NCLEX Challenge 4 Spring 2020

A nurse is caring for a client who has a deep vein thrombosis and is prescribed heparin by continuous IV infusion at 1,200 units/hr. Available is heparin 25,000 units in 500 ml D5W. The nurse should set the IV pump to deliver how many mL/hr?

24 mL/hr

A nurse is teaching a middle-age client about hypertension. Which of the following information should the nurse include in the teaching?

"Diuretics are the first type of medication to control hypertension." The nurse should include in the teaching that diuretic medication is the first type of medication to control hypertension, by decreasing blood volume and lowering blood pressure.

A nurse is reviewing discharge instructions with a client who has Raynaud's disease. Which of the following client statements indicates an understanding of the teaching?

"I am going to take a stress management class." The nurse should instruct the client that stress can elicit attacks. The client should learn to avoid stressful situations when possible and learn to manage stress to limit the occurrence of attacks.

A nurse is reviewing the laboratory results for a client who has a history of atherosclerosis and notes elevated cholesterol levels. Which of the following statement by the client indicates the nurse should plan follow-up teaching on a low cholesterol diet?

"I eat two eggs for breakfast each morning" Clients should limit egg yolks to two to three per week.

A nurse is preparing to insert an IV catheter for a client and has selected the insertion site. Place the following steps in the order in which the nurse should perform them.

-Cleanse site -Apple Tourniquet -Dilate Vein -Insert Cath -Flush Cath After the nurse first applies a tourniquet or BP cuff to help select the vein for the IV infusion, he should remove the device, cleanse the site with soap and water, allow it to dry, and then cleanse it with an antiseptic swab, again allowing it to dry. Then he should reapply the tourniquet or BP cuff, dilate the vein, check for pulsation, then insert the venous access device. After noting a blood return, he should stabilize the catheter, release the tourniquet, flush the catheter, and then secure it.

A nurse is preparing to administer a transfusion of RBCs to a client who has heart failure. For which of the following manifestations should the nurse monitor to prevent fluid volume overload?

-Dyspnea -Jugular vein distention -Confusion Dyspnea is a clinical manifestation of fluid volume overload. Jugular vein distention is a clinical manifestation of fluid volume overload. Confusion is a clinical manifestation of fluid volume overload.

A nurse in a long-term care facility enters the day room and finds the window curtains on fire. Clients are panicking and the room is filling with smoke. Indicate the emergency actions the nurse must take?

-Remove the clients from the room -Activate the fire alarm -Close the door -Extinguish the fire In the event of a fire, it is helpful to recall the mnemonic RACE to prioritize the actions to take: R - Rescue and remove the clients, A - Activate the alarm, C - Confine the fire, and E - Extinguish the fire. The nurse's priority action is to remove the clients from the room. The nurse should then sound the fire alarm and close the door to confine the fire. Finally and if possible, the nurse should extinguish the fire.

A nurse is caring for a client and identifies an infiltration at the IV catheter site. Identify the order the nurse should perform the following actions.

-Stop the infusion -remove the iv catheter -apply a sterile dressing -elevate the extremity -apple warm or cold compress The nurse should first stop the infusion. Next, the nurse should remove the IV catheter and apply a sterile dressing to the insertion site. The nurse should elevate the extremity and apply warm or cold compresses according to agency policy.

A nurse is teaching a client about snacks that are appropriate on a low-fat, low-sodium, low cholesterol diet. Which of the following food choices by the client indicates the need for further teaching?

A slice of cheese The client should limit the intake of cheese due to high levels of fat and sodium.

A nurse is providing discharge teaching to a client who has peripheral arterial disease (PAD). Which of the following instructions should the nurse include in the teaching?

Adjust the thermostat so that the environment is warm. The client's instructions should include keeping the environment warm to prevent vasoconstriction. Wearing gloves, warm clothes, and socks will help prevent vasoconstriction.

A nurse is assessing a client who had left femoral cardiac angiography. Identify where the nurse will palpate to assess the most distal pulse on the affected side.

Bottom left food The most distal pulse refers to the pulse that is at the farthest point on the affected extremity. The dorsalis pedis pulse on the anterior foot is the most distal pulse below the femoral artery. Because the client had left-sided angiography, the correct answer will be the left pedal pulse.

A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse the client is developing this condition?

Breathlessness Manifestations of left-sided heart failure include crackles or wheezes and breathlessness due to pulmonary congestion.

A nurse in a clinic is caring for a client who has recently begun taking warfarin. The nurse is reviewing potential drug and food interaction risks and should instruct the client to avoid which of the following.

Cabbage Cabbage should be limited in the diet when taking warfarin, because it is rich in vitamin K.

A nurse is assessing for paradoxical blood pressure on a client who has constructive pericarditis. Which of the following findings should the nurse expect?

Decrease in systolic pressure by more than 10 mm Hg during inspiration The nurse should expect a client who has constrictive pericarditis to have a decrease in systolic pressure by more than 10 mm Hg during inspiration, which is paradoxical blood pressure. This is also an expected finding for a client who has pulmonary hypertension or cardiac tamponade.

A nurse is providing teaching to a client who has hypertension and a new prescription for captopril. Which of the following instructions should the nurse provide?

Do not use salt substitutes while taking this medication Captopril, an ACE inhibitor, can cause hyperkalemia due to potassium retention by the kidney. The client should avoid salt substitutes, as most of them are high in potassium.

A nurse is caring for a client who has infective endocarditis. Which of the following manifestations is the priority for the nurse to monitor for?

Dyspnea When using the airway, breathing, circulation (ABC) approach to client care, the nurse determines the priority manifestation to monitor for is dyspnea. Dyspnea can be an indication of left-sided heart failure, or a pulmonary infarction due to embolization.

A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following instructions should the nurse include is the teaching?

Exercise at least three times per week. The nurse encourage the client to stay as active as possible and to develop a regular exercise regimen. Clients who have heart failure who remain active appear to have improved outcomes. The client should try to walk at least three times per week and should slowly increase the amount of time walked over several months. Regular exercise strengthens the heart and cardiovascular system, thereby improving circulation and lowering blood pressure.

A nurse is caring for a client who has a large lower-leg ulcer. Which of the following foods should the nurse suggest to the client to provide the most protein for wound healing?

Grilled salmon Poultry, fish, eggs, and beef are complete proteins and are optimal sources of protein to support wound healing.

A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor for his disorder?

Hypercholesterolemia, hypertension, obesity, smoking Hypercholesterolemia is correct. Cholesterol levels outside the healthful range increase clients' risk for heart disease, and they can change these levels. Hypertension is correct. Although it may not always be possible to eliminate hypertension, clients can change their blood pressure levels and thus reduce their risk for atherosclerosis. Obesity is correct. Clients who are overweight or obese can reduce their risk for heart disease by losing weight. Smoking is correct. Clients who smoke can reduce their risk for heart disease by quitting smoking.

A nurse is assessing a client's peripheral circulation. In which of the following locations should the nurse palpate to assess the posterior tibial pulse"

Inside ankle The posterior tibial pulse is located on the inner ankle, one-third of the way along a line between the tip of the medial malleolus (end of the tibia) and the point of the heel. It is most easily palpated about 2.5 cm higher, where it runs behind the medial malleolus.

A nurse is measuring a client for a knee-high antiembolic stockings to help prevent venous stasis. Which of the following actions should the nurse take?

Measure from the heel to the popliteal space. If the stocking is too short, if could impair circulation at its upper end. If it is too long, it can bunch together, which would cause pressure and irritate the skin. Measuring the length from the feet to the popliteal space helps the nurse identify the right size stockings for the client's legs.

A nurse is providing instruction to a new nurse about caring for clients who are receiving diuretic therapy to treat heart failure. The nurse should explain that which of the following medications puts clients at risk for both hyperkalemia an hyponatremia?

Spironolactone Spironolactone is a potassium-sparing diuretic. It blocks the effects of aldosterone in the renal tubules, causing a loss of sodium and water and the retention of potassium. The possible adverse reactions include hyperkalemia and hyponatremia.

A nurse is establishing health promotion goals for a female client who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following goals should the nurse include?

The client will walk for 30 min 5 days a week. CDC recommendations include engaging in a moderate exercise, such as walking, for a total of 150 min each week.

A nurse is caring for a client who has a new diagnosis of essential hypertension. The nurse should monitor the client for which of the following findings that is consistent with this diagnosis?

Vertigo The nurse should monitor the client for findings such as vertigo, headache, facial flushing, and fainting. These manifestations are consistent with a new diagnosis of essential hypertension.

A nurse is caring for a client who has hypertension and is afraid to take his blood pressure medication. Which of the following nursing statements is an example of therapeutic communication response of reflection?

You seem upset about taking your blood pressure medication." This statement is a reflective comment that describes the patient's feelings. A reflective comment repeats what a patient has said or describes the person's feelings.

A nurse is providing teaching about a heart healthy diet to a group of clients with hypertension. Which of the following statements by one of the clients indicates a need for further teaching?

"I may eat 10 ounces of lean protein each day." Lean meats should be limited to 5 to 6 oz per day. This statement by a client requires additional teaching.

A nurse is providing discharge instructions for a client who has congestive heart failure. Which of the following client statements indicates to the nurse that the teaching was effective?

"I plan to slow down if I am tired the day after exercising." Clients who experience chest pain or dyspnea while exercising or experience fatigue the next day are probably advancing the activity too quickly and should slow down.

A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Which of the following client statements should indicate to the nurse the need for additional teaching?

"I will take my medications at the first sign of an attack." Taking medications at the onset of an episode of Raynaud's disease may help to reduce the severity of the manifestations, but it will not prevent the onset of vasoconstriction.

A nurse is providing teaching to a client who has hypertension and a new prescription for hydrochlorothiazide. Which of the following instructions should the nurse provide?

Take the medication early in the day The nurse should instruct the client to take hydrochlorothiazide early in the day to avoid nocturia.

A nurse is caring for a client who is prescribed warfarin therapy for an artificial heart valve. Which of the following laboratory values should the nurse monitor for a therapeutic effect of warfarin?

Prothrombin time (PT) This test is used to monitor warfarin therapy. For a client receiving full anticoagulant therapy, the PT should typically be approximately two to three times the normal value, depending on the indication for therapeutic anticoagulation

A nurse is assessing a client's circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?

Carotid The nurse should avoid assessing the carotid pulse sites bilaterally at the same time. This action can induce syncope by reducing blood flow to the brain and causing a reflex drop in the blood pressure and heart rate.

The nurse is caring for a client who has heart failure and a history of asthma. The nurse reviews the provider's orders and recognizes that clarification is needed for which of the following medications?

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

A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?

Check the client's vital signs. It is possible that the client's nausea is secondary to digoxin toxicity. By obtaining vital signs, the nurse can assess for bradycardia, which is a symptom of digoxin toxicity. The nurse should withhold the medication and call the provider if the client's heart rate is less than 60 bpm.

A nurse is preparing to administer heparin subcutaneously to a client who has a deep vein thrombosis. Which of the following techniques should the nurse use?

Cleanse the skin with an alcohol swab, insert the needle, inject the heparin, and observe for bleeding. This is the correct technique for the nurse to use to inject heparin.

A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect?

Elevated central venous pressure (CVP). CVP is a measurement of the pressure in the right atria or ventricle at the end of diastole. An elevated CVP is indicative of heart failure.

The nurse is planning care for a client who has a deep-vein thrombosis (DVT) and is receiving anti-coagulation therapy. Which of the following interventions should the nurse include in the plan of care?

Encourage the client to walk. The client should avoid sitting or standing for long periods of time. After the client begins anticoagulant therapy, the nurse should encourage the client to walk.

A nurse in a public clinic is planning a health fair for older adult clients in the community. In teaching medication safety, which of the following foods should the nurse advise the clients to avoid when taking their prescriptions?

Grapefruit juice There is a high rate of food-drug interactions between grapefruit juice and many medications frequently taken by older adults, especially lipid-lowering agents. It is thought that one or more of the chemicals (most likely flavonoids) in grapefruit juice alter the activity of specific enzymes (such as CYP3A4 and CYP1A2) in the intestinal tract. These enzymes decrease the rate at which medications enter the systemic circulation. This could allow a larger amount of these drugs to reach the bloodstream, resulting in increased drug levels and possibly toxicity.

a nurse is assessing a client who is at risk for deep-vein thrombosis (DVT). Which of the following findings is a manifestation of DVT.

Groin tenderness Groin tenderness Calf pain, groin pain, and unilateral leg swelling are manifestations of DVT.

A nurse is caring for a client who has heart failure and is receiving IV furosemide. The nurse should monitor the client for which of the following electrolyte imbalances?

Hyperuricemia Rationale: uric acid, notify the provider for any tenderness or swelling of the joints The nurse should monitor the client who is receiving IV furosemide for hyperuricemia. The nurse should instruct the client to notify the provider for any tenderness or swelling of the joints.

A nurse is assessing a 3 yer old child who has aortic stenosis. Which of the following findings should the nurse expect?

Hypotension Weak Pulses Murmur Hypotension is correct. Hypotension with aortic stenosis is a result of decreased cardiac output. Weak pulses is correct. Weak pulses with aortic stenosis are a result of decreased cardiac output. Murmur is correct. A narrowing of the aortic valve cause a characteristic murmur in children who have aortic stenosis.Murmur is correct. A narrowing of the aortic valve cause a characteristic murmur in children who have aortic stenosis.

While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care?

Impaired tissue perfusion When using the airway, breathing, and circulation (ABC) priority-setting framework, the nurse should identify impaired perfusion of tissues as the priority finding. The presence of varicose veins indicates venous reflux is present which inhibits perfusion to all the tissues. The nurse should note the client has signs of chronic venous insufficiency as well which include edema, a feeling of heaviness in the legs, and the presence of venous stasis ulcers.

A nurse is caring for a client who has peripheral arterial disease (PAD). Which of the following symptoms should the nurse expect to find in the early stage of the disease?

Intermittent claudication Intermittent claudication is ischemic pain that is precipitated by exercise, resolves with rest, and is reproducible. The pain associated with claudication arises when cellular oxygen demand exceeds supply. It occurs early in the disease course, and is typically the initial reason clients who have PAD seek medical attention.

A nurse is planning care for a client who has a deep vein thrombosis of the lower leg. Which of the following interventions should the nurse include in the plan of care?

Keep the clients affected leg elevated while in bed The nurse should keep the client's leg elevated when he is in bed to decrease edema.

A nurse is reviewing the laboratory results of a male adult client who is at risk for peripheral arterial disease from atherosclerosis. The nurse should identify that which of the following results places the client at risk?

LDL 172 mg/dL The nurse should identify that an LDL of 172 mg/dL places the client at risk for peripheral arterial disease from atherosclerosis. The expected reference range for an adult is less than 130 mg/dL.

A nurse is preforming a cardiac assessment. Identify where the nurse should place the stethoscope to auscultate the client's apical pulse?

Left 5th intercostal space The nurse should auscultate the client's apical pulse over the apex of the heart, at the anatomical landmarks of the 5th intercostal space and below the left nipple line 7.6 cm (about 3 in) to the left of the sternum.

A nurse is providing dietary teaching for a client who chronic obstructive pulmonary disease. Which of the following instructions should the nurse include?

Limit water intake with meals The nurse should instruct the client to limit low nutrient liquids during meals to prevent early satiety and increase intake of nutrient dense foods.

A nurse is assessing a client who has hypercholesterolemia and is receiving simvastatin. Which of the following findings should the nurse recognize as a potential adverse effect?

Muscle weakness Myopathy is an adverse effect of this medication. Signs of myopathy include muscle aches, tenderness, and muscle weakness.

A nurse is giving a presentation about preventing deep-vein thrombosis (DVT). Which of the following should the nurse exclude as a risk for this disorder?

Oral contraceptive use Immobility Oral contraceptive use is correct. Thromboembolic events are an adverse effect of oral contraceptives. Immobility is correct. Immobility leads to stasis of blood, thus increasing the risk for clot formation.

A nurse is completing discharge planning for a client who has bacterial endocarditis. The client will need to receive 12 weeks of antibiotic therapy. Which of the following venous access devices should the nurse identify as appropriate for the client?

Peripherally inserted central catheter A peripherally inserted central catheter (PICC) line is the venous access device commonly used when the client needs extended, but not permanent, intravenous access. The PICC line may remain in place for weeks or months. PICC lines can also be used to draw blood samples without the need for additional venipunctures.

When planning delegation of tasks to assistive personnel (AP), a nurse considers the five rights of delegation. Which of the following should the nurse consider when using one of the five rights of delegation?

The AP has the knowledge and skill to perform the task The right person is one of the five rights of delegation. The nurse should seek information from the AP about his individual skill level before delegating the task.