• 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
... [Show More] coat 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 head [Show Less]