NCLEX Challenge 4 - label with a client ID bracelet prior to infusi...

NCLEX Challenge 4 1.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?Oncology nurse 2.A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse’s highest priority?Administering a nebulized beta-adrenergic 3.A nurse is auscultating the breath sounds of a client who has asthma.When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds?Wheezes 4.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.Cleanse the site with an antiseptic swab Apply a tourniquet or BP cuff Dilate the vein Insert the catheter Flush the catheter 5.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.Inhale deeply and then exhale completely Place her lips firmly around the mouthpiece Breathe in deeply over 2 to 3 seconds while pushing down on the canister Hold her breath for 10 seconds Exhale slowly through pursed lips Waited 60 seconds between each puff

6.A nurse is preparing to apply wrist restraints to a client to prevent her from pulling out an IV catheter. Which of the following actions should the nurse take?Keep the padded portion of the restraints against the wrists 7.A nurse is providing discharge teaching to a client who has asthma and new prescriptions for cromolyn and albuterol, both by nebulizer. Which of the following statements by the client indicates an understanding of the teaching?“I will be sure to take the albuterol before taking the cromolyn.” 8.A nurse is caring for a client who is confused and has pulled out her peripheral IV catheter three times. Which of the following actions should the nurse consider?Place mitten restraints on the client’s hands 9.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 a client receiving the live attenuated influenza vaccine (LAIV)?The client’s age is 62

• A nurse is caring for a client who has chronic obstructive

pulmonary disease (COPD). The client tells the nurse, “I can feel 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

• A nurse is instructing a client who is newly diagnosed with

pulmonary tuberculosis (TB) about the use of antitubercular medications. Which of the following information should the nurse include in the teaching?A typical course of treatment involve 6 to 9 months of consistent medication use

• A nurse is admitting a client who is having an exacerbation of his

asthma. When reviewing the provider’s orders, the nurse recognizes that clarification is needed for which of the following medications?Propranolol

• 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?Place the client on his left side in Trendelenburg position

• A nurse is caring for a client who suspects recent exposure to

inhalation anthrax. Which of the following findings indicate possible exposure?Flu-like symptoms

• 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

• A nurse in an emergency department is preparing to administer

theophylline by continuous intravenous (IV) infusion to a client who is experiencing an asthma attack. Which of the following actions should the nurse take?Infuse the medication with an IV pump

• 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?“I should expect the hospice team to help me manage my dyspnea.”

• A nurse is admitting a client who has pertussis. Which of the

following types of transmission-based precautions should the nurse initiate?Droplet

• 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

• A nurse is preparing to insert a peripheral IV catheter. Which of

the following antiseptics is the nurse’s best choice for preparing the client’s skin at the insertion site?Chlorhexidine

• A nurse is teaching a client who has emphysema about self-

management strategies. Which of the following statements by the client indicates an understanding of the teaching?“I will follow a daily diet high in calories and protein.”

• 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.”

• A nurse is teaching a client who has chronic obstructive

pulmonary disease about ways to facilitate eating. Which of the following statements indicates a need for further teaching?“I will take my bronchodilators after meals.”

• 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

• A nurse is caring for a client who has a central venous catheter

and reports a gurgling sound on the side of the catheter insertion.Which of the following complications should the nurse suspect?Catheter migration