Following discharge teaching, a male client with duodenal
ulcer tells the nurse the he will drink plenty of dairy
products, such as milk, to help coat
... [Show More] and protect his ulcer.
What is the best follow-up action by the nurse?
• Review with the client the need to avoid foods that are
rich in milk and cream
• A male client with hypertension, who received new
antihypertensive prescriptions at his last visit returns to the
clinic two weeks later to evaluate his blood pressure (BP).
His BP is 158/106 and he admits that he has not been
taking the prescribed medication because the drugs make
him “feel bad”. In explaining the need for hypertension
control, the nurse should stress that an elevated BP places
the client at risk for which pathophysiological condition?
• Stroke secondary to hemorrhage
• The nurse observes an unlicensed assistive personnel (UAP)
positioning a newly admitted client who has a seizure
disorder. The client is supine and the UAP is placing soft
pillows along the side rails. What action should the nurse
implement?
• Instruct the UAP to obtain soft blankets to secure to the
side rails instead of pillows.
• An adolescent with major depressive disorder has been
taking duloxetine (Cymbalta) for the past 12 days. Which
assessment finding requires immediate follow-up?
• Describes life without purpose
• A 60-year-old female client with a positive family history of
ovarian cancer has developed an abdominal mass and is
being evaluated for possible ovarian cancer. Her
Papanicolau (Pap) smear results are negative. What
information should the nurse include in the client’s teaching
plan?
• Further evaluation involving surgery may be needed
• A client who recently underwear a tracheostomy is being
prepared for discharge to home. Which instructions is most
important for the nurse to include in the discharge plan?
• Teach tracheal suctioning techniques
• In assessing an adult client with a partial rebreather mask,
the nurse notes that the oxygen reservoir bag does not
deflate completely during inspiration and the client’s
respiratory rate is 14 breaths / minute. What action should
the nurse implement?
• Document the assessment data
• Rational: reservoir bag should not deflate completely
during inspiration and the client’s respiratory rate is
within normal limits.
• During shift report, the central electrocardiogram (EKG)
monitoring system alarms. Which client alarm should the
nurse investigate firs?
• Respiratory apnea of 30 seconds
• During a home visit, the nurse observed an elderly client
with diabetes slip and fall. What action should the nurse
take first?
• Check the client for lacerations or fractures
• At 0600 while admitting a woman for a schedule repeat
cesarean section (C-Section), the client tells the nurse that
she drank a cup a coffee at 0400 because she wanted to
avoid getting a headache. Which action should the nurse
take first?
• Inform the anesthesia care provider
• After placing a stethoscope as seen in the picture, the nurse
auscultates S1 and S2 heart sounds. To determine if an S3
heart sound is present, what action should the nurse take
first?
• Listen with the bell at the same location
• A 66-year-old woman is retiring and will no longer have a
health insurance through her place of employment. Which
agency should the client be referred to by the employee
health nurse for health insurance needs?
• Medicare
• A client who is taking an oral dose of a tetracycline
complains of gastrointestinal upset. What snack should the
nurse instruct the client to take with the tetracycline?
• Toasted wheat bread and jelly
• Following a lumbar puncture, a client voices several
complaints. What complaint indicated to the nurse that the
client is experiencing a complication?
• “I have a headache that gets worse when I sit up”
• “I am having pain in my lower back when I move my
legs”
• “My throat hurts when I swallow”
• “I feel sick to my stomach and am going to throw up”
• An elderly client seems confused and reports the onset of
nausea, dysuria, and urgency with incontinence. Which
action should the nurse implement?
• Obtain a clean catch mid-stream specimen
• The nurse is assisting the mother of a child with
phenylketonuria (PKU) to select foods that are in keeping
with the child’s dietary restrictions. Which foods are
contraindicated for this child?
• Foods sweetened with aspartame
• Before preparing a client for the first surgical case of the
day, a part-time scrub nurse asks the circulating nurse if a 3
minute surgical hand scrub is adequate preparation for this
client. Which response should the circulating nurse
provide?
• Direct the nurse to continue the surgical hand scrub for
a 5 minute duration
• Which breakfast selection indicates that the client
understands the nurse’s instructions about the dietary
management of osteoporosis?
• Bagel with jelly and skim milk
• The charge nurse of a critical care unit is informed at the
beginning of the shift that less than the optimal number of
registered nurses will be working that shift. In planning
assignments, which client should receive the most care
hours by a registered nurse (RN)?
• An 82-year-old client with Alzheimer’s disease newlyfractures femur who has a Foley catheter and soft
wrist restrains applied [Show Less]