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