100 CORRECT AID GRADE A

NCLEX Challenge 3ALL ANSWERS

100% CORRECT AID GRADE ‘A’

• A nurse is preparing to administer clindamycin 300 mg by intermittent

IV bolus over 30 min to a client who has staphylococci infection.Available is clindamycin premixed in 50 mL 0.90% sodium chloride (NaCl). The nurse should set the IV pump to deliver how many mL/hr?(Round the answer to the nearest whole number).

100 mL/hr

• A nurse is preparing to administer 0.9% sodium chloride (NSS) 3000

mL IV to infuse over 24 hr. The drop factor on the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number).

21 gtt/min

• 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?

Sodium 152 Potassium 3.6 Chloride 105 Glucose 102

BUN 18

Creatinine 0.7 Dehydration

• A nurse is calculating a client’s intake and output for an 8-hr shift. The

client’s intake included 1,000 mL 0.9% sodium chloride IV, one 6-oz cup of coffee, 6 oz of water, one 180-mL bowl of soup; 3 oz of flavored gelatin, and 3 oz of ice cream. How many mL should the nurse document as the client’s total intake for the shift? (Round the answer to the nearest whole number).

1,720 mL

• A nurse is caring for a client whose arterial blood gas results show a pH

of 7.3 and a PaCO2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances?

Respiratory acidosis

• A nurse is planning care for a client who has dehydration and is

receiving a continuous IV infusion of 0.9% sodium chloride. Which of the following interventions should the nurse include in the plan of care?

Check the client’s IV infusion every 8 hr.

• A nurse is teaching a client who will undergo a bronchoscopy

procedure. The provider will use a rigid scope and general anesthesia.The nurse should explain that the client’s neck will be in which of the following positions?

A hyperextended position

• A nurse is assessing a client who has fluid overload. Which of the

following findings should the nurse expect? (Select all that apply.)

Increased heart rate Increased blood pressure Increased respiratory rate

• A nurse is teaching a client who is obese and has obstructive sleep

apnea how to decrease the number of nightly apneic episodes. Which of the following client statements indicates an understanding of the teaching?

“If I could lose about 50 pounds, I might stop having so many apneic episodes.”

• 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

• A nurse is assessing for cyanosis in a client who has dark skin. Which

of the following sites should the nurse examine to identify cyanosis in this client?

Conjunctiva

• 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

• A nurse is providing teaching to a group of adult athletes about

preventing the effects of dehydration on the body. Which of the following manifestations should the nurse include in the teaching?

Impaired motor control

• A nurse is caring for a client who is receiving IV fluids to correct

dehydration. Which of the following laboratory values should indicate to the nurse that the client is effectively responding to treatment?

Urine specific gravity 1.020

• A nurse is assessing four clients for fluid balance. The nurse

should identify that which of the following clients is exhibiting manifestations of dehydration?

A client who has a temperature of 39°C (102°F)

• A nurse is caring for a client who is receiving oxygen at 2 L/min via a

nasal cannula. The nurse recognizes the client is receiving which of the following inspired oxygen concentration?

28%

• A nurse is attending a social event when another guest coughs

weakly once, grasps his throat with his hands, and cannot talk. Which of the following actions should the nurse take?

Perform the Heimlich maneuver

• A nurse is caring for a client who is postoperative and whose

respirations 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

• A nurse is caring for a client who develops an airway obstruction from

a foreign body but remains conscious. Which of the following actions should the nurse take first?

Administer the abdominal thrust maneuver