NCLEX Challenge 4 Summer 2018
nurse is inserting IV catheter for an older pt in prep for an outpatient procedure. which vein should nurse select
median vein in the forearm
nurse caring for client with advanced lung cancer. pt provider has recommended hospice services. which statement by client indicates understanding of hospice care
"I should expect hospice team to help me manage my dyspnea" hospice care is in any setting; must be 6mo to live or less to be eligible; does not provide treatment, only comfort
nurse is teaching pt who has emphysema about self-management strategies. which of the following statements from pt indicates understanding
"I will follow a daily diet high in calories and protein" these pt have a greater than usual nutritional requirements for calories and protein and often need nutritional supplements between meals pt should lay on back to practice diaphragmatic breathing; pt must get flu shot and avoid crowds; when pursed lip breathing inhale slowly through nose and exhale slowly through pursed lips
nurse is providing discharge teaching to a pt who has asthma and new prescriptions for cromolyn and albuterol, both by nebulizer. which indicates a client understanding?
"I will take albuterol before taking cromolyn" bronchodilator must always be used prior to the leukotriene modifier so the airways may be opened ensuring the max dose of med will get to client's lungs albuterol is used for acute broncospasms (short-acting), cromolyn used for asthma treatment (long acting); should administer these meds before exercising; should inhale different meds 2-5 min apart
nurse is teaching a pt who has COPD about ways to facilitate eating. which indicates further need for teaching
"I will take my bronchodilators after meals" bronchodilators must be taken before meals; resting before meals for 30 min decreases fatigue; eating small frequent meals decreases SOB; foods that are not gas-forming are ideal
nurse is teaching client who is about to undergo the insertion of a nontunneled central venous access device. which statement should nurse id as indication the pt undersatnds instructions
"I will turn my head in the opposite direction during insertion" bed rest is not a requirement for central cath insertion, but it is for cardiac cath insertion; Valsalva maneuver should be performed to prevent air embolus; persistent hiccups is a complication of pacemaker insertion, not central cath insertion
client has right subclavian central venous cath. when reconnecting new admin set, which instruction should nurse give pt?
"bear down while holding breath" this prevents air from entering lumen, heart, and pulmonary circulation pt should be in trendelenburg position so catheter exit site is at/below level of heart; head should turn to left for better access
nurse is assessing pt who is to undergo a left lobectomy to treat lung cancer. pt tells nurse she is scared and wishes she had never smoked. what should nurse say
"its ok to feel scared. let's talk about what you are afraid of"
nurse is providing discharge teaching about nutrition to parents of child who has cystic fibrosis (CF). which response by parents indicates an understanding of the teaching
"we will give our child pancreatic enzymes with snacks and meals" CF messes with digestion and absorption of nutrients so digestive enzymes must be taken a diet high in calories and protein with unrestricted fats and salt is typically recommended to meet the nutritional needs of the child who has CF; fluids should not be restricted either
nurse is caring for pt who is to receive a unit of packed RBCs. nurse should prime blood admin tubing using which IV solution
0.9% sodium chloride LR, 5% dextrose in water, and 5% dextrose in 0.45% sodium chloride hemolyzes RBCs
nurse in a community health center is assessing the results of a TB skin test she performed for a pt. which result indicates exposure to and possible infection with TB?
15 mm induration (hardened area)
nurse planning care for child with cystic fibrosis and prescrip. to receive chest physiotherapy (CPT). what should nurse do
administer albuterol prior to CPT improves airways clearance vibration is performed during expirations; never do CPT after eating; percussion is for conditions that cause atelectasis or increased sputum
nurse is in urgent care center caring for pt having an acute asthma exacerbation. which of the following actions is the nurse's highest priority
administering nebulized beta-adrenergic greatest risk is safety to airway obstruction, beta-adrenergic meds act as bronchodilators
nurse is teaching pt who has been taking prednisone to treat asthma and has a new prescrip to d/c med. the nurse should explain to the pt to reduce the dose gradually to prevent what
adrenocortical insufficiency
nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130. nurse should begin the infusion at which of the following times
as soon as the nurse can prepare the pt and administration set procedure should be completed within 4 housr
nurse is assessing pt who has COPD. nurse should expect the pt chest to be which shape
barrel
nurse is caring for pt who has active TB and is to be started on IV rifampin Rx. nurse should instruct the pt of what adverse effects that can happen with this med?
body secretions turning a red-orange colour also causes diarrhea and nausea teeth stained from taking liquid iron preps; black stools from iron supplements
nurse caring for pt who has a central venous catheter and reports hearing a gurgling sound on side of catheter insertion. which of the following complications should the nurse suspect?
catheter migration gurgling sound means migration; change in length means dislodgment; fluid leaking from site or pain and swelling mean rupture; difficulty administering fluids or drawing up blood through line mean occlusion
nurse caring for pt who has lung cancer and is scheduled for lobectomy. nurse should prepare pt to expect what after the procedure
chest tube pt will have a chest tube for air and fluid drainage and severe chest pain. will require a posterolateral or anterolateral chest incision. pulmonary function studies will be performed before lobectomy
nurse is preparing to insert a peripheral IV cath. which antiseptic is nurse's best choice for preparing the client's skin at insertion site
chlorhexidine
nurse caring for pt with exposure to inhalational anthrax due to bioterrorism. which meds should nurse expect as common Rx?
ciprofloxacin, doxycycline, and amoxicillin
nurse is caring for pt who has central venous catheter and develops acute SOB. which action should nurse take first?
clamp catheter
nurse is preparing to insert IV cath for pt and has selected insertion site. place the steps in which nurse should perform them
cleanse with antiseptic swab, apply tourniquet/BP cuff, dilate vein, insert catheter, release tourniquet, flush catheter, secure it
nurse is assessing client prior to administering seasonal flu vaccine. pt says he read about flu being given as nasal spray and wants it. nurse should recognize which is a contraindication
client is 62 must be 2-49 to receive nasal spray
nurse in a provider's office is assessing an older adult pt whose son reports pt has been sick w respiratory illness for the past 5 days. which of the following assessment findings is a manifestation of pneumonia in older adult cilent
confusion confused, weakness, tachycardia and anorexia are manifestations of pneumonia in older adults. narrowed pulse pressure is hypovolemic shock, night sweats mean TB
nurse in ED is assessing older adult client who has community-acquired pneumonia. which should nurse expect
confusion due to hypoxemia dull sounds upon chest percussion and hypotension are expected findings for pneumonia pt; unequal pupils mean increased intracranial pressure
nurse is admitting pt who has pertussis. what precaution should nurse initiate
droplet
nurse is caring for pt who has emphysema. which of the following findings should nurse expect to assess in this pt?
dyspnea, barrel chest, and clubbing of fingers heart rate will increase and respirations will be shallow
nurse is teaching pt who is beginning treatment for TB. the nurse should instruct client that which of the following herbs can interact with treatment
echinacea appears to be an immune system booster, but reduces the actions of medications used to treat TB milk thistle reduces effects of oral contraceptive; green tea helps treat cancers of stomach skin bladder and breast; st. john's wort can increase effects of antidepressants
nurse is caring for pt who has COPD. pt tells nurse "I can feel congestion in my lungs, and I certainly cough a lot but can't get anything up." what should nurse to do help with tenacious bronchial secretions
encourage pt to drink 2-3L of water daily
nurse caring for pt with pneumonia. which of the following actions should the nurse take to promote thinning of respiratory secretions
encourage to increase fluid intake increasing fluid promotes liquefaction and thinning of pulm. secretions which improves pt ability to cough and remove secretions IS use, coughing, and deep breathing promotes expectoration, not thinning; ambulation prevents accumulation of respiratory secretions
nurse is caring for pt who suspects recent exposure to inhalation anthrax. which finding indicates possible exposure
flu-like symptoms
nurse of med-surge unit is performing an admission assessment of a client who has COPD with emphysema. pt reports he has frequent productive cough and is SOB. the nurse should anticipate which assessment finding
increased anteroposterior diameter of chest because of chronic hyperinflation of lungs pt will have respiratory acidosis because of increased arterial CO2 and decreased O2 levels; petechiae on chest/abdomen is seen on pt who has pulmonary embolism
nurse is caring for pt who has emphysema and has difficulty with mobility. pt receives home health care and spends most of day in a reclining chair. which physiological response to prolonged immobility should the nurse expect
increased calcium excretion prolonged immobility leads to breakdown of bone tissue. results in increased calcium excretion. prolonged immobility also leads to reduction of metabolic rate, increased risk for thrombus formation, and other electrolyte imbalances
nurse in ED is preparing to administer theophylline by continuous IV infusion to a client who is experiencing an asthma attack. which action should nurse take?
infuse medication with an IV pump rapid administration may cause hypotension and death. no faster than 25 mg/min
nurse is teaching pt who has asthma how to use a metered-dose inhaler (MDI). nurse identifies the sequence of steps the client should follow which are:
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
nurse is collaborating on care for pt who has COPD. which task should the nurse recommend be referred to an occupational therapist for assistance?
instructing how to use kitchen tools to prepare a meal
nurse is preparing to apply wrist restraints to a client to prevent her from pulling out an IV catheter. which action should nurse take first
keep padded portion of restraints against the wrists to protect the skin from breakdown and abraison must have 2 fingers of room; must be attached to movable part of bed; knot must be able to be quickly released in an emergency
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 sites should the nurse plan to use to obtain blood specimen
left forearm site is the antecubital fossa which allows for easy access and does not interfere with IV
nurse is assessing a client who has pulmonary TB. which findings should nurse expect
lethargy low-grade fever, weight loss, and a productive cough with purulent sputum streaked with blood are other indications
nurse is caring for pt receiving TPN via peripherally inserted central catheter (PICC). when assessing pt, nurse notes swelling above PICC insertion site. which action should nurse take first
measure circumference of both upper arms once you measure, you can notify the provider to recommend removal of PICC line or initiating other treatment such as low-dose thromolytic therapy
a nurse is implementing a plan of care for a client who has AIDS with recurring pneumonia. which of the following actions should the nurse take?
obtain a sputum culture to determine which antibiotic is needed cough and deep breathing should be implemented every 2-4h; HOB should be 30-45 degrees; fluid intake should be around 3000mL/day to loosen sputum
nurse is selecting staff member to double check blood label with client ID bracelet prior to infusing a unit of blood. nurse should identify that which of the following persons is qualified
oncology nurse another nurse or provider must double check the blood label and client ID prior to an infusion
nurse is assessing pt who has asthma. which ares should nurse evaluate as most reliable indicator of central cyanosis
oral mucosa
nurse is caring for a pt who has central venous catheter and suddenly develops chest pain, dyspnea, dizziness, and tachycardia. nurse suspects air embolism and clamps cath immediately. what other action should nurse take
place client of left side in trendelenburg position position helps trap air in apex of right atrium rather than allowing it to enter the right ventricle and move to pulmonary arterial system chest tube insertion is for pneumothorax; remove catheter for rupture; replace infusion system for central line-related sepsis
nurse is caring for pt who is confused and has pulled out her peripheral IV cath 3 times. which should the nurse do?
place mitten resstraints on the client's hands must obtain a prescription; moving the client closer to nurse station will not improve the client's confusion nor keep her from pulling out IV; administering sedative can increase confusion
nurse is admitting a pt who is having an exacerbation of his asthma. when reviewing the provider's orders, the nurse recognizes that clarification is needed for which of the following meds?
propranolol meds that block beta-2 receptors are contraindicated in pt with asthma
nurse is teaching pt with asthma how to use albuterol inhaler. which action by client indicates understanding of teaching?
pt holds breath for 10 sec after inhaling med pt should take a slow, deep inhale for 3-5 sec while administering med; wait 20-30 secs between inhalations and 2-5 min between different meds
nurse is caring for pt who experienced an infection at insertion site of her IV catheter. which finding should nurse expect
purulent drainage is noted from site numbness at IV insertion site means nerve damage; cord-like, hard vein means phlebitis; sloughing comes means infiltration of some meds (antineoplastics)
nurse is assessing a pt who has IV therapy-related phlebitis. nurse uses the infusion nurses societ's phlebitis scale to assess the severity of phlebitis and documents pt phlebitis as grade level 1. which assessment finding correlates with grade level 1?
redness at IV access site with pain is level 1 level 3: red streaks, palpable venous cord level 4: purulent drainage at IV site
nurse is attempting to flush IV saline lock for pt. pt reports pain above cath site. which action should the nurse take?
remove IV saline lock evidence indicates the lock is not functioning properly
nurse is preparing pt for outpatient surgery. after nurse inserts IV cat, the client reports pain in the insertion area. which action should nurse take
remove cath and insert into a different site it is possible the cath is against a valve for near a nerve and causing more pain than an IV cath should
nurse is prepping pt for placement of cath for TPN. which access sites should nurse plan to prepare for cath instertion
right subclavian vein
nurse is admitting pt who has active TB to a room on med-surge unit. which room assignment should nurse make for client
room with air exhaust directly to outdoor environment eliminates contamination of other client-care areas. this type of ventilation is referred to as airborne infection isolation room
nurse is assessing pt receiving one unit of packed RBCs to treat intraoperative blood loss. pt reports chills and back pain, client BP is 80/64. which action should nurse take first
stop infusion
nurse is caring for pt and identifies an infiltration at IV cath site. wht is the order the nurse should perform following actions
stop infusion, remove IV catheter, apply sterile dressing, elevate extremity, apply warm/cold compresses
nurse is instructing pt newly Dx with TB about use of antitubercular meds. which info should nurse include in teaching?
typical course of treatment involves 6-9 months of consistent medication use
nurse is caring for pt with single lumen central venous cath. which action should the nurse take when accessing the catheter
use 10mL syringe to flush catheter ...because the pressure that is exerted by smaller barrel syringes increases the risk for rupture caths should be flushed with sterile normal saline (not water); sterile technique is used when accessing central venous cath; slow, gentle pressure must be applied to syringe plunger so if there is resistance, you can stop procedure immediately to prevent damage to cath/dislodge clots
nurse is developing a POC for a pt who has COPD. Nurse should include which of the following interventions?
use pursed-lip breathing this type of breathing lengthens expiratory phase of respiration and increases pressure in the airway during exhalation. reduces airway resistance and decreases trapped air. COPD pt have poor exercise tolerance in early morning due to pulmonary secretions that build up at night; should have high calorie high protein diet to prevent weight loss; should drink 2-3 L of water/day unless otherwise indicated
nurse is auscultating breath sounds of pt who has asthma. when client exhales, nurse hears continuous high-pitched squeaking sounds. the nurse should document this as which of the following adventitious breath sounds
wheezes crackles sound like rolling hair between fingers behind ear; rhonchi are continuous rumbling, snoring, or rattling sounds from fluid or mucous; stridor is a continuous, shrill musical sound of constant pitch (and very bad!)