• Following discharge teaching, a male client with duodenal ulcer tells the nurse
d d d d d d d d d d d d
the he willdrink plenty of dairy products, such as milk, to help coat and protect
d d d d d d d d d d d d d d d d
his ulcer. What is thebest follow-up action by the nurse?
d d d d d d d d d d
• Review with the client the need to avoid foods that are rich in milk and cre
d d d d d d d d d d d d d d d
am
• A 66-year-
d
old woman is retiring and will no longer have a health insurance through her
d d d d d d d d d d d d d
place of employment. Which agency should the client be referred to by the em
d d d d d d d d d d d d d
ployeehealth nurse for health insurance needs?
d d d d d d
• Medicare
• A client who is taking an oral dose of a tetracycline complains of gastrointest
d d d d d d d d d d d d d
inal upset.What snack should the nurse instruct the client to take with the tetr
d d d d d d d d d d d d d d
acycline?
• Toasted wheat bread and jelly d d d d
• Following a lumbar puncture, a client voices several complaints. What
d d d d d d d d d d
complaintindicated to the nurse that the client is experiencing a compli
d d d d d d d d d d d
cation?
• “I have a headache that gets worse when I sit up”
d d d d d d d d d d
• “I am having pain in my lower back when I move my legs”
d d d d d d d d d d d d
• “My throat hurts when I swallow”
d d d d d
• “I feel sick to my stomach and am going to throw up”
d d d d d d d d d d d
• An elderly client seems confused and reports the onset of nausea, dysuria, a
d d d d d d d d d d d d
nd urgencywith incontinence. Which action should the nurse implement?
d d d d d d d d d
• Obtain a clean catch mid-stream specimen d d d d d
•
• A male client with hypertension, who received new antihypertensive prescript
d d d d d d d d d
ions at his last visit returns to the clinic two weeks later to evaluate his blood p
d d d d d d d d d d d d d d d d
, ressure (BP). His BPis 158/106 and he admits that he has not been taking the p
d d d d d d d d d d d d d d d d
rescribed medication because the drugs make him “feel bad”. In explaining th
d d d d d d d d d d d
e need for hypertension control, the nurseshould stress that an elevated BP pla
d d d d d d d d d d d d d
ces the client at risk for which pathophysiological condition?
d d d d d d d d
• The nurse observes an unlicensed assistive personnel (UAP) positioning a
d d d d d d d d d d
newly admitted client who has a seizure disorder. The client is supine and th
d d d d d d d d d d d d d
e UAP is placingsoft pillows along the side rails. What action should the nur
d d d d d d d d d d d d d d
se implement?
d
• The nurse observes an unlicensed assistive personnel (UAP) positioning a
d d d d d d d d d d
newly admitted client who has a seizure disorder. The client is supine and th
d d d d d d d d d d d d d
e UAP is placingsoft pillows along the side rails. What action should the nur
d d d d d d d d d d d d d d
se implement?
d
• The nurse observes an unlicensed assistive personnel (UAP) positioning a
d d d d d d d d d d
newly admitted client who has a seizure disorder. The client is supine and th
d d d d d d d d d d d d d
e UAP is placingsoft pillows along the side rails. What action should the nur
d d d d d d d d d d d d d d
se implement?
d
• The nurse observes an unlicensed assistive personnel (UAP) positioning a
d d d d d d d d d d
newly admitted client who has a seizure disorder. The client is supine and th
d d d d d d d d d d d d d
e UAP is placingsoft pillows along the side rails. What action should the nur
d d d d d d d d d d d d d d
se implement?
d
• Instruct the UAP to obtain soft blankets to secure to the side rails i
d d d d d d d d d d d d d
nstead ofpillows. d d
• An adolescent with major depressive disorder has been taking duloxetine (Cy
d d d d d d d d d d
mbalta) forthe past 12 days. Which assessment finding requires immediate fo
d d d d d d d d d d d
llow-up?
• Describes life without purpose d d d
• A 60-year-
d
old female client with a positive family history of ovarian cancer has develop
d d d d d d d d d d d d
ed an abdominal mass and is being evaluated for possible ovarian cancer. Her
d d d d d d d d d d d d
d Papanicolau (Pap) smear results are negative. What information should the n
d d d d d d d d d d
urse includein the client’s teaching plan?
d d d d d d
, • Further evaluation involving surgery may be needed
d d d d d d
• A client who recently underwear a tracheostomy is being prepared for dischar
d d d d d d d d d d d
ge to home.Which instructions is most important for the nurse to include in the
d d d d d d d d d d d d d d
d discharge plan? d
• Teach tracheal suctioning techniques
d d d
• In assessing an adult client with a partial rebreather mask, the nurse notes that the
d d d d d d d d d d d d d d
oxygen
d
reservoir bag does not deflate completely during inspiration and the client’s re
d d d d d d d d d d d
spiratoryrate is 14 breaths / minute. What action should the nurse implement?
d d d d d d d d d d d d
• Document the assessment data d d d
• Rational: reservoir bag should not deflate completely during inspirati
d d d d d d d d
on and theclient’s respiratory rate is within normal limits.
d d d d d d d d d
• During shift report, the central electrocardiogram (EKG) monitoring syst
d d d d d d d d
em alarms.Which client alarm should the nurse investigate firs?
d d d d d d d d d
, • Respiratory apnea of 30 seconds d d d d
• During a home visit, the nurse observed an elderly client with diabetes slip and
d d d d d d d d d d d d d
fall. Whataction should the nurse take first?
d d d d d d d d
• Check the client for lacerations or fractures
d d d d d d
• At 0600 while admitting a woman for a schedule repeat cesarean section (C-
d d d d d d d d d d d d
Section), the d
client tells the nurse that she drank a cup a coffee at 0400 because she wante
d d d d d d d d d d d d d d d
d to avoidgetting a headache. Which action should the nurse take first?
d d d d d d d d d d d d
• Inform the anesthesia care provider d d d d
• After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2
d d d d d d d d d d d d d d
d heart
sounds. To determine if an S3 heart sound is present, what action should the n
d d d d d d d d d d d d d d
urse takefirst? d d
• Listen with the bell at the same location
d d d d d d d
• The nurse is assisting the mother of a child with phenylketonuria (PKU) to se
d d d d d d d d d d d d d
lect foodsthat are in keeping with the child’s dietary restrictions. Which food
d d d d d d d d d d d d
s are contraindicatedfor this child?
d d d d d
• Foods sweetened with aspartame d d d
• Before preparing a client for the first surgical case of the day, a part-
d d d d d d d d d d d d d
time scrub nurse asksthe circulating nurse if a 3 minute surgical hand scrub is a
d d d d d d d d d d d d d d d
dequate preparation for this client. Which response should the circulating nurs
d d d d d d d d d d
e provide?
d
• Direct the nurse to continue the surgical hand scrub for a 5 minute duratio
d d d d d d d d d d d d d
n
• Which breakfast selection indicates that the client understands the nurse’s i
d d d d d d d d d d
nstructionsabout the dietary management of osteoporosis?
d d d d d d
• Bagel with jelly and skim milk d d d d d
d d d d d d d d d d d d
the he willdrink plenty of dairy products, such as milk, to help coat and protect
d d d d d d d d d d d d d d d d
his ulcer. What is thebest follow-up action by the nurse?
d d d d d d d d d d
• Review with the client the need to avoid foods that are rich in milk and cre
d d d d d d d d d d d d d d d
am
• A 66-year-
d
old woman is retiring and will no longer have a health insurance through her
d d d d d d d d d d d d d
place of employment. Which agency should the client be referred to by the em
d d d d d d d d d d d d d
ployeehealth nurse for health insurance needs?
d d d d d d
• Medicare
• A client who is taking an oral dose of a tetracycline complains of gastrointest
d d d d d d d d d d d d d
inal upset.What snack should the nurse instruct the client to take with the tetr
d d d d d d d d d d d d d d
acycline?
• Toasted wheat bread and jelly d d d d
• Following a lumbar puncture, a client voices several complaints. What
d d d d d d d d d d
complaintindicated to the nurse that the client is experiencing a compli
d d d d d d d d d d d
cation?
• “I have a headache that gets worse when I sit up”
d d d d d d d d d d
• “I am having pain in my lower back when I move my legs”
d d d d d d d d d d d d
• “My throat hurts when I swallow”
d d d d d
• “I feel sick to my stomach and am going to throw up”
d d d d d d d d d d d
• An elderly client seems confused and reports the onset of nausea, dysuria, a
d d d d d d d d d d d d
nd urgencywith incontinence. Which action should the nurse implement?
d d d d d d d d d
• Obtain a clean catch mid-stream specimen d d d d d
•
• A male client with hypertension, who received new antihypertensive prescript
d d d d d d d d d
ions at his last visit returns to the clinic two weeks later to evaluate his blood p
d d d d d d d d d d d d d d d d
, ressure (BP). His BPis 158/106 and he admits that he has not been taking the p
d d d d d d d d d d d d d d d d
rescribed medication because the drugs make him “feel bad”. In explaining th
d d d d d d d d d d d
e need for hypertension control, the nurseshould stress that an elevated BP pla
d d d d d d d d d d d d d
ces the client at risk for which pathophysiological condition?
d d d d d d d d
• The nurse observes an unlicensed assistive personnel (UAP) positioning a
d d d d d d d d d d
newly admitted client who has a seizure disorder. The client is supine and th
d d d d d d d d d d d d d
e UAP is placingsoft pillows along the side rails. What action should the nur
d d d d d d d d d d d d d d
se implement?
d
• The nurse observes an unlicensed assistive personnel (UAP) positioning a
d d d d d d d d d d
newly admitted client who has a seizure disorder. The client is supine and th
d d d d d d d d d d d d d
e UAP is placingsoft pillows along the side rails. What action should the nur
d d d d d d d d d d d d d d
se implement?
d
• The nurse observes an unlicensed assistive personnel (UAP) positioning a
d d d d d d d d d d
newly admitted client who has a seizure disorder. The client is supine and th
d d d d d d d d d d d d d
e UAP is placingsoft pillows along the side rails. What action should the nur
d d d d d d d d d d d d d d
se implement?
d
• The nurse observes an unlicensed assistive personnel (UAP) positioning a
d d d d d d d d d d
newly admitted client who has a seizure disorder. The client is supine and th
d d d d d d d d d d d d d
e UAP is placingsoft pillows along the side rails. What action should the nur
d d d d d d d d d d d d d d
se implement?
d
• Instruct the UAP to obtain soft blankets to secure to the side rails i
d d d d d d d d d d d d d
nstead ofpillows. d d
• An adolescent with major depressive disorder has been taking duloxetine (Cy
d d d d d d d d d d
mbalta) forthe past 12 days. Which assessment finding requires immediate fo
d d d d d d d d d d d
llow-up?
• Describes life without purpose d d d
• A 60-year-
d
old female client with a positive family history of ovarian cancer has develop
d d d d d d d d d d d d
ed an abdominal mass and is being evaluated for possible ovarian cancer. Her
d d d d d d d d d d d d
d Papanicolau (Pap) smear results are negative. What information should the n
d d d d d d d d d d
urse includein the client’s teaching plan?
d d d d d d
, • Further evaluation involving surgery may be needed
d d d d d d
• A client who recently underwear a tracheostomy is being prepared for dischar
d d d d d d d d d d d
ge to home.Which instructions is most important for the nurse to include in the
d d d d d d d d d d d d d d
d discharge plan? d
• Teach tracheal suctioning techniques
d d d
• In assessing an adult client with a partial rebreather mask, the nurse notes that the
d d d d d d d d d d d d d d
oxygen
d
reservoir bag does not deflate completely during inspiration and the client’s re
d d d d d d d d d d d
spiratoryrate is 14 breaths / minute. What action should the nurse implement?
d d d d d d d d d d d d
• Document the assessment data d d d
• Rational: reservoir bag should not deflate completely during inspirati
d d d d d d d d
on and theclient’s respiratory rate is within normal limits.
d d d d d d d d d
• During shift report, the central electrocardiogram (EKG) monitoring syst
d d d d d d d d
em alarms.Which client alarm should the nurse investigate firs?
d d d d d d d d d
, • Respiratory apnea of 30 seconds d d d d
• During a home visit, the nurse observed an elderly client with diabetes slip and
d d d d d d d d d d d d d
fall. Whataction should the nurse take first?
d d d d d d d d
• Check the client for lacerations or fractures
d d d d d d
• At 0600 while admitting a woman for a schedule repeat cesarean section (C-
d d d d d d d d d d d d
Section), the d
client tells the nurse that she drank a cup a coffee at 0400 because she wante
d d d d d d d d d d d d d d d
d to avoidgetting a headache. Which action should the nurse take first?
d d d d d d d d d d d d
• Inform the anesthesia care provider d d d d
• After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2
d d d d d d d d d d d d d d
d heart
sounds. To determine if an S3 heart sound is present, what action should the n
d d d d d d d d d d d d d d
urse takefirst? d d
• Listen with the bell at the same location
d d d d d d d
• The nurse is assisting the mother of a child with phenylketonuria (PKU) to se
d d d d d d d d d d d d d
lect foodsthat are in keeping with the child’s dietary restrictions. Which food
d d d d d d d d d d d d
s are contraindicatedfor this child?
d d d d d
• Foods sweetened with aspartame d d d
• Before preparing a client for the first surgical case of the day, a part-
d d d d d d d d d d d d d
time scrub nurse asksthe circulating nurse if a 3 minute surgical hand scrub is a
d d d d d d d d d d d d d d d
dequate preparation for this client. Which response should the circulating nurs
d d d d d d d d d d
e provide?
d
• Direct the nurse to continue the surgical hand scrub for a 5 minute duratio
d d d d d d d d d d d d d
n
• Which breakfast selection indicates that the client understands the nurse’s i
d d d d d d d d d d
nstructionsabout the dietary management of osteoporosis?
d d d d d d
• Bagel with jelly and skim milk d d d d d
