NURSING NCLEX Module 8 Exam Questions and Answers
Submission Details
• Submission Date: 1/17/2017
• Submission Time: 9:55 PM
• Points Awarded:
... [Show More] 115
• Points Missed: 10
• Number of Attempts Allowed: 1
• Not Scored: 0
• Percentage: 92%
1. Questions
1. 1.ID: 9476967734
A nurse notes that the site of a client’s peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous near the insertion point of the catheter. On the basis of this assessment, the nurse should take which action first?
A. Remove the IV catheter Correct
B. Slow the rate of infusion
C. Notify the health care provider
D. Check for loose catheter connections
Awarded 1.0 points out of 1.0 possible points.
2. 2.ID: 9476963098
A nurse hangs a 500mL bag of intravenous (IV) fluid for an assigned client. One hour later the client complains of chest tightness, is dyspneic and apprehensive, and has an irregular pulse. The IV bag has 100 mL remaining. Which action should the nurse take first?
A. Remove the IV
B. Sit the client up in bed
C. Shut off the IV infusion Correct
D. Slow the rate of infusion
Awarded 1.0 points out of 1.0 possible points.
3. 3.ID: 9476961248
A nurse discontinues an infusion of a unit of packed red blood cells (RBCs) because the client is experiencing a transfusion reaction. After discontinuing the transfusion, which action should the nurse take next?
A. Remove the IV catheter
B. Contact the health care provider Correct
C. Change the solution to 5% dextrose in water
D. Obtain a culture of the tip of the catheter device removed from the client
Awarded 1.0 points out of 1.0 possible points.
4. 4.ID: 9476963017
The nurse determines that the client is exhibiting signs of a hemolytic transfusion reaction while receiving a blood transfusion. The nurse should perform these actions in
which priority order? Arrange the actions in the order that they should be performed. All options must be used.
Correct
A. Stopping the infusion of blood
B. Hanging an IV bag of normal saline solution (NS) at a keepveinopen (KVO) rate
C. Notifying the health care provider
D. Obtaining vital signs/oxygen saturation
E. Documenting the findings
Awarded 1.0 points out of 1.0 possible points.
2. 5.ID: 9476964571
A client with heart failure is being given furosemide and digoxin. The client calls the nurse and complains of anorexia and nausea. Which action should the nurse take first?
A. Administer an antiemetic
B. Administer the daily dose of digoxin
C. Discontinue the morning dose of furosemide
D. Checkthe result of laboratory testing for potassium on the sample drawn 3 hours ago Correct
Awarded 1.0 points out of 1.0 possible points.
2. 6.ID: 9476961282
The health care provider (HCP)prescribes the administration of totalparenteral nutrition (TPN), to be started at a rate of 50 mL/hr by way of infusion pump through an established subclavian central line. After the first 2 hours of the TPN infusion, the client suddenly complains of difficulty breathing and chest pain. The nurse should take which immediate action?
A. Obtain blood for culture
B. Clamp the TPN infusion line Correct
C. Obtain an electrocardiogram (ECG)
D. Obtain a sample for blood glucose testing
Rationale: One complication of a subclavian central line is embolism, caused by air or thrombus. Sudden onset of chest pain shortly after the initiation of TPN may mean that this complication has developed. The infusion is clamped (the line should not be discontinued, however), the client turned on the left side with the head down, and the HCP notified immediately. Depending on agency protocol, the rapid response team would also be called. Blood cultures are not necessary in this situation, because infection is not the concern. Likewise, there is no useful reason for checking the blood glucose level. An ECG may be obtained, but this is not the immediate priority. If the client shows signs of an air embolism, the nurse should examine the catheter to determine whether an open port has allowed air into the circulatory system.
TestTaking Strategy: Note the strategic word “immediate.” Focus on the data provided in the question to determine that an embolus has occurred. Eliminate blood cultures and blood glucose testing, which, respectively, relate to infection and hyperglycemia, which is not likely to occur during the first 2 hours of TPN administration. To select from the remaining options, focus on the strategic word “immediate”; this will direct you to the correct option. Review the complications of TPN and the associated nursing interventions
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: TotalParenteral Nutrition
Giddens Concepts: Clinical Judgment, Perfusion
HESI Concepts: Clinical DecisionMaking/Clinical Judgment, PerfusionClotting
Awarded 1.0 points out of 1.0 possible points.
3. 7.ID: 9476957598
The health care provider prescribes 2000 mL of 5% dextrose and normal saline 0.45% for infusion over 24 hours. The drop factor is 15 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round to the nearest whole number).
Correct
Correct Responses
A. 21
Rationale: Use the IV flow rate formula:
Awarded 1.0 points out of 1.0 possible points.
2. 8.ID: 9476963091
A nurse is assessing a peripheral intravenous (IV) site and notes blanching, coolness, and edema at the insertion site. What should the nurse do first?
A. Remove the IV Correct
B. Apply a warm compress
C. Check for blood return
D. Measure the area of infiltration
Awarded 1.0 points out of 1.0 possible points.
2. 9.ID: 9476964540
A home care nurse has been assigned a client who has been discharged home with a prescription for total parenteral nutrition (TPN). Which parameters does the nurse plan to check at each visit as a means of identifying complications of the TPN therapy? Select all that apply.
A. Weight Correct
B. Glucose test Correct
C. Temperature Correct
D. Peripheral pulses
E. Hemoglobin and hematocrit
Awarded 3.0 points out of 3.0 possible points.
3. 10.ID: 9476959510
A nurse is caring for a group of adult clients on an acute care nursing unit. Which clients does the nurse recognize as the most likely candidates for total parenteral nutrition (TPN)? Select all that apply.
A. A client with pancreatitis Correct
B. A client with severe sepsis Correct
C. A client with renal calculi
D. A client who has undergone repair of a hiatal hernia
E. A client with a severe exacerbation of ulcerative colitis Correct
Awarded 2.0 points out of 3.0 possible points.
4. 11.ID: 9476957565
A client with a peripheral intravenous (IV) line in place has a new prescription for infusion of total parenteral nutrition (TPN), a solution containing 25% glucose. Which action should be taken by the nurse?
A. Hanging the IV solution as prescribed
B. Questioning the health care provider about the prescription Correct
C. Diluting the solution with sterile water to halfstrength
D. Hanging the IV solution but setting the infusion at just half the prescribed rate
Awarded 1.0 points out of 1.0 possible points.
5. 12.ID: 9476967726
The first bag of total parenteral nutrition (TPN) solution has arrived on the clinical unit for a client beginning this nutritional therapy. The solution is to be infused by way of a central line.
Which essential piece of equipment should the nurse obtain before hanging the solution?
A. Pulse oximeter
B. Blood glucose meter
C. Electronic infusion device Correct
D. Noninvasive blood pressure monitor
Awarded 1.0 points out of 1.0 possible points.
6. 13.ID: 9476972002
A nurse is monitoring a client who is receiving total parenteral nutrition (TPN). Which t signs and symptoms causes the nurse to suspect that the client is experiencing hyperglycemia as a complication?
A. Pallor, weak pulse, and anuria
B. Nausea, vomiting, and oliguria
C. Nausea, thirst, and increased urine output Correct
D. Sweating, chills, and decreased urine output
Awarded 1.0 points out of 1.0 possible points.
7. 14.ID: 9476957590
At 1600 the nurse checks a client’s total parenteral nutrition (TPN) infusion bag and notes that the solution is running at a rate of 100 mL/hr. The bag was hung the previous day at 1800. The nurse plans to change the infusion bag and tubing this evening at what time?
A. 1700 Incorrect
B. 1800 Correct
C. 2000
D. 2100
Awarded 0.0 points out of 1.0 possible points.
8. 15.ID: 9476970165
A nurse is changing the central line dressing of a client receiving total parenteral nutrition (TPN). The nurse notes moisture under the dressing covering the catheter insertion site. What should the nurse assess next?
A. Temperature
B. Time of the last dressing change
C. Expiration date on the infusion bag
D. Tightness of the tubing connections Correct
Awarded 1.0 points out of 1.0 possible points.
9. 16.ID: 9476970170
A client receiving total parenteral nutrition (TPN) requires fat emulsion (lipids), which will be piggybacked to the TPN solution. On obtaining a bottle of fat emulsion, the nurse notes that fat globules are floating at the top of the solution. Which action should the nurse take?
A. Shake the bottle vigorously
B. Request a new bottle from the pharmacy Correct
C. Rotate the bottle gently back and forth to mix the globules
D. Run the bottle under warm water until the globules disappear
Awarded 1.0 points out of 1.0 possible points.
10. 17.ID: 9476963029
A nurse is preparing a client for the insertion of a central intravenous line into the subclavian vein by the health care provider. The nurse gathers the equipment, places it at the bedside, and prepares to assist the health care provider with the procedure. As further preparation for the procedure, the nurse places the client in which position?
A. Flat on the left side
B. In the prone position
C. In the supine position
D. In a slight Trendelenburg position Correct
Awarded 1.0 points out of 1.0 possible points.
11. 18.ID: 9476959516
A client is receiving total parenteral nutrition (TPN) with fat emulsion (lipids) piggybacked to the TPN solution. For which signs of an adverse reaction to the fat emulsion should the nurse monitor the client? Select all that apply.
A. Chills Correct
B. Pallor
C. Headache Correct
D. Chest and back pain Correct
E. Nausea and vomiting Correct
F. Subnormal temperature
Awarded 4.0 points out of 4.0 possible points.
12. 19.ID: 9476959599
The nurse is preparing to change the solution bag and intravenous tubing of a client receiving total parenteral nutrition (TPN) through a left subclavian central venous line. Which essential action does the nurse ask the client to perform just before switching the tubing?
A. Turn the head to the left
B. Turn the head to the right
C. Exhale slowly and evenly
D. Take a deep breath and hold it Correct
Awarded 1.0 points out of 1.0 possible points.
13. 20.ID: 9476961270
A nurse suspects that a client receiving total parenteral nutrition (TPN) through a central line has an air embolism. The nurse immediately places the client in which position?
A. Left side with the head lower than the feet Correct
B. Left side with the head higher than the feet
C. Right side with the head lower than the feet
D. Right side with the head higher than the feet
Awarded 1.0 points out of 1.0 possible points.
14. 21.ID: 9476970158
A nurse is making initial rounds on a group of assigned clients. Which client should the nurse see first?
A. A client receiving total parenteral nutrition (TPN) at a rate of 50 mL/hr for
the last 24 hours
B. A client receiving TPN at a rate of 50 mL/hr whose temp was 99° F on
the previous shift
C. A client receiving TPN at a rate of 100 mL/hr who has complained of
needing frequent trips to the bathroom to void
D. A client whose TPN solution was decreased to a rate of 25 mL/hr who is now complaining of weakness, headache, and sweating Correct
Awarded 1.0 points out of 1.0 possible points.
15. 22.ID: 9476964581
A nurse answers a call bell and finds that the total parenteral nutrition (TPN) solution bag of an assigned client is empty. The new prescription was written for a new bag at the beginning of the shift, but it has not yet arrived from the pharmacy. Which action should the nurse take first?
A. Call the health care provider
B. Call the pharmacy for further instructions
C. Hang a solution of 10% dextrose in water Correct
D. Hang a solution of 5% dextrose in 0.9% sodium chloride
Awarded 1.0 points out of 1.0 possible points.
16. 23.ID: 9476957513
A young female client with schizophrenia says to the nurse, “Since I started on olanzapine last year, I’m doing well in school and all, but I’ve gained so much weight, and it’s really bothering me. What can I do about this?” Which response by the nurse would be therapeutic?
A. “Well, I think you’re overreacting. Today people think they should be
skinnyminnies, even though it’s not healthy.”
B. “Weight gain can be a side effect of the medication, so you need to
watch your diet and exercise. How much weight have you gained?” Correct
C. “That medication isn’t any more likely to cause weight gain than the
others you’re taking. Perhaps we could go over your diet and exercise habits.”
D. “I want you to stop taking this medication immediately, and I’m calling the doctor, because this is a very serious side effect and you may need dialysis.”
Awarded 1.0 points out of 1.0 possible points.
17. 24.ID: 9476961262
A client with schizophrenia has been taking an antipsychotic medication for 2 months. For which adverse effect should the nurse monitor the client closely?
A. Akathisia Correct
B. Pelvic thrusts
C. Athetoid limbs
D. Protruding tongue
Awarded 1.0 points out of 1.0 possible points.
18. 25.ID: 9476957544
A client with schizophrenia who has been taking an antipsychotic medication calls the clinic nurse and says, “I need to cancel my appointment with the psychiatrist again, because I still have this awful sore throat. It’s so bad that my mouth has a sore.” How does the nurse respond to the client?
A. “I wouldn’t be upset. It happens when you aren’t drinking enough water.”
B. “I think you need to come in for blood work today, because this may be an adverse effect of your medicine.” Correct
C. “Do you remember when you started this medication? Your psychiatrist
told you how important it is to keep your appointments with him.”
D. “You probably have a simple flu, but it might help if you gargle with some antiseptic mouthwash every 2 hours or so and drink plenty of water.”
Awarded 1.0 points out of 1.0 possible points.
19. 26.ID: 9476967709
A client rings the call bell and complains of pain at the site of an IV infusion. The nurse assesses the site and determines that phlebitis has developed. Which actions should the nurse take? Select all that apply.
A. Removing the IV catheter at that site Correct
B. Applying warm, moist compresses to the IV site Correct
C. Notifying the health care provider about the finding Correct
D. Encouraging the client to scrub the site while in the shower
E. Starting a new IV line in a proximal portion of the same vein
Awarded 3.0 points out of 3.0 possible points.
20. 27.ID: 9476964536
A nurse notes that the site of a client’s peripheral IV catheter is reddened, warm, painful, and slightly edematous in the area of the insertion site. After taking appropriate steps to care for the client, the nurse documents in the medical record that the client has experienced which problem?
A. Phlebitis of the vein Correct
B. Infiltration of the IV line
C. Hypersensitivity to the IV solution
D. An allergic reaction to the IV catheter material
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