nclex challenge 4
A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the 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.
A client has a right subclavian central venous catheter. When reconnecting a new administration set, which of the following instructions should the nurse give the client?
"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 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?
"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.
A nurse is assessing a client who is to undergo a left lobectomy to treat lung cancer. The client tells the nurse that she is scared and wishes 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.
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 nurse the client has phlebitis at the IV insertion site?
"The area surrounding the insertion site feels warm to the touch." The IV fluid is at room temperature, so the area around the injection site will feel cool, not warm, to the touch when the IV is infiltrated. A warm area around the injection site indicates infection or phlebitis.
An assistive personnel (AP) comes to work with a new set of artificial nails. The nurse takes the AP to a private location to discuss the issue. Which of the following statements by the nurse is appropriate?
"There is a higher risk of infection for our clients associated with artificial nails." Short, natural nails are less likely to harbor pathogens that can be harmful to clients. The CDC recommends health care workers avoid wearing artificial nails when caring for clients who are at risk for infection. Additionally, guidelines from the World Health Organization prohibit artificial nails for caregivers in every setting.
A nurse is caring for a child who has asthma and a prescription for montelukast granules. Which of the following instructions should the nurse provide the client's parent on administering the medication?
Administer the medication 2 hr before exercise. Montelukast should be given daily during the evening, except when being used for exercise-induced bronchospasm. It should then be given 2 hr before exercise, and not given again for 24 hr.
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? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
200 Convert lb to kg:STEP 1: What is the unit of measurement to calculate? kgSTEP 2: Set up the equation and solve for X.2.2 lb/1 kg = client's weight in lb/X kg2.2 lb/1 kg = 88 lb/X kgX = 40STEP 3: Round, if necessary.STEP 4: Reassess to determine whether the conversion to kg makes sense. If 2.2 lb = 1 kg, it makes sense that 88 lb = 40 kg.Calculate Dose:STEP 1: What is the unit of measurement to calculate? mgSTEP 2: Set up the equation and solve for X.mg x kg/dose = X5 mg x 40 kg = 200 mgSTEP 3: Round, if necessary.STEP 4: Reassess to determine whether the amount to administer makes sense. If the provider prescribed cefpodoxime 5 mg/kg/dose and the client weighs 40 kg, it makes sense to administer 200 mg per dose. The nurse should administer cefpodoxime 200 mg PO every 12 hr.
A nurse is teaching a client who has been taking prednisone to treat asthma and has a new prescription to discontinue the medication. The nurse should explain to the client to reduce the dose gradually to prevent which of the following adverse effects?
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.
A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes?
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.
A nurse is caring for a client who has active pulmonary tuberculosis (TB) and is to be started on intravenous rifampin therapy. The nurse should instruct the client that this medication can cause which of the following adverse effects?
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.
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?
Catheter migration A client report of hearing a gurgling sound on the side of the catheter insertion is a manifestation of catheter migration.
A nurse is assessing a client who is receiving total parenteral nutrition (TPN) therapy via an infusion pump. Which of the following actions should the nurse take?
Change the IV tubing every 24 hr. The nurse should change the client's IV tubing every 24 hr, or per facility protocol, to prevent bacteria from developing in the tubing.
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?
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 the emergency department is assessing an older adult client who has community- acquired pneumonia. Which of the following findings should the nurse expect?
Confusion Confusion due to hypoxemia is an expected finding for an older-adult who has pneumonia.
While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first?
Discontinue the existing IV line. The greatest risk to the client is injury from the IV infiltration damaging soft tissues surrounding the catheter. Therefore, the first action the nurse should take is to discontinue the existing IV line.
A nurse is caring for a client who has 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.
A nurse is assessing a child who is postoperative following a 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 caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect?
Hemolytic hemolytic transfusion reaction occurs when antibodies in the recipient's blood react to foreign blood cells introduced by the transfusion. The antibodies bind to the foreign cells and destroy them in a process known as hemolysis. The destroyed cells are excreted by the kidneys (hemoglobinuria), causing the red-tinged urine. Hemolytic transfusion reactions can result in acute renal injury, disseminated intravascular coagulation, and circulatory collapse.
A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first?
Measure the 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.
A nurse is caring for a client who is receiving radiation therapy to treat lung cancer. Which of the following actions should the nurse take?
Observe for signs of infection. Radiation therapy to sites containing bone marrow (such as the sternum) can lower the WBC count (leukopenia), thus increasing the client's risk for infection. Screening the client for signs of infection is essential at this time.
A client is planning to perform nasotracheal suction for a client who has 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 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.
A nurse overhears two assistive personnel (AP) from the medical-surgical unit discussing a hospitalized client while in the cafeteria. Which of the following is the priority nursing action?
Quietly tell the APs that this is not appropriate. The nurse has a professional duty to protect the client's confidential information. When using the urgent vs. nonurgent approach to client care, the nurse determines the priority is to stop the APs before there is an additional breach of confidentiality.
A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB?
Sputum culture for acid-fast bacillus Although the Mantoux (skin test) and the chest x-ray may be useful screening tools for TB, the presence of acid-fast bacillus noted in the client's sputum, secretions, or tissues is the only method that can actually confirm the diagnosis.
A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the 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.
A nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of the following actions by the client indicates an understanding of the 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.
A nurse is assessing a client prior to administering a seasonal influenza vaccine. The client says he read about an influenza vaccine that is given as a nasal spray and wants to receive it. The nurse should recognize that which of the following findings is a contraindication for the client receiving the live attenuated influenza vaccine (LAIV)?
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.
A nurse is admitting a client who requires droplet precautions due to influenza. Which of the following actions should the nurse take?
Wear a mask when providing care to the client. The nurse should wear a mask when within 3 feet of a client who requires droplet precautions.
A nurse is caring for a child who has pertussis. The child's parent asks the nurse what the common name for this disease is. The nurse should respond with which of the following common names?
Whooping cough Whooping cough is the common name for pertussis
A nurse in a provider's office is assessing a client. The nurse should identify that which of the following findings are manifestations of pulmonary tuberculosis? (Select all that apply)
night sweats, low grade fever, blood in the sputum
A nurse is caring for a child who is experiencing status asthmaticus. Which of the following interventions is the priority for the nurse to take?
Administer a short-acting ß2 -agonist (SABA). When using the urgent versus non-urgent approach to client care, the nurse should determine that the priority action is to administer a nebulized high-dose SABA to relieve bronchoconstriction and improve ventilation.
A nurse is working with an emergency response team in caring for a group of people who may have been exposed to anthrax while doing farm work, but are not exhibiting manifestation of illness. Which of the following is the appropriate action for the nurse to take?
Administer antibiotic therapy. The nurse should administer an antibiotic and the anthrax vaccine within 24 hr as prophylaxis to all clients exposed to anthrax and are not exhibiting manifestations of illness.
A nurse on a medical-surgical 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?
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.
A nurse is collaborating on care for a client who has COPD. Which of the following tasks 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.
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. (Move the steps into the box on the right, placing them in the selected order of performance. All steps must be used.)
The nurse should first stop the infusion. Next, the nurse should remove the IV catheter and apply a sterile dressing to the insertion site. The nurse should elevate the extremity and apply warm or cold compresses according to agency policy.
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?
eggs The nurse should assess the client for allergies to 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 teaching the mother of a 5-year-old child who has cystic fibrosis about pancreatic enzymes. The nurse should understand that further teaching is necessary when the mother states which of the following?
"I will give my son the enzymes between meals." The parent should give the child pancreatic enzymes with every meal and snack.
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 bolus in 100 mL of 0.9% sodium chloride, two units of packed RBCs of 275 mL and 250 mL; two IV bolus infusions of 250 mL of 0.9% sodium chloride, ranitidine 50 mg IV intermittent bolus in 50 mL of dextrose 5% in water. How many mL of intake should the nurse record?
2525 Lactated Ringer's 150 mL x 9 hr = 1350 mLcefazolin = 100 mLpacked RBCs 275 mL + 250 mL = 525 mL0.9% sodium chloride bolus 250 mL + 250 mL = 500 mLranitidine = 50 mLTotal intake = 2525 mL
A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the 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.
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?
Have the client wear a mask. When a client who has a communicable disease must leave his room, it is important to protect everyone with whom the client comes in contact. Having the client wear a mask protects others from airborne particles should the client cough.
A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?
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.
A nurse is caring for client who has a single lumen central venous catheter. Which of the following actions 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 preparing to insert an IV catheter for a client and has selected the insertion site. Place the following steps in the order in which the nurse should perform them. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
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.
A nurse in a clinic sees a client who has an acute asthma exacerbation. Which of the following medications should reduce the symptoms?
Albuterol via jet nebulizer The nurse should identify that albuterol is a bronchodilator used as the first medication of choice to stop bronchospasm or constriction in clients who have acute asthma exacerbation.
A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority?
Assess the client's respiratory status. The first action the nurse should take using the nursing process is to collect data from the client. The nurse should immediately assess the client's respiratory status before determining the appropriate interventions.
A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client 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 teaching a client who has asthma how to use a metered-dose inhaler (MDI). The nurse identifies the sequence of steps the client should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all steps.)
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.
A nurse is assessing a client who has intravenous therapy-related phlebitis. The nurse uses the Infusion Nurses Society's phlebitis scale to assess the severity of phlebitis and documents the client's phlebitis as a grade level 1. Which of the following assessment findings correlates with a grade level of 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.
A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect?
agitation the nurse should expect agitation due to neurological changes from poor oxygen exchange
