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
10. 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
11. 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
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
10. 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
11. 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
