ATI NCLEX CHALLENGE 3

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 while using my oxygen

a nurse is caring for a client who has a trach. select the 3 findings that require immediate follow-up

oxygen saturation on day 2 tracheal secretions RR day 2

A nurse is caring for a client on the medical surgical unit. complete the diagram by dragging ....

potential condition -- hypocalcemia actions to take -- check serum albumin levels & initiate seizure precautions monitor -- bowel sounds & signs of impaired memory

a nurse is auscultating a clients lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take?

repeat auscultation after asking the client to breathe deeply and cough

a nurse is assessing a client who has a pleural effusion. which of the following findings should the nurse expect?

dullness percussed over the clients lung fields

a nurse is caring for a client who has an oxygen saturation of 88%. which of the following actions should the nurse take?

encourage the client to take deep breaths

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

nausea and vomiting

a nurse is caring for a clint who has a trach. which of the following interventions should the nurse implement when performing trach care

secure new trach ties before removing the old ones

A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia

weak pulse

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 caring for a client who is receiving oxygen at 2L/min via nasal cannula. The nurse recognizes the client is receiving which of the following inspired oxygen concentration?

28%

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?

300mL

a nurse is preparing to suction a client who has a trach. identify the sequence

- adjust the suction - don sterile gloves - check the function of the suction catheter - hyper oxygenate pt - insert catheter without suction - apply suction while rotating catheter - assess for clearance of secretions

A nurse is preparing to provide tracheostomy care for a client who has a non-disposable tracheostomy tube. Which of the following equipment should the nurse plan to use? (select all that apply)

- clean gloves - sterile cotton-tipped applicators - sterile basin

a nurse is assessing a client who has oxygen toxicity which of the following findings should the nurse expect

muscle twitching

A nurse is caring for client who is placed on supplemental oxygen for hypoxia. the nurse should identify that which of the following findings indicate the intervention was effective?

pink mucous membranes

a nurse is reviewing a clients lab results. which of the following lab values should the nurse report to the provider?

sodium 126 mEq/L

a nurse is caring for a client who is receiving IV fluids to correct dehydration. Which of the following lab values should indicate to the nurse that the client is effectively responding to treatment

urine specific gravity 1.020

A nurse is admitting a client who is dehydrated. Which of the following BUN levels should the nurse expect the client to have upon admission

35mg/dL

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 loose about 50 lbs i might stop having so many apneic episodes

a nurse is reviewing a clients lab values and discovers the client has a serum potassium of 6.2mEq/L. which of the following interventions should the nurse anticipate?

administering a sodium polystyrene sulfonate

a nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. the nurse auscultates decreased breath sounds in the lower lobes of both lungs. the nurse should realize that this finding is most likely an indication of which of the following conditions?

atelectasis

a nurse is teaching a newly licensed nurse about a nonrebreather oxygen m ask. Which of the following instructions should the nurse include?

a nonrebreather mask should fit snugly over a clients face

a nurse is admitting a client to med surg unit following a fall at home

administer IV fluid bolus is anticipated obtain xray of hip is anticipated clients weight is anticipated supplemental oxygen is nonessential administer spironolactone is contraidicated iron supplement is nonessential

a nurse in a providers office is reviewing the lab results of a client who takes furosemide for hypertension. the nurse notes that the clients potassium level is 3.3 mEq/L. the nurse should monitor the clint for which of the following complications?

cardiac dysrhythmias

a nurse is assessing a client who has obstructive sleep apnea which of the following findings should the nurse expect?

decreased energy

a nurse in the emergency department is caring for a client -- drag 1 condition and 1 client finding to fill in each blank in the following sentence

fluid volume deficit vomiting and diarrhea

a nurse is teaching a class about oxygen transport in the cardiopulmonary system. which of the following transports oxygen in the blood?

hemoglobin

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 caring for a client who has the following ABG results: HOC3 - 18mEq, PaCO2 - 28mm Hg, pH - 7.30. the nurse recognizes the client is experiencing which of the following acid base imbalances?

metabolic acidosis

a nurse is admitting a client who reports flu-like symptoms with hyperactive reflexes and a new onset of confusion. the nurse should recognize that the client is experiencing which of the following conditions?

metabolic alkalosis

A nurse in the PACU is assessing a client who has an endotracheal tube (ET) tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect?

movement of the ET tube into the right main bronchus

A nurse is caring for a client who has a trach. Which of the following actions should the nurse take?

perform trach care for the client every 4 hours

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

suction two to three times with a 60-second pause between passes

A nurse is assessing a client who reports frequent vomiting and diarrhea or the past 3 days. which of the following findings should the nurse expect? (select all that apply)

- poor skin turgor - hypotension - flat neck veins

a nurse is providing teaching for a client who has a pres. for home oxygen. which of the following instructions should the nurse include?

- post a no smoking sign in the home - attach oxygen containers to a fixed object - notify fire department oxygen is in the home

a nurse is calculating the total fluid intake for a client during a 4-hr period the client consumes 1 cup of coffee, 4oz of orange juice, 3oz of water, 1 cup of flavored gelatin, 1 cup of tea, 5oz of broth, and 3oz of water. the nurse should record how many mL of intake on the clients record?

1170

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 has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take?

attach a humidifier bottle to the base of the flow meter

a nurse is caring for a child who has a trach. after suctioning the trach the nurse should use which of the following findings to determine that the procedure was effective

clear breath sounds

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 reviewing a clients lab report of blood gas findings: HCO3 - 18 mEq/L and PaCO2 28mm Hg. 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 a postop ileus and an NG tube that has drained 2500mL in the past 6hrs. Which of the following electrolyte imbalances should the nurse monitor the client for?

decreased potassium level

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 that these findings are consistent with which of the following conditions?

dehydration

a nurse is preparing to measure a clients level of oxygen saturation and observes edema of both hands and thickened toe nails. The nurse should apply the pulse oximeter probe to which of the following locations?

earlobe

a nurse is receives a call from a parent of a child who has von Willebrand disease and has a nosebleed. which of the following instructions should the nurse give to the parent?

have your child sit with her head tilted forward and hold pressure on her nose for 10 minutes

a nurse is assessing a client who has obstructive sleep apnea. which of the following findings should the nurse expect?

headache

a nurse is caring for a client who as a UTI the client is at an increased risk for developing _________ and __________

hypokalemia fluid volume defecit

a nurse is caring for a client who has a trach. the client has manifestations of ____________ and _________

hypoxia and pneumonia

A nurse s teaching a client who has acute kidney disease about fluid restrictions. Which of the following statements by the client should the nurse identify as understanding of the teaching?

i will make a list of my favorite beverages

A nurse is caring for a client with a trach. the clients partner has been taught to perform suctioning. which of the following actions by the partner should indicate to the nurse a readiness for the clients discharge?

performing the procedure independently

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 minutes

a nurse is teaching a class about pulmonary circulation. the nurse should include that blood flows from the heart to the lungs from the right ventricle starting from which following locations?

pulmonary artery

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

sodium polystyrene

A nurse is teaching a client who has a prescription for home oxygen therapy. Which of the following instructions should the nurse include?

store oxygen tanks up right

A nurse is assessing a client who as circulatory overload. Which of the following findings should the nurse expect?

tachycardia

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 caring for a 3 y/o child who was admitted with acute diarrhea and dehydration. which of the following findings indicates that oral rehydration therapy has been effective?

urine specific gravity 1.015

a nurse is reviewing the lab results of a client who has fluid volume deficit. the nurse would expect which of the following findings?

urine specific gravity 1.035

A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect?

weak, irregular pulse