Question:
The nurse makes selections from the hospital menu for a client who is confused and
suspicious of others. Which menu choice is best?
You answered this question Correctly
1. Ham and vegetable casserole
2. Cheese and crackers
3. Caffeine free tea
4. Packaged sugar free Jell-O
Rationale
Strategies
4. Correct: A client who is suspicious of others needs foods that are packaged and can
see them opened.
1. Incorrect: A client who is suspicious of others needs to be able to identify the
ingredients in the food that is being eaten. A casserole contains many ingredients and
the client may fear that something has been added to the food.
2. Incorrect: Finger foods are best for clients that are manic.
3. Incorrect: Drinks and foods with no caffeine are okay for the confused and suspicious
client but this menu choice is not the best choice from the list here.
Question:
Two days after a myocardial infarction, a client begins reporting orthopnea and
dyspnea. Further assessment reveals bi-basilar crackles, jugular venous distension, an
S3 heart sound, a BP of 100/60 mm Hg, and apical pulse of 90 beats per minute. The
urine output has steadily declined over the past 12 hours. What should the nurse
do first?
You answered this question Correctly
1. Notify the primary healthcare provider.
2. Increase the IV rate.
3. Elevate the head of the bed.
4. Observe for cardiac arrhythmias.
Rationale
Strategies
3. Correct: Elevate the head of the bed first. The client is reporting inability
to breathe. (Orthopnea means the client needs to sit up to breathe better.) With ANY
,client having difficulty breathing, the first intervention for the nurse is to sit the client up.
This client is showing s/s of heart failure.
1. Incorrect: Your next step is to call the primary healthcare provider after you do
something to try to fix the problem.
2. Incorrect: Increasing the IV rate is contraindicated and would make the problem
worse.
4. Incorrect: After an MI, all clients are observed for cardiac arrhythmias. This, however,
does not fix the problem.
Question:
Which menu selection by the client diagnosed with nephrotic syndrome indicates that
teaching of proper diet was understood?
You answered this question Correctly
1. Pancakes with whipped butter, syrup, bacon, apple juice
2. Scrambled eggs, sliced turkey, biscuit, whole milk
3. Grits, fresh fruit, toast, coffee
4. Bagel with jelly, hash browns, tea
Rationale
Strategies
2. Correct: Client needs low sodium and increased proteins.
1. Incorrect: This selection is too high in sodium and fats.
3. Incorrect: This selection has no protein. Remember, nephrotic syndrome is the
exception to the rule of limiting protein. These clients need increased protein to
compensate for the large loss of protein in the urine.
4. Incorrect: This selection has no protein. Remember, nephrotic syndrome is
the exception to the rule of limiting protein. These clients need increased protein to
compensate for the large loss of protein in the urine.
Question:
The nurse assesses a multigravida who is four hours postpartum. Findings include that
fundus is firm, 1 centimeter above the umbilicus, and deviated to the right side. The
lochia is moderately heavy and bright red. Which nursing intervention has priority?
You answered this question Correctly
1. Massage the fundus.
2. Administer intravenous oxytocin.
3. Document these normal findings.
, 4. Assist the client up to void.
Rationale
Strategies
4. Correct: These findings are caused by a full bladder, which prevents the uterus from
contracting down and achieving homeostasis. Once the bladder is empty, the fundus will
contract adequately and return to its normal location at level of umbilicus or 1 finger
breadth below the umbilicus and in the midline. A distended bladder will displace the
uterus, usually to the right.
1. Incorrect: The nurse may check fundus after client voids to ensure that this fixes the
problem.
2. Incorrect: Administering oxytocin is not the first intervention for this issue.
3. Incorrect: These are not normal findings so this would be incorrect information for the
nurse to document.
Question:
What risk factors should the nurse include when conducting a class about type 2
diabetes mellitus?
You answered this question Correctly
1. Fat distribution greater in abdomen than in hips.
2. Being underweight.
3. Having type 1 diabetes as a child increases risk for type 2 diabetes.
4. Caucasians are more likely to develop type 2 diabetes than Hispanics.
5. Polycystic ovary syndrome.
Rationale
Strategies
1. , & 5. Correct: If the body stores fat primarily in the abdomen, risk of type 2 diabetes is
greater than if body stores fat elsewhere, such as hips and thighs. Women with
polycystic ovary syndrome have increased risk of diabetes.
2. Incorrect: Being overweight is a primary risk factor for type 2 diabetes. The more
fatty tissue, the more resistant cells become to insulin.
3. Incorrect: A type 1 diabetic will remain a type 1 diabetic.
4. Incorrect: Blacks, Hispanics, American Indians, and Asian Americans are more likely
to develop type 2 diabetes than Caucasians are.
Question:
, What should the nurse include when providing education to a client receiving
tetracycline?
You answered this question Correctly
1. Wear long sleeves when going outside.
2. Take tetracycline on a full stomach.
3. Wait at least two hours after taking tetracycline prior to taking iron supplements.
4. Tetracycline can decrease the effectiveness of birth control pills.
5. Do not take this medicine after the expiration date on the label has passed.
Rationale
Strategies
1. , 3., 4., & 5. Correct: Avoid exposure to sunlight or artificial UV rays (sunlamps or
tanning beds). Tetracycline can make your skin more sensitive to sunlight and sunburn
may result. Use a sunscreen (minimum SPF 15) and wear protective clothing if you
must be out in the sun. Take tetracycline on an empty stomach and do not take iron
supplements, multivitamins, calcium supplements, antacids, or laxatives within 2 hours
before or after taking tetracycline. These products can make this medicine less
effective. Tetracycline can make birth control pills less effective. Use a second method
of birth control while you are taking this medicine to keep from getting pregnant. Throw
away any unused tetracycline when it expires or when it is no longer needed. Do not
take this medicine after the expiration date on the label has passed. Expired tetracycline
can cause a dangerous syndrome resulting in damage to the kidneys.
2. Incorrect: Take tetracycline on an empty stomach and do not take iron supplements,
multivitamins, calcium supplements, antacids, or laxatives within 2 hours before or after
taking tetracycline. These products can make this medicine less effective.
Question:
A 72 year old client admitted with a diagnosis of bleeding ulcers has been prescribed
ranitidine 50 mg IVPB every 8 hours and omeprazole 10 mg po every morning.
Based on this data what intervention should the nurse take first?
Exhibit You answered this question Correctly
1. Stop the infusion of ranitidine.
2. Send the client for a CT scan of the head.
3. Provide oxygen at 2L/NC.
4. Notify the primary healthcare provider.
Rationale
Strategies
The nurse makes selections from the hospital menu for a client who is confused and
suspicious of others. Which menu choice is best?
You answered this question Correctly
1. Ham and vegetable casserole
2. Cheese and crackers
3. Caffeine free tea
4. Packaged sugar free Jell-O
Rationale
Strategies
4. Correct: A client who is suspicious of others needs foods that are packaged and can
see them opened.
1. Incorrect: A client who is suspicious of others needs to be able to identify the
ingredients in the food that is being eaten. A casserole contains many ingredients and
the client may fear that something has been added to the food.
2. Incorrect: Finger foods are best for clients that are manic.
3. Incorrect: Drinks and foods with no caffeine are okay for the confused and suspicious
client but this menu choice is not the best choice from the list here.
Question:
Two days after a myocardial infarction, a client begins reporting orthopnea and
dyspnea. Further assessment reveals bi-basilar crackles, jugular venous distension, an
S3 heart sound, a BP of 100/60 mm Hg, and apical pulse of 90 beats per minute. The
urine output has steadily declined over the past 12 hours. What should the nurse
do first?
You answered this question Correctly
1. Notify the primary healthcare provider.
2. Increase the IV rate.
3. Elevate the head of the bed.
4. Observe for cardiac arrhythmias.
Rationale
Strategies
3. Correct: Elevate the head of the bed first. The client is reporting inability
to breathe. (Orthopnea means the client needs to sit up to breathe better.) With ANY
,client having difficulty breathing, the first intervention for the nurse is to sit the client up.
This client is showing s/s of heart failure.
1. Incorrect: Your next step is to call the primary healthcare provider after you do
something to try to fix the problem.
2. Incorrect: Increasing the IV rate is contraindicated and would make the problem
worse.
4. Incorrect: After an MI, all clients are observed for cardiac arrhythmias. This, however,
does not fix the problem.
Question:
Which menu selection by the client diagnosed with nephrotic syndrome indicates that
teaching of proper diet was understood?
You answered this question Correctly
1. Pancakes with whipped butter, syrup, bacon, apple juice
2. Scrambled eggs, sliced turkey, biscuit, whole milk
3. Grits, fresh fruit, toast, coffee
4. Bagel with jelly, hash browns, tea
Rationale
Strategies
2. Correct: Client needs low sodium and increased proteins.
1. Incorrect: This selection is too high in sodium and fats.
3. Incorrect: This selection has no protein. Remember, nephrotic syndrome is the
exception to the rule of limiting protein. These clients need increased protein to
compensate for the large loss of protein in the urine.
4. Incorrect: This selection has no protein. Remember, nephrotic syndrome is
the exception to the rule of limiting protein. These clients need increased protein to
compensate for the large loss of protein in the urine.
Question:
The nurse assesses a multigravida who is four hours postpartum. Findings include that
fundus is firm, 1 centimeter above the umbilicus, and deviated to the right side. The
lochia is moderately heavy and bright red. Which nursing intervention has priority?
You answered this question Correctly
1. Massage the fundus.
2. Administer intravenous oxytocin.
3. Document these normal findings.
, 4. Assist the client up to void.
Rationale
Strategies
4. Correct: These findings are caused by a full bladder, which prevents the uterus from
contracting down and achieving homeostasis. Once the bladder is empty, the fundus will
contract adequately and return to its normal location at level of umbilicus or 1 finger
breadth below the umbilicus and in the midline. A distended bladder will displace the
uterus, usually to the right.
1. Incorrect: The nurse may check fundus after client voids to ensure that this fixes the
problem.
2. Incorrect: Administering oxytocin is not the first intervention for this issue.
3. Incorrect: These are not normal findings so this would be incorrect information for the
nurse to document.
Question:
What risk factors should the nurse include when conducting a class about type 2
diabetes mellitus?
You answered this question Correctly
1. Fat distribution greater in abdomen than in hips.
2. Being underweight.
3. Having type 1 diabetes as a child increases risk for type 2 diabetes.
4. Caucasians are more likely to develop type 2 diabetes than Hispanics.
5. Polycystic ovary syndrome.
Rationale
Strategies
1. , & 5. Correct: If the body stores fat primarily in the abdomen, risk of type 2 diabetes is
greater than if body stores fat elsewhere, such as hips and thighs. Women with
polycystic ovary syndrome have increased risk of diabetes.
2. Incorrect: Being overweight is a primary risk factor for type 2 diabetes. The more
fatty tissue, the more resistant cells become to insulin.
3. Incorrect: A type 1 diabetic will remain a type 1 diabetic.
4. Incorrect: Blacks, Hispanics, American Indians, and Asian Americans are more likely
to develop type 2 diabetes than Caucasians are.
Question:
, What should the nurse include when providing education to a client receiving
tetracycline?
You answered this question Correctly
1. Wear long sleeves when going outside.
2. Take tetracycline on a full stomach.
3. Wait at least two hours after taking tetracycline prior to taking iron supplements.
4. Tetracycline can decrease the effectiveness of birth control pills.
5. Do not take this medicine after the expiration date on the label has passed.
Rationale
Strategies
1. , 3., 4., & 5. Correct: Avoid exposure to sunlight or artificial UV rays (sunlamps or
tanning beds). Tetracycline can make your skin more sensitive to sunlight and sunburn
may result. Use a sunscreen (minimum SPF 15) and wear protective clothing if you
must be out in the sun. Take tetracycline on an empty stomach and do not take iron
supplements, multivitamins, calcium supplements, antacids, or laxatives within 2 hours
before or after taking tetracycline. These products can make this medicine less
effective. Tetracycline can make birth control pills less effective. Use a second method
of birth control while you are taking this medicine to keep from getting pregnant. Throw
away any unused tetracycline when it expires or when it is no longer needed. Do not
take this medicine after the expiration date on the label has passed. Expired tetracycline
can cause a dangerous syndrome resulting in damage to the kidneys.
2. Incorrect: Take tetracycline on an empty stomach and do not take iron supplements,
multivitamins, calcium supplements, antacids, or laxatives within 2 hours before or after
taking tetracycline. These products can make this medicine less effective.
Question:
A 72 year old client admitted with a diagnosis of bleeding ulcers has been prescribed
ranitidine 50 mg IVPB every 8 hours and omeprazole 10 mg po every morning.
Based on this data what intervention should the nurse take first?
Exhibit You answered this question Correctly
1. Stop the infusion of ranitidine.
2. Send the client for a CT scan of the head.
3. Provide oxygen at 2L/NC.
4. Notify the primary healthcare provider.
Rationale
Strategies
