NCLEX challenge 4

a nurse is caring for a client who is receiving a blood transfusion. The client is likely experiencing ____ as evidenced by ____

Transfusion-associated circulatory overload; respiratory assessment

The proper steps the nurse should perform to insert an IV catheter - flush the catheter - apply a tourniquet or bp cuff - dilate the vein - cleanse the site with an antiseptic swab - insert the catheter

1. cleanse the site with an antiseptic swab 2. apply a tourniquet or bp cuff 3. dilate the vein 4. insert the catheter 5. flush the catheter

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 - elevate the extremity - apply a sterile dressing - apply warm or cold compresses

1. stop the infusion 2. remove the IV catheter 3. apply a sterile dressing 4. elevate the extremity 5. apply warm or cold compress

A nurse is caring for an adolescent client who has pneumonia and a prescription for cefpodoxime 5 mg/kg PO every 12 hr for 5 days. The client weighs 88 lb. How many mg should the nurse administer per dose?

200 mg

A nurse is reviewing a client's prescription for 1,000 ml of 5% dextrose in water IV to infuse over 8 hr. At 1400, the nurse observes that there is 500 ml of solution remaining in the client's current IV bag. At what time should the nurse administer the next bag of IV solution? A. 1500 B. 1600 C. 1700 D. 1800

D. 1800 The IV will infuse at 125 mL/hr. The next bag of IV solution will need to be administered at 1800.

A nurse is planning care for a client who is to receive packed RBCs. The nurse should plan for the total infusion time to not exceed which of the following? A. 2 hr B. 6 hr C. 8 hr D. 4 hr

D. 4hr

A 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? A. When the client has finished eating lunch B. When the client states he is ready to start the infusion C. 2 hr after obtaining blood from the blood bank D. As soon as the nurse can prepare the client and the administration set

D. As soon as the nurse can prepare the client and the administration set

A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes? A. pigeon B. Funnel C. kyphotic D. barrel

D. barrel

A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in the client? (select all that apply) A. dyspnea B. bradycardia C. barrel chest D. clubbing of the fingers E. deep respirations

a. dyspnea, C. barrel chest, D. clubbing of the fingers

A nurse is calculating the intake of a client during the past 9 hr. The client's intake includes lactated Ringer's IV at 150 mL/hr, cefazolin 2 g IV intermittent blous in 100 ml of 0.9% sodium chloride, two units of packed RBCs of 275 and 250 mL; two IV bolus infusions of 250 mL of 0.9% sodium chloride, famotidine 20 mg IV intermittent bolus in 50 ml of 0.9% sodium chloride. How many mL of intake should the nurse record?

2525 mL

A nurse is caring for a client who has a single lumen central venous catheter. Which of the following actions should the nurse take when accessing the catheter? A. Use a 10ml syringe to flush the catheter B. Flush the lumen with sterile water after each use C. Use clean technique when accessing the catheter D. apply firm pressure to the syringe plunger when flushing the lumen

A. Use a 10ml syringe to flush the catheter

A nurse is discussing the treatment plan of a client who has cystic fibrosis with the provider. For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client. A. high calorie and high protein diet with unrestricted fats B. oxygen at 8L/min via simple facemask C. percussion and postural drainage TID following meals D. Contact isolation E. Quantitative sweat chloride test F. high-frequency chest compression BID

A. anticipated B. contraindicated C. contraindicated D. anticipated E. nonessential F. anticipated

A nurse is caring for a client following exposure to inhalation anthrax due to bioterrorism. Which of the following medications should the nurse expect as a common medication to treat anthrax? (Select all that apply) A. ciprofloxacin B. doxycycline C. amoxicillin D. penicillin G E. cefotaxime

A. ciprofloxacin B. doxycycline C. amoxicillin

select the 5 findings that require follow-up A. disorientation B. barrel shaped chest C. yellow sputum D. nebulizer use E. ankle edema F. SaO2 92% G. clubbing of fingers H. lives alone

A. disorientation, C.yellow sputum, D. nebulizer use, E. ankle edema, H. lives alone

A nurse is assessing a client who has a peripheral IV with a continuous infusion. Which of the following findings is a manifestation of phlebitis? (select all that apply) A. erythema B. damp dressing C. throbbing D. warmth at insertion site E. streak formation

A. erythema, C. throbbing, D. warmth at insertion site, E. streak formation

A nurse is assessing a client who has pulmonary tuberculosis. Which of the following findings should the nurse expect? A. lethargy B. high-grade fever C. weight gain D. dry cough

A. lethargy

A nurse is selecting a qualified staff member to double check a blood label with a client ID bracelet prior to infusing a unit of blood. The nurse should identify that which of the following persons is qualified? A. oncology nurse B. assistive personnel C. senior nursing student D. phlebotomist

A. oncology nurse

A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via NC. The client reports difficulty breathing. Which of the following actions is the nurse's priority? A. increase the oxygen flow to 3L/min B. Assess the client's respiratory status C. call the emergency services for the client D. Have the client cough and expectorate secretions

B. Assess the client's respiratory status

A nurse is caring for a client who has lung cancer and is scheduled for a lobectomy. The nurse should prepare the client to expect which of the following after the procedure? A. a sternal incision B. a chest tube C. moderate pain D. pulmonary function studies

B. 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.

The nurse is assisting with catheter care for the client to prevent a central line-associated bloodstream infection (CLABSI bundle). Which of the following actions should the nurse take? Select all that apply A. use clean technique when changing the catheter dressing B. change the catheter dressing every 2 days C. clean the access port on the CVAD line with povidone-iodine prior to use D. perform hand hygiene for 10 sec prior to changing the catheter dressing E. use friction when cleaning the access port

B. change the catheter dressing every 2 days C. clean the access port on the CVAD line with povidone-iodine prior to use E. use friction when cleaning the access port

A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray? A. ask the x-ray tech to come to the client's room to obtain a portable x-ray B. have the client wear a mask C. Notify the x-ray department that the client requires airborne precautions D. wear a filtration mask and gloves during transport

B. have the client wear a mask

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? A. "i will have to be admitted to a long term care facility in order to receive hospice care B. i should expect the hospice team to help me manage my dyspnea C. hospice care services are available to pts who are terminally ill regardless of their life expectancy D. my oncologist will continue to look for a cure for my cancer while I am receiving hospice care.

B. i should expect the hospice team to help me manage my dyspnea

A nurse is teaching a client who is about to undergo the insertion of a nontunneled central venous access device. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "i will have to stay in bed for several hours after the procedure" B. i will turn my head in the opposite direction during insertion C. i will need to hold my breath when they first put the needle in D. I will call the clinic if i have persistent hiccups

B. i will turn my head in the opposite direction during insertion

A nurse on a med-surg unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client? A. respiratory alkalosis B. increased anteroposterior diameter of the chest C. oxygen sat level 96% D. petechiae on chest

B. increased anteroposterior diameter of the chest

A nurse is caring for a client who has anemia. Labs, VS, and nursing notes are given. Which should be reported immediately to the provider? (select 4) A. Iv site B. oxygen sat C. temp D. back pain E. breath sounds F. urine color G. blood pressure

C. temp, D. back pain, F. urine color, G. blood pressure

A 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? A. metabolic acidosis B. metabolic alkalosis C. respiratory acidosis D. respiratory alkalosis

B. 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 caring for a client who is receiving radiation therpay to treat lung cancer. Which of the following actions should the nurse take? A. review lab test results for low hemoglobin B. observe for signs of infection C. monitor the mouth for signs of xerostomia D. Examine the skin for generalized urticaria

B. observe for signs of infection skin is effected due to hypersensitivity but it is not generalized. Radiation therapy sites contain bone marrow and can lower WBC leading to risk for infection.

A nurse is caring for a client who has a central venous catheter and suddenly develops chest pain, dyspnea, dizziness, and tachycardia. The nurse suspects air embolism and clamps the catheter immediately. What other action should the nurse take at this time? A. prepare for chest tube insertion B. place the client on his left side in Trendelenburg position C. remove the catheter D. replace the infusion system

B. 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 planning to obtain a sputum specimen for a client. Which of the following actions should the nurse plan to take? A. Save the sputum specimen in a clean container B. rinse the client's mouth before collecting the specimen C. Obtain the specimen from the client in the evening D. collect the sputum specimen after a meal

B. rinse the client's mouth before collecting the specimen

A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take? A. strip the client's chest tube every 2 hrs B. tape the connections on the client's chest tube C. loop the tubing of the chest tube on the client's bed D. place the chest tube drainage system above the level of the client's heart

B. tape the connections on the client's chest tube

A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nutse the client has phlebitis at the IV insertion site? A. "the infusion rate has stopped but the tubing is not kinked" B. the area surrounding the insertion site feels warm to the tough C. There is fluid leaking around the insertion site D. There is no blood return when the tubing is aspirated

B. the area surrounding the insertion site feels warm to the tough

A charge nurse is teaching a new nurse how to initiate IV access on a client. Which of the following actions by the new nurse indicates an understanding of the teaching? A. shaves the selected insertion site with a razor prior to the procedure B. washes hands with soap and water before the procedure C. applies sterile gloves prior to inserting the IV catheter D. applies the tourniquet 1 in above the selected insertion site

B. washes hands with soap and water before the procedure

A nurse prepares to replace the nearly empty container of total parenteral nutrition (TPN) for a client when she finds that there has been a delay in receiving the new container of solution from the pharmacy. Which of the following solutions should the nurse infuse until the next container of TPN solution becomes available? A. Lactated Ringer's B. 3% sodium chloride C. Dextrose 10% in water D. 0.9& sodium chloride

C. Dextrose 10% in water Sudden withdrawal from TPN, which is a hypertonic solution that contains dextrose, vitamins, electrolytes and sometimes lipids, can result in a sudden drop in the client's blood glucose levels. Administering an infusion of 10% dextrose will prevent hypoglycemia.

A nurse is caring for a client who has a prescription for one unit of packed RBCs. The nurse should plan to remain in the room with the client at which of the following times during the infusion to observe for a transfusion reaction? A. the first 2 min B. the final 2 min C. The first 15 min D. The final 15 min

C. The first 15 min

A nurse is teaching the mother of a child who has cystic fibrosis and has a prescription for pancreatic enzymes three times per day. Which of the following statements indicates that the mother understands the teaching? A. "my child will take the enzymes to improve her metabolism" B. My child will take the enzymes following meals C. my child will take the enzymes to help digest the fat in foods D. my child will take the enzymes 2 hrs before meals

C. my child will take the enzymes to help digest the fat in foods

A client has a right subclavian central venous catheter. When reconnecting a new administration set, which of the following instructons should the nurse give the client? A. "exhale slowly" B. "turn head to the right" C. "Sit in semi-fowler's position" D. "bear down while holding breath

D. "bear down while holding breath

A nurse in a community health center is assessing the results of tuberculin skin test she performed for a client. Which of the following results indicates exposure to and a possible infection with tuberculosis (TB)? A. 4 mm erythema B. 5 mm induration C. 10 mm wheal D. 15 mm induration

D. 15 mm induration

A nurse is caring for a client who has a central venous catheter and reports hearing a gurgling sound on the side of the catheter insertion. Which of the following complications should the nurse suspect? A. catheter occlusion B. catheter rupture C. catheter dislodgment D. catheter migration

D. catheter migration

A nurse in the emergency department is assessing an older adult client who has community-acquired pneumonia. Which of the following findings should the nurse expect? A. unequal pupils B. hypertension C. tympany upon chest percussion D. confusion

D. confusion

A nurse is attempting to flush the IV saline lock for a client. The client reports pain above the catheter site. Which of the following actions should the nurse take? A. inject the solution more slowly while flushing the IV saline lock B. apply a warm compress to the IV site C. Apply firm pressure to the plunger of the syringe during the IV flush to improve patency D. remove the IV saline lock

D. remove the IV saline lock

A nurse is caring for a client who has a central venous catheter and develops acute shortness of breath. Which of the following actions should the nurse take first? A. clamp the catheter B. position the client in left lateral Trendelenburg C. initiate oxygen therapy D. auscultate breath sounds

a. 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.

A nurse in a community health clinic is administering seasonal inactive influenza vaccine. Before administering it, the nurse must confirm that the client is not allergic to which of the following? A. shellfish B. eggs C. gelatin D. yeast

b. eggs The seasonal influenza vaccine contains small amounts of egg protein and can induce a severe allergic reaction in clients who are hypersensitive

A nurse is caring for a client who has COPD. The nurse should identify the client is at risk for which of the following acid-base imbalances? A. metabolic alkalosis B. respiratory acidosis C. respiratory alkalosis D. metabolic acidosis

b. respiratory acidosis

A nurse in a provider's office is assessing an older adult client whose son reports that the client has been sick with a respiratory illness for the past 6 days. Which of the following assessment findings is a manifestation of pneumonia in the older adult client? A. bradycardia B. night sweats C. confusion D. narrowed pulse pressure

c. confusion