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NCLEX Challenge 1 1.A nurse administers an incorrect medication to a client. Following an assessment of the client, the nurse determines that the client has experienced no untoward effects as a result of the medication. The nurse does not complete an incident report because no harm came to the client. Which of the following ethical principles did the nurse violate?Veracity 2.A nurse is teaching a client about the physical effects of chemotherapy. Following the teaching, the nurse asks the client to described one physical effect. The nurse is focusing on which of the following elements of the communication process?Feedback 3.A nurse is preparing to administer gabapentin 900 mg PO once daily for a client who has neuropathic pain. The amount available is gabapentin 300 mg/capsule. How many capsules 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.)
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4.A nurse is discussing culturally competent care at a nursing staff inservice. Which of the following information should the nurse include when discussing clients’ cultures?Nurses should focus on clients’ cultures, rather than their ethnicity, when providing care 5.A nurse is caring for several clients. For which of the following situations should the nurse complete an incident report?A client discovers that his dentures are missing 6.A nurse is giving change-of-shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR?Code status 7.A nurse manager is preparing to confront a staff nurse who is abusing alcohol. Which of the following defense mechanisms should the nurse manager expect the staff nurse to use?Denial 8.A nurse is providing discharge teaching for a client who is postoperative following a simple mastectomy. The client is to begin outpatient radiation therapy the next day. Which of the following instructions about maintaining skin integrity should the nurse include? This study source was downloaded by 100000819885058 from CourseHero.com on 02-08-2022 04:59:05 GMT -06:00
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Do not apply heat to the area of irradiation 9.When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. Which of the following actions should the nurse take?Contact the provider to question the dosage 10.A nurse is caring for a client who has cancer and is scheduled for immediate chemotherapy. The client tells the nurse that she wants to try nontraditional treatments first. Which of the following responses should the nurse make?“Tell me more about your concerns about taking chemotherapy.” 11.A nurse is preparing to administer morphine 4 mg IV bolus to a client who reports pain. Available is morphine 10 mg/mL. Which of the following actions should the nurse take?Have another nurse witness the disposal of the extra medication 12.A nurse is caring for a client who has fallen while getting out of bed and states, “I’m okay! I guess I should have called for help to the bathroom.” After assessing the client, the nurse notifies the provider. Which of the following documentation should the nurse include in the client’s medical record?“The provider was notified.” 13.A nurse manager is presenting to a group of unit nurses the categories regulated under the Controlled Substances Act. Which of the following medication prescriptions should the nurse include under Schedule II?Morphine 14.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 15.A nurse manager has recently become aware of a conflict between the pharmacy and the staff nurses regarding sending and receiving medications. Which of the following actions should the nurse take first to resolve the conflict?Identify the problem 16.A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which of the following statements should the nurse identify as an indication that the client needs further teaching? This study source was downloaded by 100000819885058 from CourseHero.com on 02-08-2022 04:59:05 GMT -06:00
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“It’s unfortunate that I have to be in the hospital for this treatment.” 17.A nurse is caring for a client who is dying of 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?Nonmaleficence 18.A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?Secure the restraints using a quick-release tie 19.A nurse at a provider’s office is providing teaching to a client who is taking chemotherapy and losing weight. Which of the following should the nurse recommend to increase calorie and protein intake? (Select all that apply.) Top fruits with yogurt Add cream to soups Use milk instead of water in recipes Dip meats in eggs and bread crumbs before cooking 20.A nurse on a medical-surgical unit is preparing to contact a provider about a client’s condition.The client is 6 hr. 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 21.A nurse is caring for a client is receiving hydromorphone HCL via PCA pump and reports continuous pain of 6 on a scale from 0 to 10. Which of the following actions should the nurse take first?Check the display on the PCA pump 22.A nurse is planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer, and who has neutropenia. The nurse should include which of the following restrictions in the client’s plan of care?Fresh flowers and potted plants in the room 23.A nurse is planning care for a client who has immunosuppression following chemotherapy.Which of the following interventions should the nurse include in the plan of care? This study source was downloaded by 100000819885058 from CourseHero.com on 02-08-2022 04:59:05 GMT -06:00
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Limit the number of health care workers entering the room 24.A nurse observes that a client who has depression is sitting alone in the room crying. As the nurse approaches, the client states, “I’m feeling really down and don’t want to talk to anyone right now.” Which of the following responses should the nurse make?“I’ll just sit here with you for a few minutes then.” 25.A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block?Hypotension 26.A nurse manager received a client request not to have a specific staff nurse care for her while at the acute care facility. Which of the following is the appropriate action by the nurse manager?Address the concern with the specific staff nurse 27.A public health nurse is assessing an older adult client who lives with a family member. The nurse identifies several bruises in various stages of healing. The client and family member explain that the bruises are a result of clumsiness. However, based on the distribution of the bruises, the nurse suspects abuse. Which of the following actions should the nurse take first?Report the findings to a supervisor 28.A charge nurse has access to the facility’s electronic client records. It is appropriate for the charge nurse to share her personal password with whom?No one 29.A charge nurse is supervising a newly licensed nurse provide care for a client who has a PCA pump. Which of the following statements made by the nurse requires further action by the charge nurse?“I discarded the remaining 2 mg of morphine from the PCA pump. Please document that you witnessed it.” 30.A nurse is preparing to administer meperidine 75 mg IM to a client who reports postoperative pain. Available is meperidine 100 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) 0.8 mL 31.A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain?Self-report of pain This study source was downloaded by 100000819885058 from CourseHero.com on 02-08-2022 04:59:05 GMT -06:00
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