NCLEX_Challenge_4.

NU I301 INCLEX IChallenge I4
1. A I nurse I is I selecting I a Iqualified I staff I member I to I double I check I a I blood
Ilabel Iwith Ia Iclient IID Ibracelet Iprior Ito Iinfusing Ia Iunit Iof Iblood. IThe

Inurse I should I identify Ithat I which I of I the I following I persons I is I qualified?




Oncology Inurse

2. A I nurse I in I an I urgent I care I center I is I caring I for I a I client I who I is I having I an
Iacute Iasthma Iexacerbation. IWhich Iof Ithe Ifollowing Iactions Iis Ithe

Inurse’s Ihighest Ipriority?




Administering I a I nebulized I beta-adrenergic

3. A I nurse I is I auscultating I the I breath I sounds I of I a I client I who I has I asthma.
IW hen I the I client Iexhales, I the I nurse I hears I continuous I high-pitched

Isqueaking I sounds. I The I nurse I should I document I this I as I which I of I the

Ifollowing Iadventitious Ibreath Isounds?




Wheezes

4. A I nurse I is Ipreparing I to Iinsert I an IIV Icatheter Ifor Ia I client I and Ihas
Iselected Ithe Iinsertion Isite. IPlace Ithe Ifollowing Isteps I in Ithe Iorder Iin

Iwhich Ithe Inurse Ishould Iperform Ithem.




Cleanse I the I site I with I an I antiseptic I swabIApply
Ia Itourniquet Ior IBP Icuff

Dilate Ithe Ivein
IInsert Ithe Icatheter

IFlush Ithe Icatheter




5. A Inurse Iis Iteaching Ia Iclient Iwho Ihas Iasthma Ihow Ito Iuse Ia Imetered-
Idose Iinhaler I(MDI). IThe Inurse Iidentifies Ithe Isequence Iof Isteps Ithe

Iclient Ishould Ifollow.




Inhale I deeply I and I then I exhale I completely
IPlace Iher Ilips Ifirmly Iaround Ithe Imouthpiece

Breathe I in I deeply I over I 2 I to I 3 I seconds I while I pushing I down I on I theIcanister
Hold I her I breath I for I 10 I seconds
Exhale I slowly I through I pursed I lips
IWaited I 60 I seconds I between I each I puff

, 6. A Inurse Iis I preparing Ito Iapply Iwrist I restraints Ito Ia Iclient Ito Iprevent Iher
Ifrom Ipulling Iout Ian IIV Icatheter. IWhich Iof Ithe Ifollowing Iactions Ishould

Ithe Inurse Itake?




Keep Ithe I padded I portion I of I the I restraints I against I the I wrists

7. A Inurse Iis Iproviding Idischarge Iteaching Ito Ia Iclient Iwho Ihas Iasthma Iand
Inew Iprescriptions Ifor Icromolyn Iand Ialbuterol, Iboth Iby Inebulizer. IWhich

Iof I the I following I statements I by I the I client I indicates I an I understanding Iof

Ithe Iteaching?




“I Iwill Ibe Isure Ito Itake Ithe Ialbuterol Ibefore Itaking Ithe Icromolyn.”

8. A I nurse I is I caring I for I a I client I who I is I confused I and I has I pulled Iout I her
Ip eripheral IIV Icatheter Ithree Itimes. IWhich I of Ithe Ifollowing Iactions

Ishould Ithe Inurse Iconsider?




Place Imitten Irestraints Ion Ithe Iclient’s Ihands

9. A I nurse I is I assessing I a I client I prior I to I administering I a I seasonal I influenza
Ivaccine. I The I client I says I he I read I about I an I influenza I vaccine I that I is Igiven

I as I a I nasal I spray I and I wants Ito I receive Iit. IThe I nurse I should Irecognize Ithat

Iwhich Iof Ithe Ifollowing Ifindings Iis Ia Icontraindication Ifor IaIclient Ireceiving

Ithe Ilive Iattenuated Iinfluenza Ivaccine I(LAIV)?




The I client’s I age I is I 62

10. A Inurse Iis Icaring Ifor Ia Iclient Iwho Ihas Ichronic Iobstructive Ipulmonary
Idisease I(COPD). IThe Iclient Itells Ithe Inurse, I“I Ican Ifeel Icongestion I in Imy

I lungs, I and I I I certainly I cough I a I lot, I but I I I can’t I seem I toIb ring I anything

I up.” I Which I of Ithe I following I actions I should Ithe I nurse Itake Ito Ihelp Ithis

Iclient Iwith Itenacious Ibronchial Isecretions?




Encouraging Ithe I client Ito Idrink I2 Ito I3 IL Iof Iwater Idaily

11. A I nurse I is I instructing I a I client I who Iis I newly I diagnosed I with
Ip ulmonary Ituberculosis I(TB) I about Ithe Iuse Iof Iantitubercular

Imedications. I Which I of I the I following I information I should I the I nurse

Iinclude Iin Ithe Iteaching?




A I typical I course Iof Itreatment I involve I 6 I to I 9 I months I of I consistent
Im edication Iuse