NCLEX Challenge 8
A nurse in a long-term care facility is caring for an older adult client who has dementia and begins to
have frequent episodes of urinary incontinence. After the provider determines no medical cause for the
client’s incontinence, which of the following interventions should the nurse initiate to manage this
behavior?
Take the client to the bathroom every 2 hr.
A nurse is completing discharge teaching to a client about nutrition therapy for wound healing following
major surgery. Which of the following vitamins that promote wound healing should the nurse include in
the teaching? (Select all that apply.)
Vitamin A
Vitamin B12
Vitamin C
Vitamin K
A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which
of the following actions should the nurse take first?
Evaluate the client’s neurological status.
A nurse is in a client’s room when the client begins having a tonic-clonic seizure. Which of the following
actions should the nurse take first?
Turn the client’s head to the side.
, A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person,
place, and time, and has advance directives. The client is scheduled for a procedure that requires
informed consent. Which of the following persons should sign the informed consent?
The client.
A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the
nurse examine to identify cyanosis in this client?
Conjunctivae.
A nurse is caring for a 2-year-old child who has seizures and is receiving phenytoin in suspension form.
Which of the following actions should the nurse take before administering each dose?
Shake the container vigorously.
A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which
of the following nutrients should the nurse include in the teaching?
Protein.
A nurse is caring for a client who has pruritus following treatment for scabies. Which of the following
actions should the nurse take?
Provide mittens for the client to wear at night.
A nurse is caring for a client who has a suspected diagnosis of myasthenia gravis. The provider prescribes
a Tensilon test. Which of the following findings indicates a positive test?
Muscle contractions become progressively stronger.
A nurse in a long-term care facility is caring for an older adult client who has dementia and begins to
have frequent episodes of urinary incontinence. After the provider determines no medical cause for the
client’s incontinence, which of the following interventions should the nurse initiate to manage this
behavior?
Take the client to the bathroom every 2 hr.
A nurse is completing discharge teaching to a client about nutrition therapy for wound healing following
major surgery. Which of the following vitamins that promote wound healing should the nurse include in
the teaching? (Select all that apply.)
Vitamin A
Vitamin B12
Vitamin C
Vitamin K
A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which
of the following actions should the nurse take first?
Evaluate the client’s neurological status.
A nurse is in a client’s room when the client begins having a tonic-clonic seizure. Which of the following
actions should the nurse take first?
Turn the client’s head to the side.
, A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person,
place, and time, and has advance directives. The client is scheduled for a procedure that requires
informed consent. Which of the following persons should sign the informed consent?
The client.
A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the
nurse examine to identify cyanosis in this client?
Conjunctivae.
A nurse is caring for a 2-year-old child who has seizures and is receiving phenytoin in suspension form.
Which of the following actions should the nurse take before administering each dose?
Shake the container vigorously.
A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which
of the following nutrients should the nurse include in the teaching?
Protein.
A nurse is caring for a client who has pruritus following treatment for scabies. Which of the following
actions should the nurse take?
Provide mittens for the client to wear at night.
A nurse is caring for a client who has a suspected diagnosis of myasthenia gravis. The provider prescribes
a Tensilon test. Which of the following findings indicates a positive test?
Muscle contractions become progressively stronger.
