NCLEX Challenge 4 Summer 2020
client has right subclavian central venous cath. when reconnecting new admin set, which instruction should nurse give pt?
"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 planning care for a child who has cystic fibrosis and a prescription to receive chest physiotherapy (CPT). 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.
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 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.
The 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 The nurse should infuse the blood as soon as possible and complete the procedure within 4 hr.
nurse caring for pt with pneumonia. which of the following actions should the nurse take to promote 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.
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 the breakdown of bone tissue. This results in increased calcium excretion.
A nurse is assessing a client who has pulmonary tuberculosis. Which of the following findings should the nurse expect?
Lethargy Manifestations of pulmonary tuberculosis include lethargy and fatigue.
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 The nurse should use the median vein in the forearm because it is distal to other potential venipuncture sites and it avoids areas of flexion. The bones in the forearm provide natural splinting and protection for IV insertion sites in the forearm and allow more freedom of movement for the client.
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 the intravenous access site with pain Redness at the intravenous access site with or without pain is scored as a grade level 1. Red streaks, palpable venous cord is level 3 Purulent drainage at the intravenous access site is scored at a grade level 4.
nurse is attempting to flush IV saline lock for pt. pt reports pain above cath site. which action 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.
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 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.
nurse is caring for pt with single lumen central venous cath. which action should the nurse take when accessing the catheter
Use a 10-mL syringe to flush the catheter. During the flushing procedure, the nurse should use a 10-mL barrel syringe, because the pressure that is exerted by smaller barrel syringes increases the risk for rupturing the catheter.
A nurse is caring for a client who has advanced lung cancer. The client's 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 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.
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 the chest The nurse should anticipate an increased anteroposterior diameter of the chest (barrel chest) because of chronic hyperinflation of the lungs.
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 the medication with an IV pump. Theophylline should be administered slowly on an infusion pump. Rapid administration may cause hypotension and death.
nurse is assessing pt who has asthma. which ares should nurse evaluate as 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.
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 be sure to take the albuterol before taking the cromolyn." The client should always use the bronchodilator (albuterol) prior to using the leukotriene modifier (cromolyn). Using the bronchodilator first allows the airways to be opened, ensuring that the maximum dose of medication will get to the client's lungs.
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." Clients who have emphysema have greater-than-usual nutritional requirements for calories and protein and often need nutritional supplements between meals.
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 should be taken before meals, not after, in order to reduce shortness of breath. This statement by the client indicates a need for further teaching.
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 A client report of hearing a gurgling sound on the side of the catheter insertion is a manifestation of catheter migration.
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
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 caring for a client who suspects recent exposure to inhalation anthrax. Which of the following findings indicate possible exposure?
Flu-like symptoms Anthrax is an acute disease caused by the organism Bacillus anthracis. Although it appears in nature, it is often considered an agent of bioterrorism. Initial symptoms of inhalation anthrax include flu-like symptoms such as a cough, fever, chills, headache, and weakness.
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. The nurse should obtain a sputum culture to determine which antibiotic is needed for the organism that is causing the pneumonia.
nurse is prepping pt for placement of cath for TPN. which access sites should nurse plan to prepare for cath instertion
Right subclavian vein The right subclavian vein is the most common access site for total parenteral nutrition.
The nurse is assessing a client who is to undergo a left lobectomy to treat kung cancer. The client tells the nurse that she is scared and wished 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.
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 interferes with the availability of pancreatic enzymes necessary for digestion and absorption of nutrients. Therefore, pancreatic enzymes must be taken with all meals and snacks.
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 The nurse should prime the tubing with 0.9% sodium chloride, as this is the only IV solution that does not hemolyze RBCs.
The nurse in a community health center is assessing the results of a tuberculin skin test she performed for a client. Which of the following results indicates exposure to and a possible infection with tuberculosis?
15 mm induration A positive reaction to a tuberculin skin test is an induration (a hardened area) that is 10 mm or greater in diameter. The nurse should measure the area of induration, not any accompanying erythema or swelling.
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 Chlorhexidine is the antiseptic preferred by the Infusion Nurses Society (INS) to decrease peripheral catheter insertion site infections.
nurse is admitting pt who has pertussis. what precaution should nurse initiate
Droplet The nurse should initiate droplet precautions for clients who have infections that spread by droplets larger than 5 microns, including mumps, streptococcal pharyngitis, and pertussis.
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 The nurse should teach the client that echinacea appears to be an immune system booster, thus it can reduce the actions of medications used to treat tuberculosis.
nurse is developing a POC for a pt who has COPD. Nurse should include which of the following interventions?
Instruct the client to use 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.
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 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.
nurse is teaching pt with asthma how to use albuterol inhaler. which action by client indicates understanding of 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.
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." The client should turn his head away from the insertion site to allow optimal accuracy in placing the catheter.
nurse caring for pt who has lung cancer and is scheduled for lobectomy. nurse should prepare pt to expect what 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.
nurse is admitting pt who has active TB to a room on med-surge unit. which room assignment should nurse make for 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.
nurse is instructing pt newly Dx with TB about use of antitubercular meds. which info should nurse include in teaching?
A typical course of treatment involves 6 to 9 months of consistent medication use. Pulmonary TB is a contagious bacterial infection caused by Mycobacterium tuberculosis. Active TB is usually treated with the simultaneous administration of a combination of medications to which the organisms are susceptible. Such therapy is continued until the disease is controlled. A 6- to 9-month regimen consisting of two, and often four, different medications is used. The client should not drink alcohol during this time.
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 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.
nurse is caring for pt who has active pulmonary 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 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.
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 6 days. which of the following assessment findings is a manifestation of pneumonia in older adult client
Confusion Confusion, weakness and anorexia are manifestations of pneumonia in an older adult client.
nurse caring for pt with exposure to inhalational anthrax due to bioterrorism. which meds should nurse expect as common Rx?
Ciprofloxacin Doxycycline Amoxicillin Ciprofloxacin is correct. Recommended treatment for inhalational anthrax includes a combination of antibiotics, including ciprofloxacin, that treats positive serum Gram stain.Doxycycline is correct. Recommended treatment for inhalational anthrax includes a combination of antibiotics, including doxycycline, that treats positive serum Gram stain.Amoxicillin is correct. Recommended treatment for inhalational anthrax includes a combination of antibiotics, including amoxicillin, that treats positive serum Gram stain.
nurse is caring for pt who has central venous catheter and develops acute SOB. Which action should 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.
nurse in ED is assessing older adult client who has community-acquired pneumonia. which should 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 emphysema. Which of the following findings should the nurse expect to assess in this client?
Dyspnea Clubbing of fingers Barrel Chest Dyspnea is correct. Emphysema is a lung disease involving damage to the alveoli in which they become weakened and collapse. Dyspnea is seen in clients with emphysema as the lungs try to increase the amount of oxygen available to the tissues. Barrel chest is correct. Clients with emphysema lose lung elasticity; the diaphragm becomes permanently flattened by hyperinflation of the lungs; the muscles of the rib cage become rigid; and the ribs flare outward. This produces the barrel chest typical of emphysema clients. Clubbing of the fingers is correct. Clubbing results from chronic low arterial-oxygen levels. The tips of the fingers enlarge and the nails become extremely curved from front to back.
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 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 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.
nurse is preparing to apply wrist restraints to a client to prevent her from pulling out an IV catheter. which action should nurse take?
Keep the padded portion of the restraints against the wrists. The nurse should keep the padded portion of the restraints against the client's wrist to protect the skin from abrasion and breakdown.
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 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.
The nurse is selecting a qualified staff member to double check a blood label with a client ID bracelet prior to infusing unit of blood. The nurse should identify that which of the following persons is qualified?
Oncology nurse The nurse should ask another nurse or a provider to double check the blood label and client ID prior to an infusion.
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 restraints on the client's hands. The nurse should consider placing mitten restraints on the client's hands to prevent pulling out the IV catheter. The nurse should obtain a prescription from the provider to apply these restraints.
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 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 experienced an infection at the insertion site of her intravenous catheter. Which of the following findings should the nurse expect?
Purulent drainage is noted from the site. Signs of infection include warmth, redness, swelling, and possible purulent drainage.
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
The client's age is 62. Clients must be between the ages of 2 and 49 to receive the LIAV; therefore, it is contraindicated for this client. Pregnancy and immunocompromised status are also contraindications.
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 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.
nurse is assessing pt who has COPD. nurse should expect the pt chest to be which shape
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.
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 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.
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 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.
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 The first action the nurse should take using the nursing process is to assess the client. The nurse should measure the arm and compare the result with the circumference of the other arm. If the arm is swollen, the nurse should notify the provider who inserted the PICC line. Swelling could indicate formation of a clot above the site or even catheter rupture.
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 Medications that block beta-2 receptors, such as propanolol, are contraindicated in clients with asthma.