ATI NCLEX CHALLEGE 4

A nurse is caring for a client who has a 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 is left side in Trendelenburg position (this position helps trap 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 active TB. The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to get a chest x-ray?

have the client wear a mask

A nurse is reviewing a clients prescription for 1000mL of 5% dextrose in water IV to infuse over 8 hours. At 1400, the nurse observes that there is 500mL of solution remaining in the clients current IV bag. At what time should the nurse administer the next bag of fluids?

1800 (the IV will infuse at 125mL/hr)

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 expect?

catheter migration (a gurgling sound heard on the side of the insertion of the catheter is a manifestation of catheter migration)

A nurse is assessing a client who has pulmonary tuberculosis. Which of the following findings should the nurse expect?

Lethargy

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

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

barrel chest

A nurse is calculating the intake of a client during the past 9 hours. the clients intake includes lactated ringers IV at 150mL/hr, cefazolin 2g IV intermittent bolus in 100mL of 0.9% sodium chloride, two units of packed RBCs of 275ml and 250ml; two IV bolus infusions of 250ml of 0.9% sodium chloride, famotidine 20mg IV intermittent bolus in 50ml of 0.9% sodium chloride. How many mL of intake should the nurse record?

2525mL

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 nurses priority?

assess the clients respiratory status

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 (prevents air from entering the lumen, the heart, and pulmonary circulation)

A nurse is caring for a client who has advanced lung cancer. The clients provider has recommended hospice services 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 manage my dyspnea"

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?

"I will turn my head away from the insertion site to allow optimal accuracy in placing the catheter"

A nurse is teaching the mother of a child who has cystic fibrosis and has a prescription for pancreatic enzymes three times per day. Which of the following statements indicates that the mother understands the teaching?

"My child will take the enzymes to help digest the fat in foods"

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 that the client has phlebitis at the IV insertion site?

"the area around the insertion site feels warm to touch"

A nurse is caring for a preschooler who was admitted for complications related to cystic fibrosis A nurse is discussing the treatment plan of a client who has cystic fibrosis with the provider. ---- anticipated, nonessential, contraindicated

- high frequency chest compression BID (anticipated) - high calorie, high protein with unrestricted fats (anticipated) - oxygen at 8L/min via simple face mask (contraindicated) - quantitative sweat chloride test (nonessential) - percussion and postural drainage TID following meals (contraindicated) - contact isolation (anticipated)

A nurse is caring for an adolescent client who has pneumonia and a prescription for cefpodoxime 5mg/kg PO every 12hrs for 5 days. The client weighs 88 lbs. How many mg should the nurse administer? (whole #)

200 mg/dose

A nurse is planning care for a client who is to receive packed RBCs. The nurse should plan for the total infusion time to not exceed which of the following?

4hrs (due to temp inconsistencies that develop over time and the possibility of bacterial contamination)

A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130. The nurse should begin the infusion at which of the following times?

As soon as the nurse can prepare the client and the administration set.

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 assessing the catheter?

Use a 10mL syringe to flush the catheter

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 (chest tubes help drain air and fluid and remain in place for several days post op)

A nurse is caring for a client following exposure to inhalation anthrax due to bioterrorism. Which of the following medications should the nurse expect as a common medication to treat anthrax?

ciprofloxacin doxycycline amoxicillin (recommended tx for inhalation of anthrax includes a combination of antibiotics that treats a positive serum gram stain)

A nurse in the emergency department is assessing an older adult client who has a 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 prepares to replace the nearly empty container of TPN for a client when she finds that there has been a delay in receiving the new container of solution from the pharm. Which of the following solutions should the nurse infuse until the next container of TPN solution becomes available?

dextrose 10% in water (sudden withdraw from TPN which contains dextrose can result in a sudden drop in the clients blood glucose levels -- administering dextrose 10% in water will prevent hypoglycemia)

A nurse is admitting a client who has influenza and is reporting numbness and tingling of the toes and fingers. The nurse should recognize the client is experiencing which type of acid-base imbalance?

metabolic alkalosis excessive vomiting can lead to metabolic alkalosis (dizziness, numbness and tingling of the extremities)

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

tape the connections on the clients chest tube (connections of a chest tube should be securely taped to reduce the risk of disconnection which could cause air to enter the clients pleural cavity)

A nurse is caring for a client who has anemia --- select the 4 findings that require immediate follow-up. (has a client chart)

temperature back pain urine color blood pressure (manifestations of a acute hemolytic transfusion rx -- nurse should stop transfusion, notify HCP, and send urine sample to lab)

A nurse is caring for a client who has a prescription for one unit of packed RBCs. The nurse should plan to remain in the room with the client at which of the following times during the infusion to observe for a transfusion rx?

the first 15 minutes