ANSWERS GRADED A+ ASSURED SUCCESS
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. Correct Answers c. Review with the client the need to
avoid foods that are rich in milk and cream.
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. Correct Answers b. Instruct the UAP to obtain soft
blankets to secure to the side rails instead of pillows.
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 Correct Answers c. Stroke
secondary to hemorrhage
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. Correct Answers a. 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
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. Correct
Answers a. Further evaluation involving surgery may be needed
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. Correct Answers b.
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
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 Correct Answers d. Document the
assessment data
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. Correct Answers
a. 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?
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 Correct Answers c. 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?