NCLEX Challenge 1 Summer 2018

a nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. which of the following statements by the new nurse indicates understanding?

"documentation is a communication tool for the interprofessional health care team"

a nurse is reviewing the lab results of a client who has acute radiation syndrome and notes the client has leukopenia. which of the following assessment findings should the nurse ID as being consistent with leukocytosis?

fever

a nurse is caring for a client who is post op following abdominal surgery and reports incisional pain. the surgeon has prescribed morphine 4 mg IV bolus every 6 hr as needed. before administering the medication, the nurse should complete which priority assessment?

respiratory rate

a public health nurse is assessing an older adult client who lives with a family member. the nurse identifies several bruises in various stages of healing. the client and family say they are results of clumsiness. however, based on the distribution, the nurse suspects abuse. which of the following actions should the nurse take first?

report findings to a supervisor

a charge nurse is supervising a newly licensed nurse provide care for a client who has a PCA pump. which of the following statements made by the nurse requires further action by the charge nurse?

"i discarded the remaining 2 mg of morphine from the PCA pump. please document you witnessed it" two nurses are required to witness the wasting of a narcotic

nurse is teaching a newly licensed nurse about methods to reduce costs of client care. which of the following statements indicates understanding?

"i should encourage clients to receive an annual flu immunization"

a nurse is caring for a client who is dying. the client says "my mother died in the hospital, but i did not get there before she died." which of the following statements should the nurse make?

"i wonder if you are fearful of dying alone"

nurse is preparing to administer meperidine 75 mg IM to a client who reports post op pain. available is meperidine 100 mg/mL. how many mL should the nurse administer?

0.8

a nurse is preparing to administer gabapentin 900 mg PO once daily for a client who has neuropathic pain. the amount available is 300 mg/capsule. how many capsules should the nurse administer per dose?

3

a nurse is providing teaching to a client who take opioid pain medication and has a new prescription for docusate sodium. which of the following statements by the client indicates an understanding of the teaching?

"it might take up to 3 days for the medication to work" docusate sodium is a stool softener and the therapeutic effect may take up to 3 days

a nurse intercepts a messenger at the nurses' station who has a flower delivery for a client on the unit. as the nurse accepts the flowers, the messenger says "I know mrs. welch from the neighborhood. what happened to her?" what does the nurse say

"its my responsibility to remind you that we have the respect our clients' privacy"

a nurse is talking with a client who is about to start using transcutaneous electrical nurse stimulation (TENS) to manage chronic pain. which of the following statements should the nurse identif as an indication that the client needs further teaching?

"its unfortunate that I have to be in the hospital for this treatment" TENS units are portable and can be used at home or wherever client chooses

a nurse is caring for a client who has cancer and is scheduled for immediate chemotherapy. the client tells the nurse she wants to try nontraditional treatments first. which of the following responses should the nurse make?

"tell me more about your concerns about taking chemotherapy"

a nurse is planning to use the SBAR communication tool when calling a provider. which of the following statements should the nurse include in the B step?

"the client was found unconscious on the floor in her home"

a nurse is caring for a client who has fallen while getting out of bed and states "I'm okay! I guess I should have called for help to the bathroom." after assessing the client, the nurse notifies the provider. which of the following documentation should the nurse include in client's medical record?

"the provider was notified" the nurse should document factual information, including objective and subjective data ("the patient was not injured" is a supposition)

a nurse is giving change-of-shift report using SBAR to the oncoming nurse of a client who has a traumatic brain injury. which of the following information should the nurse include in the background segment of SBAR?

code status (glasgow results and intracranial pressure readings are under the assessment segment; plan of care is under the recommendation segment)

when reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. which of the following actions should the nurse take?

contact the provider to question the dosage

a nurse manager is preparing to confront a staff nurse who is abusing alcohol. which of the following defense mechanisms should the nurse manager expect the staff nurse to use

denial this is a common defense mechanism used by people who are dealing with substance abuse

a nurse is caring for a client who requests prescription pain medication. which of the following actions should the nurse perform first?

determine location of the pain

a nurse is preparing to administer morphine 4 mg IV bolus to a client who reports pain. available is morphine 10 mg/mL. which of the following actions should the nurse take?

have another nurse witness the disposal of the extra medication

a nurse is assessing a client in labor who has had epidural anesthesia for pain relief. which of the following findings should the nurse identify as a complication from the epidural block?

hypotension maternal hypotension is an adverse effect of epidural anesthesia. the nurse should administer an IV fluid bolus prior to the placement of the epidural catheter to decrease the likelihood of this complication

a nurse manager has recently become aware of a conflict between the pharmacy and the staff nurses regarding sending and receiving medications. which of the following actions should the nurse take first to resolve conflict?

identify the problem

a nurse is planning care for a client who has immunosuppression following chemotherapy. which of the following interventions should the nurse include in the plan of care?

limit the number of health care workers entering the room to prevent possible overexposure to microorganisms that can lead to infection

a nurse manager is presenting to a group of unit nurses the categories regulated under the controlled substances act. which of the following medication prescriptions should the nurse include under schedule II?

morphine requires the provider to complete a written prescription with a signature

a charge nurse has access to the facility's electronic client records. it is appropriate for the charge nurse to share her personal password with whom?

no one

a nurse is caring for a client who is participating in a research study for an experimental chemo med. after three treatments, the experimental med is discontinued due to evidence of rapid kidney failure. the nurse should understand discontinuing this med demonstrates which ethical principle?

nonmaleficence

a nurse is caring for a client who is dying of metastatic breast cancer. she has a prescription for an opioid pain medication PRN. the nurse is concerned that administering a dose of pain medication might hasten the client's death. which of the following ethical principles should the nurse use to support the decision not to administer the medication?

nonmaleficence the duty to do no harm (utilitarianism refers to actions that are right when they contribute to the greatest good; fidelity is the duty to keep one's promise)

a nurse is providing care for a surgeon on a medical-surgical unit. a nurse from another unit asks the nurse about the surgeon's medical diagnosis. the nurse responds that he is unable to provide the info requested. the nurse is displaying which of the following ethical principles

nonmaleficence (wtf) the nurse is obligated to protect the client's confidential information (aka... confidentiality???????). a breach of confidentiality can place the client at risk for harm, nonmaleficence is the ethical duty to prevents harm to the client

a nurse is discussing culturally competent care at a nursing staff inservice. which of the following information should the nurse include when discussing clients' cultures?

nurses should focus on the clients' cultures, rather than their ethnicity, when providing care.

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?

observe for signs of infection radiation therapy to sites containing bone marrow (such as the sternum) can lower the WBC count thus increasing a risk for infection

a nurse on a med-surge unit is planning to delegate tasks to an adult volunteer. which of the following tasks should the charge nurse avoid assigning the volunteer?

observing a post-op client who is confused

a nurse is receiving a provider's prescription for a client via telephone. which of the following actions should the nurse take to ensure the accuracy of the telephone prescription?

repeat the order back to the provider, question any part of the order that is unclear or inappropriate, transcribe the order into the client's health record. (the usual rule for obtaining a signature is within 24 hrs; never leave a message)

a nurse is developing a plan of care for a client who practices Islam. which of the following actions should the nurse include in the plan?

request a tray without pork

a newly licensed nurse is applying prescribed write restraints on a client. which of the following actions should the nurse take?

secure the restraints using a quick-release tie

a nurse is performing a pain assessment for a client who is alert. the nurses should recognize that which of the following measures is the most reliable indicator of pain?

self-report of pain

a nurse is caring for an older adult client who has a WBC count of 2,000/mm3 after three rounds of chemo. which of the following actions should the nurse take?

serve cooked fruit with meals to prevent possible bacterial contamination from raw fruit

a nurse is reviewing the goals of the nurse-client therapeutic relationship with a client who is seeking counseling. which of the following information should the nurse include in this discussion?

the client achieves optimal personal growth

a hospice nurse is caring for a client who has terminal cancer and takes PO morphine for pain relief. the client reports that he had to increase the dose of morphine this week to obtain pain relief. which of the following scenarios should the nurse document as the explanation for this situation?

the client has developed a tolerance to the medication

a nurse is caring for a client who has chemo induced peripheral neuropathy. the nurse should expect the client to report having experienced which of the following symptoms?

tingling feeling in the extremities

a nurse at a providers office is teaching to a client who is taking chemo and losing weight. which of the following should the nurse recommmend to increase calorie/protein intake?

top fruits with yogurt, add cream to soup, use milk instead of water in recipes, and dip meats in eggs and bread crumbs before cooking.

a nurse observes that a client who has depression is sitting alone in the room crying. as the nurse approaches, the client states "i'm feeling really down and don't want to talk to anyone right now." which of the following responses should the nurse make?

"I'll just sit here with you for a few minutes then" this is a therapeutic response by offering self, demonstrating care and concern and showing the client that the nurse is available if the client wants to talk

a nurse is caring for several clients. which of the following situations should the nurse complete an incident report?

a client discovers that his dentures are missing. this situation is a variation from the normal standard of care and a change in the client's plan of care may be necessary. additionally, the facility may be liable for replacing the missing dentures

a nurse manager received a client request to not have a specific staff care for her while at the acute care facility. which of the following is the appropriate action by the nurse manager?

address the concern with the specific staff nurse

a nurse on a medical-surge unit is preparing to contact a provider about a clients condition. the client is 6 hr post-op from a total hysterectomy. the nurse notes the client's postop oxygen saturation is 94 and her apical HR is 110. the nurse should include info about the clients O2 sat level and HR in which component of SBAR?

assessment

a nurse notices an AP preparing a food tray to client who practices orthodox Jewish faith. on the tray is a roast beef dinner with nonfat milk. which of the following actions should the nurse take?

call the dietary department and ask for a kosher tray

a nurse is caring for a client receiving hydromorphone HCL via PCA pump and reports continuous pain of 6 on a scale of 0-10. which of the following actions should the nurse take first?

check the display on the PCA pump

a nurse is providing discharge teaching for a client who is postoperative following a simple mastectomy. the client is to begin outpatient radiation therapy the next day. which of the following instructions about maintaining skin integrity should the nurse include?

do not apply heat to the area of irridiation radiated tissue becomes thinner and might lack tissue receptors that would otherwise alert the client to a potential burn injury; client should avoid both wet and dry heat

a nurse is teaching a client about the physical effects of chemotherapy. following the teaching, the nurse asks the client to describe one physical effect. the nurse is focusing on which of the following elements of the communication process?

feedback this indicates whether the client understands the message (a channel is the means of conveying/receiving messages through senses; environment is the setting between nurse and client; message is the content)

a nurse is planning care for a client who is being treated with chemo and radiation for metastatic breast cancer, and who has neutropenia. the nurse should include which of the following restrictions in the client's plan of care?

fresh flowers and potted plants micro-organisms are likely to be present on plants which can then get to the client

a nurse administers an incorrect medication to a client. Following an assessment of the client, the nurse determines that the client has experienced no untoward effects as a result of the medication. the nurse does not complete an incident report because no harm came to the client. which of the following ethical principles did the nurse violate?

veracity veracity is the duty to tell the truth. the nurse violated this when choosing not to report the error instead of being truthful. (autonomy is accepting responsibility and meeting organizational expectations; beneficence is helping others to promote good; confidentiality is disclosing info to only those involved in client's care)