NCLEX Challenge 3 Spring 2020

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

Barrel 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 is assessing a client who is receiving total parental nutrition (TNP) therapy via an infusion pump. Which of the following actions should the nurse take?

Change the IV tubing every 24 hours 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 an older adult client who is receiving IV therapy. The nurse should recognize that which of the following findings indicates fluid volume excess?

*bounding pulse Fluid volume excess is due to excessive fluid intake or inadequate fluid excretion. Manifestations include increased blood pressure, pulse, and respirations. With fluid volume excess, the pulse is full and bounding. *pitting edema Excess extracellular fluid can lead to pitting edema in dependent areas of the body. *crackles upon auscultation Pulmonary edema can occur with fluid volume excess.

A nurse is preparing to administer TPN 1800 mL to infuse over 24 hours. The nurse should set the IV pump to deliver how many ml/hr?

75 ml/hr

A nurse is caring for a client who has lung cancer and is scheduled for a lobectomy. The nurse should prepare the client to expect which of the following after the procedure?

A chest tube A lobectomy is major surgery that involves a large posterolateral or anterolateral incision into bone, muscle, and cartilage. Chest tubes are placed to drain air and fluid and remain in place for several days postoperatively

A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse's highest priority?

Administering a nebulized beta-adrenergic The greatest risk to the client's safety is airway obstruction. Beta-adrenergic medications act as bronchodilators. They provide prompt relief of airflow obstruction by relaxing bronchiolar smooth muscle and are the initial priority intervention when a client has an acute asthma exacerbation.

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

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

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?

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 the 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 chronic obstructive pulmonary disease (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 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 how 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 has central venous catheter and suddenly develops chest pain, dyspnea, dizziness, and tachycardia. The nurse suspects air embolism and clamps the catheter immediately. What other action should the nurse take at this time?

Place the client on his left side in Trendelenburg position This position helps trap the air in the apex of the right atrium rather than allowing it to enter the right ventricle and move to the pulmonary arterial system.

A nurse is caring for a 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

A nurse is caring for a client who requires isolation for active pulmonary tuberculosis. Which of the following precautions should the nurse include when creating a sign to post outside of the client's room?

A protective mask is correct. Clients who have active pulmonary tuberculosis require airborne precautions. Everyone entering the room requires respiratory protection, in the form of an appropriate filtration mask. A closed door is correct. Clients who have active pulmonary tuberculosis require airborne precautions. Everyone entering or leaving the room should close the door behind them. A puncture-proof sharps container is correct. Nurses must always dispose of needles and sharp instruments in puncture-proof sharps containers. Hand hygiene is correct. Hand hygiene is essential before and after all contact with clients.

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 outdoor environment 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 auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds?

Wheezes Wheezes are continuous, high-pitched squeaking sounds, first evident on expiration, but possibly evident on inspiration as the airway obstruction of asthma worsens. Wheezes are often audible without a stethoscope.

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 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 80/64 mm Hg. Which of the following actions should the nurse take first?

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

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

A nurse is caring for a client who has advanced lung cancer. The client's provider has recommended hospice serviced for the client. Which of the following statements by the client indicates a correct understanding of hospice care?

I should expect the hospice team to help me manage my dyspnea. Dyspnea is a manifestation of terminal lung cancer. The primary purpose of hospice care is to provide relief of symptoms related to a terminal illness.

A nurse is attempting to flush the IV saline lock for a client. The client reports pain above the catheter site. Which of the following actions should the nurse take?

Remove the IV saline lock The nurse should remove and move the IV catheter to another location because evidence indicates that the lock is not functioning properly.

A nurse is living a presentation at a community center about chronic bronchitis. Which of the following information should the nurse include as effective for preventing this disorder?

Smoking Cessation Smoking is a major cause of chronic bronchitis; therefore, smoking cessation is an effective preventive strategy.

A nurse is providing discharge teaching to a client who has asthma and a new prescription for fluticasone/salmeterol. For which of the following adverse effects should the nurse instruct the client to report to the provider?

White coating in the mouth Fluticasone/salmeterol is an inhaled glucocorticoid and long acting beta2 adrenergic agonist combination inhalation medication that is used for daily management of asthma. It is not a rescue medication. An adverse effect of the medication is oropharyngeal candidiasis. The nurse should instruct the client to gargle after each use, use a spacer to reduce the amount of drug in the mouth and throat, and report any white patches inside the mouth or on the tongue to the provider.

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

inhale deeply then exhale completely, place lips firmly around mouthpiece, breathe in deeply over 2-3 seconds while pushing down on canister, hold breath for 10 sec, exhale slowly through pursed lips, wait 60 sec between each puff Inhaling deeply and then exhaling completely is the first step. Next, the client should place her lips firmly around the mouthpiece to direct the spray to the airways, then breathe in deeply over 2 to 3 seconds while pushing down on the canister. This slow, deep inhalation directs the medication down into the lower respiratory tract. Holding her breath for 10 seconds is next; it allows time for absorption of the medication. Then, pursed-lip breathing keeps the small airways open during slow exhalation. And finally, waiting 60 seconds between puffs allows for deeper penetration of the medication into the respiratory tract.

A charge nurse notes that a staff nurse delegates an unfair share of tasks to the assistive personnel (AP) and the nurses on next shift report the staff nurse frequently leaves tasks uncompleted. Which of the following statements should the charge nurse make to resolve this conflict?

"I need to talk to you about unit expectations regarding delegating and completing tasks" This statement opens the conversation in a nonthreatening way. The focus is on the issue of the equity of the assignment rather than on any personal characteristic of the individual.

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

"I will turn my head in the opposite direction during insertion" 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 who is to undergo a left lobectomy to treat lung cancer. The client tells the nurse that she is scared and wishes she had never smoked. Which of the following responses should the nurse make?

"It's okay to feel scared. Let's talk about what you are afraid of" It is the nurse's responsibility to acknowledge the client's statement, to encourage verbalization, and to explore the client's feelings.

An assistive personnel comes to work with a new set of artificial nails. The nurse takes the AP to a private location to discuss the issue. Which of the following statements by the nurse is appropriate?

"There is a higher risk of infection for our clients associated with artificial nails" Short, natural nails are less likely to harbor pathogens that can be harmful to clients. The CDC recommends health care workers avoid wearing artificial nails when caring for clients who are at risk for infection. Additionally, guidelines from the World Health Organization prohibit artificial nails for caregivers in every setting.

A nurse enters an older adult clients room to insert a saline lock. The client asks the nurse, "Why do i need that? I am drinking plenty of fluids." Which of the following responses should the nurse provide?

"Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours." Intermittent antibiotic medications are frequently administered parenterally. This allows the client to ambulate between medication administrations, enhances client safety and promotes comfort. The response addresses the client's concern.

A nurse is planning care for a child who has cystic fibrosis and a prescription to receive chest physiotherapy. Which of the following actions should the nurse plan to take?

Administer albuterol prior to CPT. Albuterol is a bronchodilator that relaxes and dilates the airway to promote air exchange. The nurse should administer the medication prior to implementing CPT to improve airway clearance. Albuterol facilitates the removal of the secretions as the chest wall is being percussed.

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 effects?

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 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions in the nurse's priority?

Assess the clients 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 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 Oxygen therapy can dry the mucous membranes. The nurse should attach humidification for a client receiving oxygen greater than 4 L/min via nasal cannula.

A client has a right subclavian central venous catheter. When reconnecting 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 caring for a client who has active pulmonary tuberculosis (TB) 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 caring for a client who has central venous catheter and develops acute shortness of breath. Which of the following actions should the nurse take first?

Clamp the catheter. 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 the mother of a 5 year old who has cyctic 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.

A nurse on a medical-surgical unit is preforming 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?

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

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 se 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 preparing to obtain a blood specimen from a client by venipuncture. The client is receiving IV fluids through an IV catheter inserted in the basilic vein of the right forearm. Which of the following sites should the nurse plan to use to obtain the blood specimen?

Left forearm This site is in the antecubital fossa, which allows for easy access and does not interfere with the client's IV catheter and infusion. The nurse should use this site to obtain a blood specimen.

A nurse is caring for a client who is receiving total parental nutrition via a peripherally inserted central catheter (PICC). 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 a nurse should take using the nursing process is to ASSESS the client. The nurse should measure to confirm the arm is swollen.Then the nurse should notify the provider.

A nurse is caring for a client who has asthma and developed viral pharyngitis. Which of the following findings should the nurse expect?

Negative Throat Culture A client who has viral pharyngitis will have a negative throat culture. A client who has bacterial pharyngitis usually has a throat culture positive for beta-hemolytic streptococcus

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 admitting a client who is having an exacerbation of his asthma. When reviewing the provider's orders, the nurse recognizes the clarification is needed for which of the following medications?

Propranolol Medications that block beta-2 receptors, such as propanolol, are contraindicated in clients with asthma.

A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take?

Remove the catheter and insert another into a different site It is possible that the catheter is up against a valve or near a nerve and is causing more pain than an IV catheter insertion should. The nurse should remove the source of the pain and establish peripheral IV access elsewhere.

A 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 the client to breathe deeply and cough. Although crackles often indicate fluid in the alveoli, they can also be the result of positioning or decreased ventilation. They sometimes clear after a deep breath or a cough.

A nurse is working with a 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 IV insertion site?

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

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

The client holds his breath for 10 seconds after inhaling the medication. 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 in a PACU is admitting a client who is postoperative 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 Following a tonsillectomy, the client's gag reflex can be suppressed by local anesthetics or edema. To prevent aspiration, the gag reflex must be present before the client is allowed have fluids.

A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure, which of the following nursing actions should the nurse complete first?

auscultate lung fields The first action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is to auscultate lung fields to provide knowledge of which lung areas are most affected and would be the focus of the procedure.