NCLEX Challenge 4

A nurse is teaching the mother of a 5-year-old child who has cystic fibrosis about pancreatic enzymes. The nurse should understand that further teaching is necessary when the mother states which of the following?

I will give my son the enzymes between meals. The parent should give the child pancreatic enzymes with every meal and snack. Pancreatic enzymes rarely cause adverse effects. In inappropriately large doses, they can cause nausea and diarrhea. Pancreatic enzymes improve digestion, particularly of fats. The parent can sprinkle the contents of the pancreatic enzyme capsules on a variety of foods, including applesauce.

A client has a right subclavian central venous catheter. When reconnections a new administration set, which of the following instructions should the nurse give the client?

"Bear down while holding breath" The client should perform a Valsalva maneuver by holding a breath and bearing down while the nurse disconnects the old set and reconnects the new set. This action prevents air from entering the lumen, the heart, and pulmonary circulation.

A nurse is preparing to insert an IV catheter for a client and has selected the insertion site. Place the following steps in the order in which the nurse should perform them.

1. cleanse the site with an antiseptic swab. 2. apply a tourniquet or BP cuff 3. dilate the vein 4. insert the catheter 5. flush the catheter

A nurse is teaching a client who has asthma how to use a metered-dose inhaler. The nurse identifies the sequence of steps the client should follow.

1. inhale deeply and then exhale completely 2. place her lips firmly around the mouthpiece 3. breathe in deeply over 2 to 3 seconds while pushing down on the canister 4. hold her breath for 10 seconds 5. exhale slowly through pursed lips 6. wait 60 seconds between each puff

A nurse is caring for a client and identifies an infiltration at the IV catheter site. Identify the order the nurse should perform the following actions.

1. stop the infusion 2. remove the IV catheter 3. apply a sterile dressing 4. elevate the extremity 5. apply warm or cold compress

A nurse is caring for a client who has a central venous catheter and reports hearing a gurgling sound on the side of the catheter insertion. Which of the following complications should the nurse suspect?

A client report of hearing a gurgling sound on the side of the catheter insertion is a manifestation of catheter migration.

A nurse is caring for a client who is receiving a unit of packed red blood cells. 15 minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusions reactions should the nurse suspect?

A hemolytic transfusion reaction occurs when antibodies in the recipient's blood react to foreign blood cells introduced by the transfusion. The antibodies bind to the foreign cells and destroy them in a process known as hemolysis. The destroyed cells are excreted by the kidneys (hemoglobinuria), causing the red-tinged urine. Hemolytic transfusion reactions can result in acute renal injury, disseminated intravascular coagulation, and circulatory collapse.

A nurse is working with an emergency response team in caring for a group of people who may have been exposed to anthrax doing farm work, but are not exhibiting manifestations of illness. Which of the following is the appropriate action for the nurse to take?

Administer antibiotic therapy The nurse should administer an antibiotic and the anthrax vaccine within 24 hr as prophylaxis to all clients exposed to anthrax and are not exhibiting manifestations of illness.

A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client?

A room with air exhaust directly to the outside environment eliminates contamination of other client-care areas. This type of ventilation system is referred to as an airborne infection isolation room.

A nurse is caring for a child who has asthma and a prescription for montelukast granules. Which of the following instructions should the nurse provide the client's parent on administering the medication?

Administer the medication 2 hr before exercise. Montelukast should be given daily during the evening, except when being used for exercise-induced bronchospasm. It should then be given 2 hr before exercise, and not given again for 24 hr. Montelukast is a leukotriene receptor antagonist that is used to prevent asthma symptoms. It works by blocking the action of leukotrienes (substances that cause inflammation, fluid retention, mucous secretion, and constriction) in the client's lungs. Montelukast is ineffective as a rescue medication.

A nurse is teaching a client who has been taking prednisone to treat asthma and has a new prescription to discontinue the medication. The nurse should explain to the client to reduce the dose gradually to prevent which of the following adverse effect?

Adrenocortical insufficiency. Prednisone, a corticosteroid, is similar to cortisol, the glucocorticoid hormone produced by the adrenal glands. It relieves inflammation and is used to treat certain forms of arthritis, severe allergies, autoimmune disorders, and asthma. Administration of glucocorticoids can suppress production of glucocorticoids, and an abrupt withdrawal of the drug can lead to a syndrome of adrenal insufficiency.

A home health nurse visits a client who has COPD and receives oxygen at 2L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority?

Assess the client's respiratory status. The first action the nurse should take using the nursing process is to collect data from the client. The nurse should immediately assess the client's respiratory status before determining the appropriate interventions.

A nurse in a provider's office is assessing a client. The nurse should identify that which of the following findings are manifestations of pulmonary tuberculosis?

Blood-streaked sputum is a manifestation of tuberculosis. Night sweats are a manifestation of tuberculosis. Low-grade fever is a manifestation of tuberculosis

A nurse is caring for a client who has active tuberculosis and is to be started on intravenous rifampin therapy. The nurse should instruct the client that this medication can cause which of the following adverse effects?

Body secretions turning a red-orange color. Rifampin is used in combination with other medicines to treat TB. Rifampin will cause the urine, stool, saliva, sputum, sweat, and tears to turn reddish-orange to reddish-brown.

A nurse is assessing a child who is postoperative following a tonsillectomy. Which of the following findings is a manifestation of hemorrhage?

Children who exhibit frequent swallowing should be evaluated for hemorrhage.

A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes?

Clients who have COPD use accessory muscles to assist with respiratory effort. The use of those accessory muscles causes the chest wall to eventually increase in anterior-posterior diameter, making it appear barrel shaped.

A nurse in the emergency department is assessing an older client who has community-acquired pneumonia. Which of the following findings should the nurse expect?

Confusion due to hypoxemia is an expected finding for an older-adult who has pneumonia.

While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first?

Discontinue the existing IV line. The greatest risk to the client is injury from the IV infiltration damaging soft tissues surrounding the catheter. Therefore, the first action the nurse should take is to discontinue the existing IV line.

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions?

Encourage the client to increase fluid intake. Increasing fluid intake to1,500 to 2,500 mL/day promotes liquefaction and thinning of pulmonary secretions, which improves the client's ability to cough and remove the secretions.

A nurse is caring for a client who has COPD. The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions?

Encouraging the client to drink 2 to 3 L of water daily. COPD is a term for two diseases of the respiratory system: chronic bronchitis and emphysema. Maintaining hydration through the consumption of adequate fluids will help liquefy thick secretions and facilitate their expectoration.

A nurse is caring for a client who has active pulmonary tuberculosis. The client requires airborne precautions and is receiving multi drug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray?

Have the client wear a mask. When a client who has a communicable disease must leave his room, it is important to protect everyone with whom the client comes in contact. Having the client wear a mask protects others from airborne particles should the client cough.

A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?

Instruct the client to use pursed-lip breathing. Pursed-lip breathing lengthens the expiratory phase of respiration and also increases the pressure in the airway during exhalation. This action reduces airway resistance and decreases trapped air for clients who have COPD.

A nurse is collaborating on care for a client who has COPD. Which of the following tasks should the nurse recommend be referred to an occupational therapist for assistance?

Instructing now to use kitchen tools to prepare a meal. As a member of the interdisciplinary team, the occupational therapist works with the client to develop fine motor skills and coordination, such as improving hand strength and hand movements. The occupational therapist focuses on self-management of ADLs, such as skills needed for eating, hygiene, and dressing. Occupational therapists also can teach clients to perform other independent living skills, such as cooking and shopping.

A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter. When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first?

Measure the circumference of both upper arms. The first action the nurse should take using the nursing process is to assess the client. The nurse should measure the arm and compare the result with the circumference of the other arm. If the arm is swollen, the nurse should notify the provider who inserted the PICC line. Swelling could indicate formation of a clot above the site or even catheter rupture.

A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?

Oral mucosa According to evidence-based practice, the nurse should first monitor the client's tongue and lips for manifestations of central cyanosis because cyanosis is most evident in areas with minimal pigmentation.

A nurse is caring for a client who has experienced an infection at the insertion site of her intravenous catheter. Which of the following findings should the nurse expect?

Purulent drainage is noted from the site. Signs of infection include warmth, redness, swelling, and possible purulent drainage.

A nurse is caring for a client who is receiving radiation therapy to treat lung cancer. Which of the following actions should the nurse take?

Radiation therapy to sites containing bone marrow (such as the sternum) can lower the WBC count (leukopenia), thus increasing the client's risk for infection. Screening the client for signs of infection is essential at this time.

A nurse is assessing a pt who has IV therapy-related phlebitis. The nurse uses the Infusion Nurses Society's phlebitis scale to assess the severity of phlebitis and documents the client's phlebitis as a grade level 1. Which of the following assessment findings correlates with a grade level 1?

Redness at the intravenous access site with or without pain is scored as a grade level 1.

A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB?

Sputum culture for acid-fast bacillus. Although the Mantoux (skin test) and the chest x-ray may be useful screening tools for TB, the presence of acid-fast bacillus noted in the client's sputum, secretions, or tissues is the only method that can actually confirm the diagnosis.

A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the insertion IV site?

The IV fluid is at room temperature, so the area around the injection site will feel cool, not warm, to the touch when the IV is infiltrated. A warm area around the injection site indicates infection or phlebitis.

A nurse is teaching a client who is about to undergo the insertion of a non tunneled central venous access device. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

The client should turn his head away from the insertion site to allow optimal accuracy in placing the catheter.

A nurse is assessing a client prior to administering a seasonal influenza vaccine. The client says he read about the influenza vaccine that is given as a nasal spray and wants to receive it. The nurse should recognize that which of the following findings is a contraindication for the client receiving the live attenuated influenza vaccine (LAIV)?

The client's age is 62. Clients must be between the ages of 2 and 49 to receive the LIAV; therefore, it is contraindicated for this client. Pregnancy and immunocompromised status are also contraindications.

A nurse is caring for a client who has a central venous catheter and develops acute shortness of breath. Which of the following actions should the nurse take first?

The greatest risk to this client is injury from further air entering the central venous catheter; therefore, the first action the nurse should take is to clamp the catheter.

A nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of the following actions by the client indicates an understanding of the teaching?

The medication should be retained in the lungs for a minimum of 10 seconds so the maximum amount of the dosage can be delivered properly to the airways. To use the inhaler, the client exhales normally just prior to releasing the medication, inhales deeply as the medication is released, then holds the medication in the lungs for approximately 10 seconds prior to exhaling.

A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client?

The nurse should anticipate an increased anteroposterior diameter of the chest (barrel chest) because of chronic hyperinflation of the lungs.

A nurse in a community health clinic is administering seasonal inactive influenza vaccine. Before administering it, the nurse must confirm that the client is not allergic to which of the following?

The nurse should assess the client for allergies to eggs. The seasonal influenza vaccine contains small amounts of egg protein and can induce a severe allergic reaction in clients who are hypersensitive

A nurse is assessing a client who is receiving total parenteral nutrition therapy via an infusion pump. Which of the following actions should the nurse take?

The nurse should change the client's IV tubing every 24 hr, or per facility protocol, to prevent bacteria from developing in the tubing.

A nurse is assessing for hypoxia during an asthma attack. Which of the following manifestations should the nurse expect?

The nurse should expect agitation due to neurological changes from poor oxygen exchange.

A nurse in a clinic sees a client who has an acute asthma exacerbation. Which of the following medications should reduce the symptoms?

The nurse should identify that albuterol is a bronchodilator used as the first medication of choice to stop bronchospasm or constriction in clients who have acute asthma exacerbation.

A nurse is admitting a client who requires droplet precautions due to influenza. Which of the following actions should the nurse take?

The nurse should wear a mask when within 3 feet of a client who requires droplet precautions.

A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64mm Hg. Which of the following actions should the nurse take first?

This client is experiencing an acute intravascular hemolytic transfusion reaction. The greatest risk to this client is injury from receiving additional blood; therefore, the first action the nurse should take is to stop the infusion of blood.

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?

To prevent hypoxemia, the nurse should preoxygenate the client with 100% oxygen for 30 seconds to 3 min prior to suctioning.

A nurse is caring for client who has a single lumen central venous catheter. Which of the following actions should the nurse take when accessing the catheter?

Use a 10-mL syringe to flush the catheter. During the flushing procedure, the nurse should use a 10-mL barrel syringe, because the pressure that is exerted by smaller barrel syringes increases the risk for rupturing the catheter.

A nurse is caring for a child who is experiencing status asthmatics. Which of the following interventions is the priority for the nurse to take?

When using the urgent versus non-urgent approach to client care, the nurse should determine that the priority action is to administer a nebulized high-dose SABA to relieve bronchoconstriction and improve ventilation

A nurse is caring for a child who has pertussis. The child's parents asks the nurse what the common name for this disease is. The nurse should respond with which of the following common names?

Whooping cough