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,Terms in this set (798)
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 and protect his ulcer. What is the best follow-up action by
the nurse?
a. Remind the client that it is also important to switch to
decaffeinated coffee and tea.
b. Suggest that the client also plan to eat frequent small meals to
reduce discomfort
c. Review with the client the need to avoid foods that are rich in milk
and cream.
d. Reinforce this teaching by asking the client to list a dairy food that
he might select.
Review with the client the need to avoid foods that are rich in milk
and cream
Rationale: Diets rich in milk and cream stimulate gastric acid
secretion and should be avoided.
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?
a. Blindness secondary to cataracts
b. Acute kidney injury due to glomerular damage
c. Stroke secondary to hemorrhage
d. Heart block due to myocardial damage
Stroke secondary to hemorrhage
Rationale: Stroke related to cerebral hemorrhage is major risk for
uncontrolled hypertension.
,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?
a. Ensure that the UAP has placed the pillows effectively to protect
the client.
b. Instruct the UAP to obtain soft blankets to secure to the side rails
instead of pillows.
c. Assume responsibility for placing the pillows while the UAP
completes another task.
d. Ask the UAP to use some of the pillows to prop the client in a side
lying position.
Instruct the UAP to obtain soft blankets to secure to the side rails
instead of pillows
Rationale: The nurse should instruct the UAP to pad the side rails
with soft blankest because the use of pillows could result in
suffocation and would need to be removed at the onset of the
seizure. The nurse can delegate paddling the side rails to the UAP
An adolescent with major depressive disorder has been taking
duloxetine (Cymbalta) for the past 12 days. Which assessment
finding requires immediate follow-up
a. Describes life without purpose
b. Complains of nausea and loss of appetite
c. States is often fatigued and drowsy
d. Exhibits an increase in sweating.
Describes life without purpose
Rationale: Cymbalta is a selective serotonin and norepinephrine
reuptake inhibitor that is known to increase the risk of suicidal
thinking in adolescents and young adults with major depressive
disorder. B, C and D are side effects
, 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
a. Further evaluation involving surgery may be needed
b. A pelvic exam is also needed before cancer is ruled out
c. Pap smear evaluation should be continued every six month
d. One additional negative pap smear in six months is needed.
Further evaluation involving surgery may be needed
Rationale: An abdominal mass in a client with a family history for
ovarian cancer should be evaluated carefully
A client who recently underwent a tracheostomy is being prepared
for discharge to home. Which instructions is most important for the
nurse to include in the discharge plan?
a. Explain how to use communication tools.
b. Teach tracheal suctioning techniques
c. Encourage self-care and independence.
d. Demonstrate how to clean tracheostomy site.
Teach tracheal suctioning techniques
Rationale: Suctioning helps to clear secretions and maintain an open
airway, which is critical.
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
a. Encourage the client to take deep breaths
b. Remove the mask to deflate the bag
c. Increase the liter flow of oxygen
d. Document the assessment data
Document the assessment data
Rational: reservoir bag should not deflate completely during
inspiration and the client's respiratory rate is within normal limits.
E
S
I
7
9
9
R
N
E
xi
t
E
x
a
m
Save
Students
also
studied
,Terms in this set (798)
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 and protect his ulcer. What is the best follow-up action by
the nurse?
a. Remind the client that it is also important to switch to
decaffeinated coffee and tea.
b. Suggest that the client also plan to eat frequent small meals to
reduce discomfort
c. Review with the client the need to avoid foods that are rich in milk
and cream.
d. Reinforce this teaching by asking the client to list a dairy food that
he might select.
Review with the client the need to avoid foods that are rich in milk
and cream
Rationale: Diets rich in milk and cream stimulate gastric acid
secretion and should be avoided.
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?
a. Blindness secondary to cataracts
b. Acute kidney injury due to glomerular damage
c. Stroke secondary to hemorrhage
d. Heart block due to myocardial damage
Stroke secondary to hemorrhage
Rationale: Stroke related to cerebral hemorrhage is major risk for
uncontrolled hypertension.
,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?
a. Ensure that the UAP has placed the pillows effectively to protect
the client.
b. Instruct the UAP to obtain soft blankets to secure to the side rails
instead of pillows.
c. Assume responsibility for placing the pillows while the UAP
completes another task.
d. Ask the UAP to use some of the pillows to prop the client in a side
lying position.
Instruct the UAP to obtain soft blankets to secure to the side rails
instead of pillows
Rationale: The nurse should instruct the UAP to pad the side rails
with soft blankest because the use of pillows could result in
suffocation and would need to be removed at the onset of the
seizure. The nurse can delegate paddling the side rails to the UAP
An adolescent with major depressive disorder has been taking
duloxetine (Cymbalta) for the past 12 days. Which assessment
finding requires immediate follow-up
a. Describes life without purpose
b. Complains of nausea and loss of appetite
c. States is often fatigued and drowsy
d. Exhibits an increase in sweating.
Describes life without purpose
Rationale: Cymbalta is a selective serotonin and norepinephrine
reuptake inhibitor that is known to increase the risk of suicidal
thinking in adolescents and young adults with major depressive
disorder. B, C and D are side effects
, 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
a. Further evaluation involving surgery may be needed
b. A pelvic exam is also needed before cancer is ruled out
c. Pap smear evaluation should be continued every six month
d. One additional negative pap smear in six months is needed.
Further evaluation involving surgery may be needed
Rationale: An abdominal mass in a client with a family history for
ovarian cancer should be evaluated carefully
A client who recently underwent a tracheostomy is being prepared
for discharge to home. Which instructions is most important for the
nurse to include in the discharge plan?
a. Explain how to use communication tools.
b. Teach tracheal suctioning techniques
c. Encourage self-care and independence.
d. Demonstrate how to clean tracheostomy site.
Teach tracheal suctioning techniques
Rationale: Suctioning helps to clear secretions and maintain an open
airway, which is critical.
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
a. Encourage the client to take deep breaths
b. Remove the mask to deflate the bag
c. Increase the liter flow of oxygen
d. Document the assessment data
Document the assessment data
Rational: reservoir bag should not deflate completely during
inspiration and the client's respiratory rate is within normal limits.
