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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.
ANSWER: 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 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.
,ANSWER : 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
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.
ANSWER: 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.
ANSWER: 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 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.
ANSWER: Teach tracheal suctioning techniques
Rationale: Suctioning helps to clear secretions and maintain an open airway,
which is critical.
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
ANSWER: Stroke secondary to hemorrhage
Rationale: Stroke related to cerebral hemorrhage is major risk for uncontrolled
hypertension.
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
, ANSWER: Document the assessment data
Rationale: 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 first?
a. Respiratory apnea of 30 seconds
b. Oxygen saturation rate of 88%
c. Eight premature ventricular beats every minute
d. Disconnected monitor signal for the last 6 minutes.
ANSWER: Respiratory apnea of 30 seconds
Rationale: The priority is the client whose alarm indicating respiratory apnea
that should be assessed first.
During a home visit, the nurse observed an elderly client with diabetes slip and
fall. What action should the nurse take first?
a. Give the client 4 ounces of orange juice
b. Call 911 to summon emergency assistance
c. Check the client for lacerations or fractures
d. Asses clients blood sugar level
ANSWER: Check the client for lacerations or fractures
Rationale: After the client falls, the nurse should immediately assess for the
possibility of injuries and provide first aid as needed
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?
a. Ensure preoperative lab results are available
b. Start prescribed IV with lactated Ringer's
c. Inform the anesthesia care provider
d. Contact the client's obstetrician.
ANSWER: Inform the anesthesia care provider