NCLEX Challenge 2

A nurse is caring for a client who is post op following a total hip arthroplasty. The nurse assists the client into a supine position. Which of the following actions is appropriate to prevent dislocation of the hip? A. place a wedge pillow between the legs B. Elevate the head of the bed to a fowler's position C. Position the legs in alignment with the spine D. Place a footboard on the bed

A. place a wedge pillow between the legs

A client is starting celecoxib to treat OA. The nurse should instruct the client to watch for and report which of the following adverse effects? A. black, tarry stool B. bone pain C. Dry mouth D. Polyuria

A. black, tarry stool for signs of GI bleeding

A nurse in a clinic is caring for a client who has a new diagnosis of systemic lupus erythematosus. The client is at risk for developing ___ and ____. A. chronic fatigue b. photosensitivity c. hypoglycemia d. weight loss

A. chronic fatigue b. photosensitivity

A nurse is admitting a client who was prescribed antibiotic therapy and now has C. Diff infection. Which of the following actions should the nurse take? A. disinfect equipment in the client's room daily B. Place the client in a protective environment C. use alcohol hand sanitizer after completing tasks for the client D. Have the client wear a mask when out of the room.

A. disinfect equipment in the client's room daily

A nurse caring for client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material? A. discard the dressing in the bedside trash receptacle B. Dispose of the dressing in a biohazardous waste container. C. Enclose the dressing in a single clear plastic bag and discard in the bedside trash receptacle D. double bag the dressing in clear bags and label it "Biohazard"

B. Dispose of the dressing in a biohazardous waste container.

A nurse is providing teaching to a client who has RA and a new prescription for methotrexate. Which of the following instructions should the nurse include? Select all that apply A. Expect to feel the medication's effects immediately. B. Do not drink alcoholic beverages while taking this medication C. Report unexplained bruising to the provider D. Avoid people who have infections E. Take NSAIDS to help minimize the adverse effects of the medication.

B. Do not drink alcoholic beverages while taking this medication C. Report unexplained bruising to the provider D. Avoid people who have infections

A nurse is teaching a client how to follow a low-purine diet as prescribed by the provider for the management of gout. Which of the following statements indicates the client understands the teaching? A. I will need to limit the number of fruit servings each day B. I should avoid eating liver and other organ meats C. I can drink only white wine D. I should choose red meat instead of poultry

B. I should avoid eating liver and other organ meats

A nurse is discussing informatics with a newly licensed nurse. The nurse identifies that informatics is defined as the use of information and technology for which of the following ? A. producing clinical pathways B. Managing knowledge C. Preventing burnout D. Providing a safe place to provide care.

B. Managing knowledge

A nurse is admitting a new client. Which of the following steps of the nursing process is the nurse performing when formulation goals for a positive outcome? A. Evaluation B. Planning C. Implementation D. Assessment

B. Planning

A nurse is preparing to administer naproxen 500 mg PO BID for a client who has OA. The available amount is 125mg/5 ml oral suspension. How many mL should the nurse administer per dose?

20 mL

A nurse in a clinic is talking with a client who has a new diagnosis of osteoarthritis. The nurse anticipate that the client will require teaching about which of the following medications? A. Acetaminophen B. Celecoxib C. cyclobenzapine D. Ibuprofen

A. Acetaminophen

A nurse is teaching an older adult client about a new medication. Which of the following actions should the nurse take? A. Allow extra time for instructions B. provide reading material using small-sized font C. Use a high tone of voice when speaking D. Present the information in lengthy segments

A. Allow extra time for instructions

A charge nurse is teaching a group of staff members about hand hygiene. Which of the following information should the nurse include in the teaching? Select all that apply. A. Compliance of hand washing among staff members is less than 50% B. Hand hygiene is the most important step to prevent spreading of infection C. Alcohol based hand gel is an acceptable method of hand hygiene D. one out of 40 clients obtain a health care associated infection HAI. E. clients should be instructed about hand hygiene

A. Compliance of hand washing among staff members is less than 50% B. Hand hygiene is the most important step to prevent spreading of infection C. Alcohol based hand gel is an acceptable method of hand hygiene E. clients should be instructed about hand hygiene

A nurse is teaching a client who has fibromyalgia syndrome about measures to reduce the occurrence of symptoms? which of the following interventions should the nurse include in the teaching? A. Establish a regular sleep pattern B. Avoid exercise during flare-ups C. Try jogging or running in between flare-ups D. Increase calcium intake

A. Establish a regular sleep pattern

A nurse does not take a client's apical heart rate, but documents that it was taken in the client's electronic health record (EHR). Which of the following terms describes the nurses's actions? A. Falsification B. Slander C. Battery D. Libel

A. Falsification

A nurse is caring for a client who is desiring their wound care to be provided at 1400. The nurse returns at 1400 to perform wound care for the clients. Which of the following ethical principles is the nurse demonstrating? A. Fidelity B. Veracity C. Autonomity D. Justice

A. Fidelity

A nurse is teaching about delegation with a newly licensed nurse. Which of the following statements if made by the newly licensed nurse indicates understanding? A. I am responsible for ensuring that a delegated task is completed. B. There are 4 rights of delegation C. The nurse manager is responsible for delegating nursing tasks during each shift D. It is the duty of the delegatee to perform a task without asking questions when it is delegated.

A. I am responsible for ensuring that a delegated task is completed.

A nurse is reviewing ethical principles with a nursing colleague. Which of the following statements by the nursing colleagues indicates an understanding of ethical principles? A. Nonmaleficence is our nursing obligation to do no harm to our clients B. Beneficience is our duty to provide care to out clients that causes an intentional outcome C. Justice refers to our client's loyalty to their nurse D. Veracity is the ability of our client's to provide us with truthful information

A. Nonmaleficence is our nursing obligation to do no harm to our clients

A nurse is preparing an in-service to review the Code of Ethics (COE) with a group of nursing colleagues. Which of the following statements should the nurse make during the in-service about the COE? A. Professional expectations are included in the COE b. the use of social media is not included in the COE c. student nurses are not held accountable to COE d. criteria for obtaining licensure is included in the COE.

A. Professional expectations are included in the COE

A nurse is reviewing lab values for a client who has systemic lupus erythematosus (SLE). which of the following values should give the nurse the best indication of the client's renal function? A. Serum creatinine B. Blood urea nitrogen (BUN) C. serum sodium D. urine-specific gravity

A. Serum creatinine

An infectious control nurse is teaching a class about transmission of infectious agents. The nurse should include that which of the following diseases is transmitted via airborne transmission? select all that apply A. Varicella B. C. diff C. Rubella D. Staph Aureus E. Tuberculosis

A. Varicella, C. Rubella E. Tuberculosis

A home health nurse is assessing an older adult client who reports falling a couple times over the past week. Which of the following findings should the nurse suspect is contributing to the client's falls? A. the client takes alprazolam B. the client has a nonslip bath mat in his shower C. the client uses a raised toilet seat D. The client wears fitted slippers.

A. the client takes alprazolam Alprazolam is a CNS depressant that can cause dizziness and orthostatic hypotension, which can cause the client to lose his balance and fall.

A nurse is reinforcing teaching with a client who has low health literacy. Which of the following actions should the nurse take? Select all that apply A. use teach back method B. encourage questions C. speak slowly D. use medical terminology E. Provide written materials.

A. use teach back method B. encourage questions C. speak slowly

A nurse is caring for a client who has rheumatoid arthritis and tells the nurse that she wear a copper bracelet to help her feel better. Which of the following responses should the nurse make? A. yes, i understand that you feel better wearing your bracelet B. Why do you think the copper helps with your arthritis? C. believing objects have powers to make you feel better has no scientific basis D. I think you should rely more on your medication therapy than on your bracelet.

A. yes, i understand that you feel better wearing your bracelet

A nurse is planning care for a client who is postop following a total hip arthroplasty. which of the following interventions should the nurse include in the plan of care? A. instruct the client to avoid movement of the affected leg. B. Prevent the hip flexion of the affected extremity C. position the lower extremities so that they are touching D. Ensure that the clients heels are touching the bed.

B. Prevent the hip flexion of the affected extremity

A nurse is caring for a client who is 4 hr postoperative following a hip replacement. the nurse should instruct the client to avoid which of the following activities? A. placing a large pillow between legs when turning B. Putting on shoes and socks C. Using a raised toilet seat D. Using a walker

B. Putting on shoes and socks

A public health nurse is assessing an older client who lives with a family member. The nurse identifies several bruises in various stages of healing. The client and family member explain that the bruises are a result of clumsiness. However, based on the distribution of the bruises, the nurse suspects abuse. Which of the following actions should the nurse take first? A. document the bruises in the clients chart B. Report the findings to a supervisor C. provide the client with a crisis hotline number D. Discuss respite care with the client's family.

B. Report the findings to a supervisor Sometimes when it says "Take first" think about which option is the greatest risk.

A nurse is teaching a client who has gout about medications. the nurse should teach the client to avoid the use of which of the following types of medication? A. NSAIDS B. Salicylates C. antihistamines D. Expectorants

B. Salicylates Such as aspirin and diuretics can trigger gout attacks

A nurse is teaching a client who has a new prescription for ibuprofen to treat hip pain. Which of the following instructions should the nurse include in the teaching? A. expect ringing in your ears B. Take the medication with food C. Store the medication in the refridgerator D. Monitor for weight loss

B. Take the medication with food

A nurse is assessing a client who has systemic lupus erythematosus and is taking hydrooxychloroquine. The nurse should report which of the following adverse effects to the provider immediately? A. diarrhea B. blurred vision C. pruritus D. Fatigue

B. blurred vision

A nurse is teaching an older adult who has a new prescription for a pain medication. Which of the following actions should the nurse take? A. provide written materials that are printed with a small font size B. instruct the client to keep a pain diary C. Provide the information at a 10th grade reading level D. Instruct the client to take the pain medication after the pain becomes severe.

B. instruct the client to keep a pain diary

A nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs? A. Call the family and ask them to stay with the client B. move the client to a room closer to the nurses' station C. apply wrist and leg restraints to the client D. Administer medication to sedate the client

B. move the client to a room closer to the nurses' station

A nurse is caring for a female client who has RA and a new prescription for methotrexate. The client tells the nurse she is planning a pregnancy. Which of the following instructions should the nurse give the client? A. Dietary modifications occur during pregnancy B. the medication should be discontinued 3 months prior to a planned pregnancy C. dosage of the medication will be reduced during pregnancy D. The client can breast feed when taking this medication.

B. the medication should be discontinued 3 months prior to a planned pregnancy

A charge nurse is providing an in-service to a group of staff nurses about unexpected events. Which of the follwoing should the nurse include in the teaching as an example of a sentinel event? A. a client was almost given another client's medication B. A client fell out of bed and fractured their hip C. A client had bowel surgery and died from sepsis. D. A client was prescribed a medication they were allergic to, but the prescription was canceled before the medication was given

C. A client had bowel surgery and died from sepsis. A sentinel event is an unexpected event that caused severe or permanent harm to the client and even death.

A nurse is teaching a client about risk factors for osteoarthritis. Which of the following factors should the nurse include in the teaching? select all that apply A. Bacteria B. Diuretics C. Aging D. Obesity E. smoking

C. Aging D. Obesity E. smoking

A nurse is completing discharge teaching with a client following arthroscopic knee surgery. Which of the following instructions should the nurse include in the teaching? A. remain on bedrest for the first 24 hrs B. Keep the leg in a dependent position C. Apply ice to the affected area D. Begin active range of motion

C. Apply ice to the affected area

A nurse is observing a newly licensed nurse perform hand hygiene. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? A. turns off the faucet with their hands B. uses hot water to wash their hands C. Holds their hands below the elbows while rinsing off soap D. Washes their hands for 10 seconds

C. Holds their hands below the elbows while rinsing off soap

A nurse is reviewing discharge instructions with a client who has rheumatoid arthritis and a new prescription for prednisone. Which of the following statements by the client indicates an understanding of the teaching? A. I should take my flu vaccine within one week of starting this medication B. I can expect a sore throat for the first week after starting this medication C. I should eat more bananas while taking this medication D. I should take aspirin for minor aches and pains while taking this medication

C. I should eat more bananas while taking this medication Instruct client to eat more potassium-rich foods such as bananas because Prednisone can cause a loss of potassium, and the nurse should instruct the about the manifestations of hypokalemia such as muscle weakness and cramping

A nurse is caring for an older adult client who states, "I am afraid that I am going to fall when I get up at night to use the restroom". which should be the nursing priority A. Limit the client's fluid intake in the evening B. Obtain a bedside commode for the client's use C. Leave a nightlight on in the client's room D. Put the side rails up and tell the client to call the nurse before voiding

C. Leave a nightlight on in the client's room

A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to prevent the transmission of the client's infection? A. Changing the client's bed linens each day. B. Encouraging the client to consume a high-protein diet C. Performing hand hygiene before, during, and after direct contact with the client D. Placing the client in a room with positive-pressure airflow.

C. Performing hand hygiene before, during, and after direct contact with the client

A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings is the highest priority for the nurse to report to the provider? A. client report of feelings of depression. B. Dry, raised rash on the face. C. Presence of peripheral edema. D. Joint pain in hands and knees

C. Presence of peripheral edema.

A nurse is caring for a client who is post op following hip arthroplasty. the nurse should anticipate which of the following prescriptions for this client? A. aspirin B. clopidogrel C. enoxaparin D. alteplase

C. enoxaparin The nurse should anticipate a prescription for enoxaparin as prophylaxis therapy for venous thromboembolism. Clients following hip arthroplasty are usually on anticoagulants for 3 to 6 weeks after surgery.

A nurse is teaching a class about pain management in older adult clients. Which of the following information should the nurse include? A. Pain perception decreases with aging B. Opioids should not be used in older adult clients C. older adult clients frequently underreport pain D. clients who are cognitively impaired do not feel pain.

C. older adult clients frequently underreport pain

A nurse is admitting a client who is arriving back to the unit from the PACU following hip arthroplasty. Which of the following tasks should the nurse assign to the assistive personnel (AP)? A. Obtain initial vital signs B. determine if the client is in need of pain medication C. record the amount of urine in the catheter drainage bag. D. instruct the client of the use of the incentive spirometer.

C. record the amount of urine in the catheter drainage bag.

A nurse is teaching a newly licensed nurse about cleaning medical equipment. Which of the following instructions should the nurse include? A. Clean equipment soiled with organic material without protective eyewear. B. Use disinfectants to clean blood off of blood pressure cuffs. C. remove visible material from equipment before disinfecting D. use low-level disinfection on endoscopic equipment

C. remove visible material from equipment before disinfecting

A nurse is reviewing the cause of gout with a group of nurses. Which of the following statements should the nurse make? A. "uric acid levels drop and calcium forms precipitate" B. tophi forms in the kidneys and they impair the excretion of uric acid. C. the intra-articular deposition of urate crystals causes inflammation. D. Articular cartilage thins, leading to splitting and fragmentation.

C. the intra-articular deposition of urate crystals causes inflammation.

A nurse is orienting a new assistive personnel (AP) to the unit. For which of the following actions should the nurse intervene? A. wears a gown when entering the room of a client who requires contact precautions B. dons gloves to empty a urinary drainage device C. washes and rinses her hands for 10 seconds D. wears a respirator mask when entering the room of a client who requires airborne precautions

C. washes and rinses her hands for 10 seconds

A nurse suspects that a family caregiver is neglecting an older adult client. Which of the following statements by the caregiver should the nurse identify as the priority to address? A. we only have enough money for two meals a day B. we sit outside every afternoon. C. we buy the prescriptions we can afford D. we cannot afford new batteries for his hearing aid.

C. we buy the prescriptions we can afford

A nurse is caring for a client who has methicillin- resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following actions should the nurse take? A. wear an N95 respirator mask B. wear sterile gloves C. wear clean gloves D. wear protective eyewear

C. wear clean gloves

A nurse is caring for a client who is post op following knee arthroplasty and has a continuous passive motion (CPM) machine. Which of the following actions should the nurse take? A. store the CPM machine on the floor when not in use B. Use a special pillow to rotate the affected knee internally. C. Set the CPM to fully flex to the knee joint D. Apply ice to the operative knee.

D. Apply ice to the operative knee.

A clinical nurse educator is preparing for an educational program about transmission of methicillin-resistant staph aureus (MRSA) in hospitalized clients. Which of the following information should the nurse include in the program? A. Place clients who have MRSA on airborne precautions. B. MRSA can be effectively treated with an antiviral medication C. MRSA can live on the hands for 1 hr D. Bathe clients with water and chlorhexidine gluconate

D. Bathe clients with water and chlorhexidine gluconate

A nurse is teaching a newly licensed nurse about reducing the risk of needlestick injuries. Which of the following instructions should the nurse include? A. Uses sharp containers until they are completely full. B. Dispose of large-bore needles into waterproof wastebaskets C. Bend needles without safety devices before disposing of them D. Engage the safety device immediately after using a needle.

D. Engage the safety device immediately after using a needle.

A nurse is preparing a presentation about glucosamine to a group of clients. Which of the following information should the nurse include in the teaching? A. Glucosamine can help relieve urinary frequency B. Glucosamine is used to treat viral infections c. Glucosamine can help relieve hot flashes D. Glucosamine can suppress joint inflammation

D. Glucosamine can suppress joint inflammation

A nurse is teaching a client who had a total knee arthroplasty about self-administering morphine via a patient controlled analgesia (PCA) infusion device. which of the following client statements indicates an understanding of the teaching? A. "I should only use the device when it's absolutely necessary" B. I will ask my family to push the dose button when I am asleep. C. Ill be careful about pushing the button so i don't overdose D. I should tell the nurse if I can't control my pain with this device

D. I should tell the nurse if I can't control my pain with this device

A nurse is completing discharge instructions with a client following an acute onset of gout. Which of the following client statements indicates an understanding of the treatment regimen? A. I will closely follow a high-prune diet B. I will limit my fluid intake to 1 L per day C. i will take one aspirin every day D. I will limit my alcohol intake

D. I will limit my alcohol intake

A nurse is assessing an older adult client. Which of the following findings should the nurse expect? A. Increased peripheral vision B. Increased sensitivity to touch C. Increase in size of pupils D. Increase in cerumen in the ear canal

D. Increase in cerumen in the ear canal

A nurse is teaching a client who takes acetaminophen daily to manage mild knee pain. The nurse should instruct the client to monitor for which of the following adverse reactions to this medication? A. Tinnitus B. Muscle pain C. Hyperglycemia D. Jaundice

D. Jaundice

A nurse is caring for a client who is placed on droplet precautions. Which of the following actions should the nurse take? A. wear a surgical mask when within 0.6m (2ft) of the client B. Move the client to a positive air flow room C. Remove fresh flowers from the client's room D. Place a surgical mask on the client when they leave their room

D. Place a surgical mask on the client when they leave their room

A nurse is caring for a client who has a new diagnosis of C. diff and is placed on contact precautions. Which of the following actions should the nurse take? A. Remove protective gown before removing gloves B. Use an electronic thermometer to take the client's temperature. C. Shake bed linens before placing them in a linen bag D. Remove the protective gowns before leaving the client's room.

D. Remove the protective gowns before leaving the client's room.

A nurse is reviewing laboratory values for a client. Which of the following findings indicates the presence of an infection? A. Hgb 15g/dl B. Platelet count 200,000/mm3 C. Creatine kinase 75 units/L D. WBC count 22, 000/ mm3

D. WBC count 22, 000/ mm3 An elevated WBC is a manifestation of a present infection

A nurse is assessing a client who has systemic lupus erythematosus (SLE). which of the following findings should the nurse expect? A. wrinkles in the skin B. constipation C. iritis D. facial rash

D. facial rash

A nurse is preparing a client for a total hip arthroplasty. For which of the following reasons should the nurse assess the client's vital signs? A. To prevent postoperative hypotension B. To determine how the client will tolerate the procedure. C. to assess the client's pain level D. to establish a baseline for post op assessment

D. to establish a baseline for post op assessment

A nurse is teaching a client who has gout about dietary recommendations. the nurse should teach the client that which of the following beverages can trigger an attack? A. alcohol B. orange juice c. milk d. coffee

a. alcohol

A nurse is teaching about professional values in nursing with a newly licensed nurse. Which of the following information should the nurse include? select all that apply A. nonmaleficence b. altruism c. beneficence d. social justice e. autonomy f. integrity

b. altruism d. social justice e. autonomy f. integrity

A nurse is admitting a client who has a wound infected with vancomycin-resistant enterococci (VRE). Which of the following types of precautions should the nurse plan to initiate? A. Droplet B. Contact C. Airborne D. protective

b. contact

An older client who lives alone tells a clinic nurse that he is unable to drive himself to the store and is afraid to cook on the stove. Which of the following community resources should the nurse recommend for this client? A. hospice care b. meals on wheels c. a rehabilitation facility d. temporary assistance for needy families (TANF)

b. meals on wheels

A nurse working for a home health agency is assessing an older adult male client. Which of the following findings is the priority for the nurse to address? A. Swollen gums B. priuritus C. urinary hesitancy D. Dysphagia

dysphagia

A nurse is changing the bed linen for a client who is on contact precautions. Which of the following personal protective equipment should the nurse wear? A. goggles B. N95 respirator C. face shield D. gloves

gloves

which is the right order to remove PPE

remove most contaminate first. Gloves, eyewear, gown, mask, hand hygeine.