NCLEX Challenge 2 Spring 2020
A nurse is preparing to suction a client who has a tracheostomy. Identify the sequence of actions that nurse should take. Place them in the order of performance.
Adjust the suction Don sterile gloves. Check the function of the suction catheter. Hyperoxygenate the client. Insert the catheter without suction. Apply intermittent suction while rotating the catheter. Check for secretion clearance. First, the nurse should adjust the suction, then don sterile gloves. Next, the nurse should check the function of the suction catheter by suctioning a small amount of solution into the tubing, then ask a peer to hyperoxygenate the client using a manual resuscitation bag valve mask connected to oxygen. The nurse should insert the suction catheter without suction and then apply suction for no more than 10 seconds while rotating the catheter. Finally, the nurse should assess for clearance of secretions.
A nurse is providing discharge teaching for a client who requires home oxygen therapy. Which of the following statements should the nurse identify as as indication that the client needs further teaching?
I will wear synthetic clothing and woolen socks when using my oxygen Woolen and synthetic materials can generate static electricity. Because oxygen is a flammable gas, the client should wear cotton clothing and use cotton bedding and blankets.
A nurse in a PACU is admitting to a client who is postoperative following a tonsillectomy. Which of the following actions should the nurse plan to prevent aspiration?
Withhold fluids until the client demonstrates a gag reflex Following a tonsillectomy, the client's gag reflex can be suppressed by local anesthetics or edema. To prevent aspiration, the gag reflex must be present before the client is allowed have fluids.
A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see?
pH below 7.35 With acidosis, the pH is below 7.35. However, the pH alone does not indicate whether the problem is metabolic or respiratory. A pH above 7.45 indicates alkalosis.
A nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first?
Airway patency When using the airway, breathing, circulation approach to client care, the nurse determines that the priority assessment is airway patency. After head and neck surgery, a major, life-threatening complication is airway obstruction. The priority actions involve airway maintenance and gas exchange.
A nurse is caring for a client who has hypertension and develops epistaxis. Which of the following actions should the nurse take?
Apply pressure to the nares Place ice to the bridge of the client's nose Move the client into high-Fowler's position Applying direct pressure to the lateral aspects of the nose helps to clot the blood. The nurse should apply firm and consistent pressure for several minutes until coagulation occurs. Place ice to the bridge of the client's nose is correct. Placing an ice pack on the nose causes the blood vessels to vasoconstrict, which decreases bleeding. The nurse should use a barrier, such as a wash cloth, to avoid skin damage from the direct application of ice to the skin. Ice packs should not be left on the skin for longer than 20 min. Move the client into high-Fowler's position is correct. Sitting upright facilitates breathing and decreases the risk for aspiration.
A nurse is providing dietary teaching for a client who takes furosemide. The nurse should recommend which of the following foods as the best source of potassium?
Bananas The nurse should determine that bananas are the best food source to recommend because 1 cup of bananas contains 806 mg of potassium. In addition to the potassium supplements the provider might prescribe, the client should increase his daily intake of foods that have high potassium content, such as bananas, orange juice, and spinach.
A nurse is reviewing the medical record of a client who has a potassium level of 3.0 meq/l. Which of the following findings should the nurse recognize as a potential causative factor?
Client has an NG tube to gastric suction. The client who has an NG tube to gastric suction is at risk for developing hypokalemia due to the gastrointestinal loss of potassium.
A nurse in the emergency department is caring for a client who collapsed after playing football on a hot day. After reviewing the admission laboratory findings, the nurse recognizes that these findings are consistent with which of the following conditions?
Dehydration Hypernatremic (hypertonic) dehydration occurs with excessive fluid losses due to perspiration, respiration, and inadequate fluid intake. The nurse should note that the client's sodium is above the accepted reference range, while glucose, potassium, BUN, chloride, and creatinine are within the accepted reference ranges. The client's history, collapsing after activity on a hot day, and the sodium findings are consistent with dehydration due to water deficit.
A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The clients respiratory rate is 10/mm and deep-tendon reflexes are absent. Which of the following actions should the nurse take?
Discontinue the medication infusion Magnesium toxicity is manifested by bradypnea (respiratory rate less than 12/min) and absent deep tendon reflexes. The magnesium sulfate infusion should be discontinued and calcium gluconate administered via IV.
A nurse is assessing a child who is postoperative following tonsillectomy. Which of the following findings is a manifestation of hemorrhage?
Frequent Swallowing Children who exhibit frequent swallowing should be evaluated for hemorrhage.
A nurse is assessing a client who has fluid volume deficit. The nurse should expect which of the following findings?
Increased BUN Increased BUN is an expected finding of fluid volume deficit due to the hemoconcentration of substances in the blood from excessive water loss.
A nurse is teaching a client who needs to increase their daily fluid intake. Which of the following foods has the highest percentage of water by weight?
Lettuce Lettuce is 95% water by weight.
The 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 of the following acid base imbalances?
Metabolic Alkalosis A client who has influenza has experienced excessive vomiting leading to metabolic alkalosis. Manifestations include dizziness, Circumoral paresthesias, and numbness and tingling of the extremities.
A nurse is assessing a client who has a sodium level of 116 mEq/L. Which of the following findings should the nurse expect?
Nausea and Vomiting A sodium level of 116 mEq/L is a critical value indicating hyponatremia. Nausea and vomiting are expected findings for a client with this sodium level.
A nurse is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following findings should the nurse expect?
PaCO2 50 mm Hg This laboratory value is an expected finding for a client who has respiratory acidosis.
A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take?
Perform pre-oxygenation prior to suctioning Suctioning should be performed on the endotracheal tube of a client who is mechanically ventilated to remove accumulated secretions from the airways. Possible complications of the procedure include hypoxemia, manifested by tachycardia and arrhythmia, and tissue injury. . In preparation for suctioning, and to prevent hypoxemia, the client should be pre-oxygenated using a manual resuscitator bag set at 100% oxygen.
A client is planning to perform nasotracheal suction for a client who has a COPD and an artificial airway. Which of the following actions should the nurse take?
Preoxygenate the client with 100% oxygen for up to 3 min. To prevent hypoxemia, the nurse should preoxygenate the client with 100% oxygen for 30 seconds to 3 min prior to suctioning.
A nurse is reviewing the laboratory report of client and identifies a serum potassium level of 6.8 mEq/L. Which of the following medications should the nurse plan to administer?
Sodium Polystyrene Sodium polystyrene is used for the treatment of hyperkalemia., It removes excess potassium by ion exchange through the bowel. The client's serum potassium level of 6.8 mEq/L is significantly above the reference range of 3.5 - 5.0 mEq/L..
A nurse is observing a client's nonverbal behavior. When evaluating this behavior, the nurse should factor in which of the following principles influencing nonverbal communication?
The clients sociocultural background influences nonverbal communication Sociocultural background has a major influence on what a client's nonverbal behavior means.
A nurse is caring for a client who had a total thyroidectomy and a serum calcium level of 7.6 mg/dl. Which of the following findings should the nurse expect?
Tingling of the extremeties A serum calcium level of 7.6 mg/dL is below the expected reference range, indicating hypocalcemia. A client who undergoes a total thyroidectomy is at risk for parathyroid injury which can lead to hypocalcemia. The nurse should monitor the client for reports of tingling and numbness of the extremities and around the mouth, muscle tremors, cramps and cardiac dysrhythmias.
A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client?
0.45% sodium chloride A client who has an elevated sodium level and is NPO requires a hypotonic IV solution, such as 0.45% sodium chloride or 0.225% sodium chloride.
A nurse is caring for a client who is unconscious and has a breathing pattern characterized by altering periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?
Cheyne-Stokes respiration Cheyne-Stokes respiration's (CSR) are characterized by a rhythmic increase (to the point of hyperventilation) and decrease (to the point of apnea) in the rate and depth of respiration. CSR are common respiratory alterations seen in clients who are unconscious, comatose, or moribund (approaching death).
A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect as result of the long-term inadequate oxygenation?
Clubbing of the fingers The nurse should expect the client who has chronic hypoxia or respiratory insufficiency to display clubbing of the fingers and toes. The base of the nail becomes swollen and the ends of the fingers and toes can increase in size.
A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy via nasal cannula. Which of the following should the nurse include in the teaching?
Check the cannula position on a regular basis Check the tops of the ear for skin breakdown Post "no smoking" signs in a prominent location in the home Check the cannula position on a regular basis is correct. The position of the nasal cannula should be verified every 8 hours or more often if needed. Check the tops of the ears for skin breakdown is correct. The tops of the ears, the nares and the nasal mucous membranes should be assessed regularly for skin breakdown. Post "no smoking" signs in a prominent location in the home is correct. The family is instructed to post "no smoking" signs in a prominent location in the home because oxygen increases the risk of fire injuries.
A client is admitted to the emergency room with a respiratory rate of 7/in. Arterial blood gases (ABG) revel the following values. Which of the following is an appropriate analysis of the ABGs?
Respiratory acidosis Respiratory acidosis occurs when there is retention of CO2 due to an impairment of respiratory function. It can be the result of respiratory depression, seen with anesthesia or opioid administration; inadequate chest expansion, due to a weakness of the respiratory muscles or constriction to the thorax; an obstruction of the airway, seen in aspiration, bronchoconstriction, or laryngeal edema; or from an inability of the lungs to adequately diffuse gases (O2 and CO2), resulting from conditions such as pneumonia, COPD, chest trauma, or pulmonary emboli. Arterial blood gases will reveal a pH that is lower than the normal reference range (7.35 - 7.45) and a CO2 level that is higher than the normal reference range (35 - 45 mm Hg).
A nurse is planning the dishare of a client who has sleep apnea and requires bi level positive airway pressure (BiPAP) at night. The nurse should plan to consult with which of the following health care team members to help educate the client?
Respiratory therapist Respiratory therapists help clients learn to use oxygenation and airway management devices, such as BiPAP equipment.
A nurse is instructing a group of clients regarding calcium rich foods. Which of the following foods should the nurse include in the teaching as the best source of calcium?
1 cup of milk Of the four choices, milk contains the most calcium per serving.Milk c ontains 276 mg calcium per one cup serving.
A nurse is caring for a client who had IV fluids initiated at 0330. The IV fluids are infusing at 120 ml/hr. The nurse should record how many ML of IV fluids on the intake record at 0600?
300 ml
A nurse is reviewing the medical records of four clients who have an acid-base imbalance. The nurse should recognize that which of the following clients is at risk for metabolic acidosis.
A client who has diarrhea Diarrhea can cause metabolic acidosis due to the loss of bicarbonate.
A nurse is caring for a client who has a prescription for potassium chloride (KCL) 20 meq PO daily. The nurse reviews the client's most recent laboratory results and finds the client's potassium level is 5.2 meq/l. Which of the following actions should the nurse take?
Call the prescribing physician and inform her of the client's serum potassium level results. As a potassium level of 5.2 mEq/L is above the expected reference range, the nurse should hold the medication and notify the provider of the client's serum potassium level.
A nurse is preparing to provide tracheostomy care for a client who has a non disposable tracheostomy tube. Which of the following equipment should the nurse plan to use?
Clean gloves Sterile cotton-tipped applicators Sterile Basin Clean gloves is correct. The nurse will use clean gloves to remove the soiled tracheostomy dressing. Sterile cotton-tipped applicators is correct. The nurse will need to use the sterile cotton-tipped applicators to cleanse the tracheostomy site. Sterile basin is correct. The nurse will need a sterile basin to soak the nondisposable inner cannula in.
A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being a risk for fluid volume deficit?
Client who has gastroenteritis and is febrile This client has two risk factors for the development of fluid volume deficit, or dehydration. Gastroenteritis is characterized by diarrhea and may also be associated with vomiting, so it can be a significant source of fluid loss. The client who has a fever can also lose fluid via diaphoresis, and fever raises the metabolic rate, further putting the client at increased risk for dehydration. Consequently, this is the client at greatest risk for fluid volume deficit.
A nurse is caring for a client who is receiving oxygen therapy via a nasal cannula. The nurse explains to the client that this method of oxygen delivery does which of the following?
Delivers a low concentration of oxygen A nasal cannula delivers a relatively low concentration of oxygen (24% to 44%).
A nurse is caring for a client who has the following arterial blood gas results: HCO3 18, PaCO2 28, and ph 7.30. The nurse recognized the client is experiencing which of the following acid base imbalances?
Metabolic acidosis A client experiencing metabolic acidosis would have a decreased pH, a decreased HCO3 and a decreased PaCO2.
A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCo2 of 50mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances?
Respiratory Acidosis With uncompensated respiratory acidosis, the pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg.
A nurse is reviewing a client's laboratory report of blood gas findings: HCO3 18 mEq/L and PaCO2 28 mm Hg. Which of the following pH values and conditions should the nurse expect when interpenetrating these findings?
decreased pH and and metabolic acidosis This client would have a decreased pH and be in metabolic acidosis. Other findings would include diarrhea, circulatory shock, decreased level of consciousness, abdominal pain, cardiac dysrhythmia, and increased depth and rate of respirations.
A nurse is leading a group therapy session for clients who are newly diagnosed with cancer. Which of the following statements should the nurse make?
"Lets discuss what you mean when you say that you cannot ever return to work" This is an example of clarification, which is a therapeutic communication technique. Clarification asks the group member to expand and clarify what he/she means so as to create a better understanding during the group session.
A nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apenic episodes. Which of the following client statements indicates an understanding of the teaching?
"if i lose about 50 pounds i might stop having so many apneic episodes" Sleep apnea is a disorder in which breathing stops during sleep for at least 10 seconds at least five times per hour. Excessive weight is one of the three major risk factors associated with sleep apnea and is the only one the client can modify (gender and age are the other two). Weight loss and maintenance are the primary interventions for the treatment of sleep apnea.
A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her hart rate is 110/min respiratory rate 40/min and blood pressure 140/80. Her arterial blood gases are ph 7.50, PaCO2 29, and PaO2 60, HCO3 20, and SaO2 86%. Which of the following is the priority nursing intervention?
Administer oxygen via face mask The pH reflects alkalosis, and the low PaCO2 indicates that the lungs are involved, so the client has respiratory alkalosis. The client's oxygen saturation is low, so one priority is to administer oxygen via mask attempting to achieve an oxygen saturation of at least 95%. The greatest risk to this client is hypoxia, thus the priority is to restore oxygenation.
A nurse on a medical unit is preparing to contact a provider about a client's condition. The client is a 6 hour postoperative from a total hysterectomy. The nurse notes the client's postoperative oxygen saturation is 94% and her apical heart rate is 110. The nurse should include information about the client's oxygen saturation level and heart rate in which component of the SBAR report?
Assessment The nurse should include his assessments in this level of the report. For example, the client's oxygen saturation level and the client's apical heart rate. The nurse can also include the amount of vaginal bleeding and the appearance of the wound dressing.
A nurse is caring for a client who has metabolic alkalosis. For which of the following clinical manifestations should the nurse monitor?
Bicarbonate Excess Circumoral paresthesia Bicarbonate excess is correct. Bicarbonate excess is a clinical manifestation for a client experiencing metabolic alkalosis. Circumoral paresthesia is correct. Circumoral paresthesia is a clinical manifestation for a client experiencing metabolic alkalosis.
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
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 assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The nurse should anticipate that the client will report that her earlier manifestation was
Hoarseness Laryngeal cancer, a malignant tumor of the larynx, is most often caused by long exposure to tobacco and alcohol. Hoarseness that does not resolve for several weeks is the earliest manifestation of cancer of the larynx because the tumor impedes the action of the vocal cords during speech. The voice may sound harsh and lower in pitch than normal.
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect?
Increased heart rate Increased blood pressure Increased respiratory rate Increased heart rate is correct. The nurse should expect the client who has fluid volume excess to have tachycardia and increased cardiac contractility in response to the excess fluid. Increased blood pressure is correct. The nurse should expect the client who has fluid volume excess to have increased blood pressure and bounding pulse in response to the excess fluid. Increased respiratory rate is correct. The nurse should expect the client who has fluid volume excess to have increase in respiratory rate and moist crackles heard in lungs.
A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first?
Raise the HOB Elevating the head of the bed uses gravity to reduce pressure on the diaphragm from the abdominal organs and allows for increased expansion of the lungs. The head and neck can be extended, which promotes a patent airway. This is the first action the nurse should take and is the least invasive.
A nurse is caring for a client who is postoperative and whose respiration's are shallow and 9/min. Which of the following acid-based imbalances should the nurse identify the client as being at risk for developing initially?
Respiratory acidosis Respiratory acidosis represents an increase in the acid component, carbon dioxide, due to inadequate excretion of it, and an increase in the hydrogen ion concentration (decreased pH) of the arterial blood. A major cause of this imbalance is hypoventilation from anesthetics or opioids.
A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?
Suction two to three times with a 60-second pause between passes Copious secretions may require several passes of the suction catheter. An interval of 60 seconds should be allowed between passes to prevent hypoxia.
A nurse is teaching a client who has chronic kidney disease about limiting foods that are high in potassium. Which of the following foods should the nurse instruct the client to avoid?
Tomatoes Bananas Raisins Tomatoes is correct. Tomatoes are high in potassium and should be avoided by a client who is on a potassium- restricted diet. Bananas is correct. Bananas are high in potassium and should be avoided by a client who is on a potassium-restricted diet. Raisins is correct. Raisins are high in potassium and should be avoided by a client who is on a potassium-restricted diet.
A nurse is caring for a client with a tracheostomy. The clients partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the clients discharge?
performing the procedure independently The nurse should recognize that the client is ready for discharge when the spouse demonstrates an ability to perform the procedure that will need to be performed independently at home.
