NCLEX Challenge 1 Spring 2019

Which of the following nonverbal behaviors should the nurse identify as an indication that the client has pain? (Select all that apply) Restlessness Grimacing Moaning Clenching Drowsiness

Restlessness Grimacing Clenching Moaning is verbal

Autonomy

The ethical principle of autonomy applies to an individual's right to choose and control what happens to him.

Fidelity

The ethical principle of fidelity requires the nurse to keep promises by being faithful to agreements, commitments, and responsibilities.

A nurse is caring for a client who is experiencing severe nausea and vomiting after a course of chemotherapy. The nurse should monitor the client for which of the following clinical manifestations? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

B. Metabolic alkalosis Metabolic alkalosis can occur in clients who have excessive vomiting because of the loss of hydrochloric acid.

Justice

Justice is the ethical principled based on the belief that everyone should be treated fairly.

A nurse manager is reviewing the admission history of four adults who were admitted to the medical- surgical unit during the shift. Which of the following situations is the nurse required to disclose information to an outside agency about the client of the client's circumstances? A. A dependent adult admitted for the treatment of a spinal fracture. B. A young adult client admitted for asthma and has track marks that may indicate IV drug abuse. C. A young adult client admitted for acute glomerulonephritis following a viral infection. D. An emancipated minor who has acute appendicitis and wants to leave the facility without treatment.

A. A dependent adult admitted for the treatment of a spinal fracture Physical signs of dependent adult abuse include skeletal fractures, as well as burns, bruises, welts, and lacerations. Nurses are responsible for reporting suspicion of dependent adult abuse to the proper legal authorities within the state. It is important for the nurse to note that a competent older adult has the right to make his or her own decisions about pursuing legal action. Unless a client has been found to be legally incompetent, he or she is not classified as a dependent adult.

After radiation treatment, a client reports dryness, redness, and scaling of his skin occurring within the designated radiation treatment markings. The nurse should instruct the client to take which of the following actions? A. Apply hydrating lotions. B. Apply moist heat . C. Sit in the sun for 10 min per day. D. Wash with plain soap and water.

A. Apply hydrating lotions. The nurse should instruct the client to gently apply hydrating lotions that do not contain metal, alcohol, or perfume.

A nurse had been reassigned from her regular area of work to a unit that is short staffed. Which of the following actions should the nurse take first? A. Ask what she will be assigned to do. B. Determine if she has the skills to complete the assignment. C Identify her options. D. Notify the nurse manager about her concerns for client safety.

A. Ask what she will be assigned to do. Before accepting the assignment, the nurse should clarify the complexity of the assignment, such as how many clients she will be assigned to care for, what skills are needed, and what resources are available to her.

A nurse is caring for a client who is receiving cisplatin to treat bladder cancer. After several treatments, the client reports fatigue. Which of the follwoing actions should the nurse take? A. Check the results of the client's most recent CBC. B. Assess the client for a hypersensitivity reaction. C. Evaluate the client for hypercalcemia. D. Examine the client for hepatomegaly.

A. Check the results of the client's most recent CBC. The client might have anemia as a result of myelosuppression (bone marrow suppression) from the chemotherapy. If so, she might require treatment for the anemia (transfusion, medication) and the provider might have to delay further chemotherapy until her blood counts are higher.

An AP tells the nurse manager that she observed a nurse on the unit removing a small amount of morphine from syringes prior to administering the medications to clients. Which of the following actions should the nurse manager take first? A. Gather data about the nurse's work performance and attendance history. B. Approach the involved nurse to discuss the behavior C. Notify the risk manager D. Refer the nurse to the board of nursing diversion program

A. Gather data about the nurse's work performance and attendance history. The first action the nurse should take is to conduct an investigation and determine if the allegations are true.

A nurse is caring for a client who has cancer and a new prescription for ondansetron to treat chemo-therapy induced nausea. For which of the adverse effects should the nurse monitor? A. Headache B. Dependent Edema C. Polyuria D. Photosensitivity

A. Headache Headache is a common adverse effect of ondansetron. Analgesic relief is often required.

A nurse is teaching a client who is receiving radiation therapy about skin care. Which of the following instructions should the nurse include? A. Walk outside in the early mornings. B. Wash the irradiated area following treatment sessions to remove the markings. C. Vigorously rub the skin dry after bathing. D. Keep the temperature in the home at least 33° C (91.4° F).

A. Walk outside in the early mornings. A client who is receiving radiation treatment has special skin care needs due to the drying and irritation that occurs to the skin. The client's skin is especially prone to burning, and he should be encouraged to limit time outdoors in the sun. The nurse should instruct the client to go outside during the early morning or evening to avoid intense sun rays and should encourage the client to stay under awnings, umbrellas, and other forms of shade during the time when the sun's rays are most intense.

A nurse is planning care for a client who has a terminal cancer and has a prescription for morphine. Which of the following interventions should the nurse included in the plan of care? A. Instruct the client to take diphenoxylate/atropine 5 mg PO twice a day. B. Instruct the client to actively cough to prevent a buildup of secretions in the airway. C. Instruct the client to stop taking the morphine if itching develops. D. Instruct the client to keep room lights dim during walking hours.

B. Instruct the client to actively cough to prevent a buildup of secretions in the airway. Morphine acts on the medulla to suppress cough. The nurse should teach the client to actively cough to prevent a buildup of secretions in the airway. A. Constipation is an adverse effect of morphine. Diphenoxylate/atropine is administered to treat diarrhea. The nurse should instruct the client to take a stool softener, not an antidiarrheal daily. C. Itching is an expected finding for clients who take morphine. The client should not stop taking morphine if itching develops. D. Morphine causes miosis which can impair vision. The client should keep the room lights bright during waking hours.

A nurse is caring for a client who has metastatic breast cancer. She has a prescription for an opioid pain medication PRN. The nurse is concerned that administering a dose of pain medication might hasten the client's death. Which of the following ethical principles should the nurse use to support the decision not to administer the medication. A. Utilitarianism B. Nonmaleficence C. Fidelity D. Veracity

B. Nonmaleficence Nonmaleficence is the duty to do no harm. The ethical mandate of nonmaleficence is that health care workers refrain from intentionally inflicting harm to clients.

An AP reports to the nurse that a client who is 3 days postop following a abdominal hysterectomy has a dressing that is saturated with blood. Which of the following tasks should the nurse delegate to the AP? A. Change the abdominal dressing. B. Obtain vital signs. C. Palpate for possible bladder distention. D. Observe the incision site.

B. Obtain vital signs. Obtaining vital signs is a skill within the scope of practice for an AP; therefore, the nurse can delegate this task to the AP. A. Changing the abdominal dressing requires assessment by the nurse; therefore, the nurse cannot delegate this task. C. Palpating the client's bladder requires assessment by the nurse; therefore, the nurse cannot delegate this task. D. Observing the incision site requires assessment of the client's condition; therefore, the nurse cannot delegate this task.

A nurse is teaching a client who has a new prescription for ibuprofen to treat hip pain. Which of the following instructions should the nurse include in the teaching? A. Expect ringing in your ears. B. Take the medication with food. C. Store the medication in the fridge. D. Monitor for weight loss

B. Take the medication with food. To minimize gastric irritation, the client should take ibuprofen with food or immediately after a meal.

When planning delegation of tasks to assistive personnel, a nurse considers the five rights of delegation. Which of the following should the nurse consider when using one of the five right of delegation? A. The AP's ability to prioritize B. The AP has the knowledge and skill to perform the task C. The AP's rapport with clients D. The AP's ability to complete the task without assistance

B. 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.

The nurse is reviewing the process of medication reconciliation with a newly licensed nurse. The nurse should include which of the following information. A. The American Hospital Association requires accredited facilities to have protocols in place requiring medication reconciliation. B. The purpose of medication reconciliation is to prevent adverse medication reactions. C. The nurse who performs medication reconciliation is demonstrating the ethical principal of veracity. D. The International Council of Nurses Code of Ethics stipulates that the nurse performs medication reconciliation when a client is admitted to a facility, is transferred to another facility, and when a client is discharged from a facility.

B. The purpose of medication reconciliation is to prevent adverse medication reactions. Medication reconciliation includes reviewing an accurate list of all medications the client is taking and comparing that list to new medications the provider has prescribed. This action decreases the risk of medication interactions and adverse outcomes. A. The Joint Commission requires accredited facilities to have protocols in place requiring medication reconciliation. D. The International Council of Nurses Code of Ethics stipulates that nurses have a responsibility to promote health and prevent illness, but it does not mandate medication reconciliation. The Institute for Healthcare Improvement recommends the nurse perform medication reconciliation when a client is transferred and The Joint Commission requires medication reconciliation when a client is admitted and when a client is discharged.

Beneficence

Beneficence means helping others to promote good.

A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurse's priority? A. Close the fire doors on the unit. B. Activate the fire alarm. C. Move any clients in the immediate vicinity. D. Use a fire extinguisher to put out the fire.

C. Move any clients in the immediate vicinity. The greatest risk to clients is injury from smoke and fire; therefore, the nurse's first action is to move any clients near the smoke to a safe location. The acronym RACE is a reminder of the order in which to take steps in the event of a fire. The nurse should rescue the clients, activate the fire alarm, confine the fire, and extinguish the fire.

Confidentiality

Confidentiality means disclosing information about a client only to those involved in the client's care.

A nurse is teaching a client who has stomatitis. Which of the following instructions should the nurse include? A. Rinse with a commercial mouthwash. B. Use toothpaste that contains sodium laurel sulfate. C. Cleanse the mouth with lemon-glycerine swabs. D. Brush teeth with a soft toothbrush.

D. Brush teeth with a soft toothbrush. The client should use a soft toothbrush and gently brush after each meal to reduce mouth irritation and prevent superinfections. A. Many commercial mouthwashes contain alcohol, which can irritate stomatitis. B. Sodium laurel sulfate is associated with stomatitis. The client should avoid toothpastes that contain sodium laurel sulfate. C. Lemon-glycerine swabs can irritate stomatitis.

A nurse is caring for a client scheduled to receive external radiation to the neck for cancer of the larynx. During a pre-treatment exam, the nurse explains to the client that the most likely side effect would be A. Infertility B. Diarrhea C. Dyspnea D. Dysphagia

D. Dysphagia Radiation therapy does not hurt while it is being given. But the side effects that people may get from radiation therapy can cause pain or discomfort. Only the area of treatment is affected by the radiation, so dysphagia (trouble swallowing) would be an expected side effect. Other possible side effects include hoarseness, xerostomia (dry mouth), loss of taste, and skin redness.

A nurse is providing care for a surgeon on a medical- surgical unit. A nurse from another unit asks the nurse about the surgeon's medical diagnosis. The nurse responds that he is unable to provide the information requested. The nurse is displaying which of the following ethical principles? A. Utility B. Paternalism C. Justice D. Non-maleficence

D. Non-maleficence Nonmaleficence The nurse is obligated to protect the client's confidential information. A breach of confidentiality can place the client at risk of harm. Nonmaleficence is the ethical duty to prevent harm to the client.

A nurse of a medical-surgical unit is providing care for a group of clients. The nurse should delegate collection of which of the following specimens to the AP? A. Wound drainage for culture B. Urine from an indwelling catheter C. Blood for PaCO2 D. Random stool specimen

D. Random stool specimen The nurse should delegate collection of a random stool specimen to the AP because it does not require the skills of a licensed nurse. However, the nurse, not the AP, should collect a stool specimen if a culture using a sterile swab is required.

A nurse is caring for a client who is postoperative following a cholecystectomy and reports pain. Which of the following actions should the nurse take? (Select all that apply) Offer the client a back rub. Remind the client to use incisional splinting. Identify the client's pain level. Assist the client to ambulate. Change the client's position.

Offer the client a back rub is correct. Nonpharmacological comfort measures can improve pain management. Remind the client to use incisional splinting is correct. Holding a pillow against the incision when moving, turning, or coughing can help the client with self-management of pain. Identify the client's pain level is correct. The nurse should use a standard scale to determine and document the severity of the client's pain. Assist the client to ambulate is incorrect. If the client reports pain, the nurse should implement interventions to manage the pain, such as administering analgesia and giving it time to take effect, before assisting the client to ambulate. Change the client's position is correct. Nonpharmacological measures for managing pain include repositioning, imagery, and distraction.

Paternalism

Paternalism is the belief that one individual has the right to make decisions for another. It negates the client's right to autonomy.

Utility

Utility is the ethical principle that the good of many people outweighs the good of one person.

Veracity

Veracity is the duty to tell the truth.