis, the client's blood gas values meet the following criteria: a pH less than 7.35, a PaCO2 greater than greater 45 mg/Hg, and a HCO3 that is normal or slightly elevated (22 to 26 mEq/mL).
nurse is caring for a pt who had total thyroidectomy and serum calcium level of 7.6 mg/dL. which of the following findings should the nurse expect?
tingling of extremities SE of hypocalcemia is - tingling and numbness of extremities and around the mouth - muscle tremors - hyperactive deep tendon reflexes - cardiac dysrhythmias - lengthened QT intervals - prolonged ST segments - weak and thread pulses - increased peristaltic activity leading to abdominal cramps and diarrhea.
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 pt to avoid?
tomatoes, bananas, raisins are all high-potassium foods
nurse is caring for a client who is receiving IV fluids to correct dehydration. which of the following lab values should indicate the client is effectively responding to treatment?
urine specific gravity 1.020 - this is within the expected range (1.005-1.030) - the kidney reabsorbs all available water, making the urine more concentrated and increasing the urine specific gravity
nurse is caring for a client who is receiving oxygen at 2L/min via nasal cannula. nurse recognizes client is receiving which of the following inspired oxygen concentration?
28% flow rate of 2L/min delivers 28% - flow rate of 4L/min delivers 36% - simple face masks deliver oxygen concentrations of 40-60% with flow rates of 5L/min or greater - nonrebreather mask with a minimum flow rate of 10L/min can deliver oxygen concentrations of 60-80%
nurse is caring for four hospitalized clients. which should the nurse identify as being at risk for fluid volume deficit?
client who has gastroentirits and is febrile (showing s&s of fever) gastroenteritis is characterized by diarrhea and possible vomiting which can cause significant fluid loss. fever can lose fluid via diaphoresis and raises metabolic rate. renal failure and heart failure cause fluid excess
a nurse is monitoring an older adult client immediately following a bronchoscopy. the nurse's priority is to monitor the client for which of the following?
confirming the gag reflex when using ABC priority, nurse should first assess the gag reflex to ensure pt has an open airway The client is at risk for hypoxia following a bronchoscopy and the nurse should auscultate the client's breath sounds
nurse assessing a client who has Na level of 116. which finding should the nurse expect?
nausea and vomiting pt has hyponatremia. SE of this is nausea and vomiting. extreme thirst, flushed skin, and fever are SE for hypernatremia
nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. which action should the nurse take
perform Heimlich maneuver
nurse is caring for client who has serum potassium level of 5.5. provider prescribes polystyrene sulfonate. if this med is effective, the nurse should expect which of the following changes on the client's ECG?
reduction of T-wave amplitude hyperkalemia causes peaked T waves and sometimes widened QRS on ECG; hyperkalemia does not generally affect P waves or the amplitude of the QRS complex
nurse is caring for a client who is 1 day post op following a total laryngectomy and has begun a soft diet. the client is not eating well and tells the nurse that hospital food has no taste. which of the following responses is appropriate?
"because of your surgery, you have an altered ability to smell and taste" laryngectomy pt breathe through tracheal stoma rather than mouth/nose which bypasses the location of the olfactory and gustatory nerve cells therefore decreasing taste and smell. a new set of food is unlikely to improve the situation, and closed-ended nontherapeutic responses do not help the patient
nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. nurse auscultates decreased breath sounds in the lower lobes of both lungs. nurse should realize this is most likely an indication of which of the following conditions?
atelectasis atelectasis is the collapse of part or all of a lung by blockage of air passage. prolonged bedrest with few changes in position, ineffective coughing, and underlying lung disease are risk factors for the development of atelectasis although pulmonary edema and delayed gastric emptying can cause decreased breath sounds, they are not the most likely cause in this patient; although the spleen plays a role in bacterial immunity, the nurse would be more concerned about the risk of an upper respiratory infection in a client who has undergone a splenectomy (removal of spleen)
nurse is assessing for cyanosis in pt who has dark skin. which site should the nurse examine to identify cyanosis in this client?
conjunctivae to assess skin colour changes in clients with dark skin, nurse should check body areas with minimal pigmentation such as the conjunctivae, plantar surface (soles) of feet, palmar surface (palms) of hands, and mucous membranes
nurse is teaching a client who will undergo a bronchoscopy procedure. the provider will use a rigid scope and general anesthesia. nurse should explain the client's neck will be in which position?
hyperextended position this aligns the pharynx and trachea to allow insertion of the scope far enough to adequately view airway structures to obtain tissue samples. if neck position is only extended, the provider could only insert the scope as far as the secondary bronchi
a nurse in the ER is caring for a pt who collapsed after playing football on a hot day. after reviewing the admission labs, the nurse recognizes the findings are consistent with which of the following conditions? NA: 152 glucose: 102 potassium: 3.6 chloride: 105 BUN: 18 creatinine: 0.7
dehydration (as indicated by the increase in Na) creatinine and BUN are within normal range, which does not indicate renal failure; syndrome of inappropriate antidiuretic hormone (SIADH) is associated with hyponatremia)
nurse is caring for pt receiving oxygen therapy via nasal cannula. nurse explains to the client that this method does which of the following?
delivers a low concentration of oxygen A nasal cannula delivers a relatively low concentration of oxygen (24% to 44%). - venturi mask delivers specific O2 concentrations - nonrebreather masks deliver high concentrations - face masks restrict pt ability to eat, speak or drink-
nurse is providing teaching to a group of adult athletes about preventing dehydration. what manifestations should the nurse include in the teaching?
impaired motor control rise in body temp, loss of appetite, and increased heart rate occurs with dehydration
nurse is caring for a client with a tracheostomy. client's partner has been taught to perform suctioning. which action by the partner should indicate a readiness for the client's discharge?
performing the procedure independently The nurse should recognize that the client is ready for discharge when the spouse demonstrates an ability to perform the procedure that will need to be performed independently at home.
as part of an annual physical exam, nurse is preparing a client to undergo a chest x-ray. which of the following instructions should the nurse give the client prior to the procedure?
remove all metal necklaces metal objects block visualization
nurse is auscultating a client's lung sounds and identifies crackles in the left lower lobe. which of the following interventions should the nurse take?
repeat auscultation after asking client to breathe deeply and cough - semi fowler's: it is premature to intervene based on a one-time finding. confirm finding before implementing
client is admitted to ED with resp rate of 7/min. ABG reveals these values. which is an appropriate analysis of ABGs? pH: 7.22 PaCO2: 68 base excess: -2 PaO2: 78 saturation: 80% bicarb (HCO3): 26
respiratory acidosis
what acid-base imbalance is shown by these ABG values: pH: 7.30 PaCO2: 50
respiratory acidosis
nurse is caring for client who is post op and resp are shallow and 9/min. which of the following acid-base imbalances should the nurse id the client as being at risk for developing initially?
respiratory acidosis high co2 due to inadequate excretion of it, and an increase in the hydrogen ion concentration (decreased pH) of the arterial blood. A major cause of this imbalance is hypoventilation from anesthetics or opioids.
nurse is planning discharge of a client who has sleep apnea and requires bi-level positive airway pressure (BiPAP) at night. nuse should plan to consult with which of the following health care team members?
respiratory therapist Respiratory therapists help clients learn to use oxygenation and airway management devices, such as BiPAP equipment.
nurse is caring for a client with a tracheostomy. which intervention should nuse implement when performing trach care?
secure new trach ties before removing old ones Tube dislodgement and accidental decannulation are potential complications of a tracheostomy. Both can be prevented by securing the tube in place. By keeping the old ties in place while applying new ties, the nurse can secure the tube and prevent dislodgement.
nurse assessing pt taking chlorothiazide sodium. nurse recognizes which of the following as a manifestation of hypokalemia?
shallow respirations (weakness in accessory muscles of breathing) slow tendon responses, constipation, fatigue, orthostatic hypotension, and dysrhythmias are also manifestations of hypokalemia
