1. 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?
Review with the client the need to avoid foods that are rich in milk and cream
2. 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?
Stroke secondary to hemorrhage
3. 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?
Instruct the UAP to obtain soft blankets to secure to the side rails instead of
pillows.
4. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for
the past 12 days. Which assessment finding requires immediate follow-up?
Describes life without purpose
5. 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?
Further evaluation involving surgery may be needed
6. A client who recently underwear a tracheostomy is being prepared for discharge to home.
Which instructions is most important for the nurse to include in the discharge plan?
Teach tracheal suctioning techniques
7. 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?
, Document the assessment data
Rational: reservoir bag should not deflate completely during inspiration and the
client’s respiratory rate is within normal limits.
8. During shift report, the central electrocardiogram (EKG) monitoring system alarms.
, Which Bclient Balarm Bshould Bthe Bnurse Binvestigate Bfirs?
Respiratory Bapnea Bof B30 Bseconds
9. During Ba Bhome Bvisit, Bthe Bnurse Bobserved Ban Belderly Bclient Bwith Bdiabetes Bslip Band Bfall.
BWhat Baction Bshould Bthe Bnurse Btake Bfirst?
Check Bthe Bclient Bfor Blacerations Bor Bfractures
10. At B0600 Bwhile Badmitting Ba Bwoman Bfor Ba Bschedule Brepeat Bcesarean Bsection B(C-Section),
Bthe Bclient Btells Bthe Bnurse Bthat Bshe Bdrank Ba Bcup Ba Bcoffee Bat B0400 Bbecause Bshe Bwanted
Bto Bavoid Bgetting Ba Bheadache. BWhich Baction Bshould Bthe Bnurse Btake Bfirst?
Inform Bthe Banesthesia Bcare Bprovider
11. After Bplacing Ba Bstethoscope Bas Bseen Bin Bthe Bpicture, Bthe Bnurse Bauscultates BS1 Band BS2
Bheart Bsounds. BTo Bdetermine Bif Ban BS3 Bheart Bsound Bis Bpresent, Bwhat Baction Bshould Bthe
Bnurse Btake Bfirst?
Listen Bwith Bthe Bbell Bat Bthe Bsame Blocation
12. A B66-year-old Bwoman Bis Bretiring Band Bwill Bno Blonger Bhave Ba Bhealth Binsurance Bthrough
Bher Bplace Bof Bemployment. BWhich Bagency Bshould Bthe Bclient Bbe Breferred Bto Bby Bthe
Bemployee Bhealth Bnurse Bfor Bhealth Binsurance Bneeds?
Medicare
13. A Bclient Bwho Bis Btaking Ban Boral Bdose Bof Ba Btetracycline Bcomplains Bof Bgastrointestinal
Bupset. BWhat Bsnack Bshould Bthe Bnurse Binstruct Bthe Bclient Bto Btake Bwith Bthe Btetracycline?
Toasted Bwheat Bbread Band Bjelly
14. Following Ba Blumbar Bpuncture, Ba Bclient Bvoices Bseveral Bcomplaints. BWhat
Bcomplaint Bindicated Bto Bthe Bnurse Bthat Bthe Bclient Bis Bexperiencing Ba
Bcomplication?
“I Bhave Ba Bheadache Bthat Bgets Bworse Bwhen BI Bsit Bup”
―I Bam Bhaving Bpain Bin Bmy Blower Bback Bwhen BI Bmove BmyBlegs‖
―MyBthroat Bhurts Bwhen BI Bswallow‖
“I Bfeel Bsick Bto Bmy Bstomach Band Bam Bgoing Bto Bthrow Bup”
15. An Belderly Bclient Bseems Bconfused Band Breports Bthe Bonset Bof Bnausea, Bdysuria, Band
Burgency Bwith Bincontinence. BWhich Baction Bshould Bthe Bnurse Bimplement?
Obtain Ba Bclean Bcatch Bmid-stream Bspecimen
16. The Bnurse Bis Bassisting Bthe Bmother Bof Ba Bchild Bwith Bphenylketonuria B(PKU) Bto Bselect
Bfoods Bthat Bare Bin Bkeeping Bwith Bthe Bchild’s Bdietary Brestrictions. BWhich Bfoods Bare
Bcontraindicated Bfor Bthis Bchild?
Foods Bsweetened Bwith Baspartame
17. Before Bpreparing Ba Bclient Bfor Bthe Bfirst Bsurgical Bcase Bof Bthe Bday, Ba Bpart-time Bscrub
Bnurse Basks Bthe Bcirculating Bnurse Bif Ba B3 Bminute Bsurgical Bhand Bscrub Bis Badequate
Bpreparation Bfor Bthis Bclient. BWhich Bresponse Bshould Bthe Bcirculating Bnurse Bprovide?
Direct Bthe Bnurse Bto Bcontinue Bthe Bsurgical Bhand Bscrub Bfor Ba B5 Bminute Bduration
18. Which Bbreakfast Bselection Bindicates Bthat Bthe Bclient Bunderstands Bthe Bnurse’s
Binstructions Babout Bthe Bdietary Bmanagement Bof Bosteoporosis?
Bagel Bwith Bjelly Band Bskim Bmilk
19. The Bcharge Bnurse Bof Ba Bcritical Bcare Bunit Bis Binformed Bat Bthe Bbeginning Bof Bthe Bshift Bthat
Bless Bthan Bthe Boptimal Bnumber Bof Bregistered Bnurses Bwill Bbe Bworking Bthat Bshift. BIn
Bplanning Bassignments, Bwhich Bclient Bshould Breceive Bthe Bmost Bcare Bhours Bby Ba
Bregistered Bnurse B(RN)?
An B82-year-old Bclient Bwith BAlzheimer’s Bdisease Bnewly-fractures Bfemur Bwho
, has Ba BFoley Bcatheter Band Bsoft Bwrist Brestrains Bapplied
B
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?
Review with the client the need to avoid foods that are rich in milk and cream
2. 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?
Stroke secondary to hemorrhage
3. 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?
Instruct the UAP to obtain soft blankets to secure to the side rails instead of
pillows.
4. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for
the past 12 days. Which assessment finding requires immediate follow-up?
Describes life without purpose
5. 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?
Further evaluation involving surgery may be needed
6. A client who recently underwear a tracheostomy is being prepared for discharge to home.
Which instructions is most important for the nurse to include in the discharge plan?
Teach tracheal suctioning techniques
7. 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?
, Document the assessment data
Rational: reservoir bag should not deflate completely during inspiration and the
client’s respiratory rate is within normal limits.
8. During shift report, the central electrocardiogram (EKG) monitoring system alarms.
, Which Bclient Balarm Bshould Bthe Bnurse Binvestigate Bfirs?
Respiratory Bapnea Bof B30 Bseconds
9. During Ba Bhome Bvisit, Bthe Bnurse Bobserved Ban Belderly Bclient Bwith Bdiabetes Bslip Band Bfall.
BWhat Baction Bshould Bthe Bnurse Btake Bfirst?
Check Bthe Bclient Bfor Blacerations Bor Bfractures
10. At B0600 Bwhile Badmitting Ba Bwoman Bfor Ba Bschedule Brepeat Bcesarean Bsection B(C-Section),
Bthe Bclient Btells Bthe Bnurse Bthat Bshe Bdrank Ba Bcup Ba Bcoffee Bat B0400 Bbecause Bshe Bwanted
Bto Bavoid Bgetting Ba Bheadache. BWhich Baction Bshould Bthe Bnurse Btake Bfirst?
Inform Bthe Banesthesia Bcare Bprovider
11. After Bplacing Ba Bstethoscope Bas Bseen Bin Bthe Bpicture, Bthe Bnurse Bauscultates BS1 Band BS2
Bheart Bsounds. BTo Bdetermine Bif Ban BS3 Bheart Bsound Bis Bpresent, Bwhat Baction Bshould Bthe
Bnurse Btake Bfirst?
Listen Bwith Bthe Bbell Bat Bthe Bsame Blocation
12. A B66-year-old Bwoman Bis Bretiring Band Bwill Bno Blonger Bhave Ba Bhealth Binsurance Bthrough
Bher Bplace Bof Bemployment. BWhich Bagency Bshould Bthe Bclient Bbe Breferred Bto Bby Bthe
Bemployee Bhealth Bnurse Bfor Bhealth Binsurance Bneeds?
Medicare
13. A Bclient Bwho Bis Btaking Ban Boral Bdose Bof Ba Btetracycline Bcomplains Bof Bgastrointestinal
Bupset. BWhat Bsnack Bshould Bthe Bnurse Binstruct Bthe Bclient Bto Btake Bwith Bthe Btetracycline?
Toasted Bwheat Bbread Band Bjelly
14. Following Ba Blumbar Bpuncture, Ba Bclient Bvoices Bseveral Bcomplaints. BWhat
Bcomplaint Bindicated Bto Bthe Bnurse Bthat Bthe Bclient Bis Bexperiencing Ba
Bcomplication?
“I Bhave Ba Bheadache Bthat Bgets Bworse Bwhen BI Bsit Bup”
―I Bam Bhaving Bpain Bin Bmy Blower Bback Bwhen BI Bmove BmyBlegs‖
―MyBthroat Bhurts Bwhen BI Bswallow‖
“I Bfeel Bsick Bto Bmy Bstomach Band Bam Bgoing Bto Bthrow Bup”
15. An Belderly Bclient Bseems Bconfused Band Breports Bthe Bonset Bof Bnausea, Bdysuria, Band
Burgency Bwith Bincontinence. BWhich Baction Bshould Bthe Bnurse Bimplement?
Obtain Ba Bclean Bcatch Bmid-stream Bspecimen
16. The Bnurse Bis Bassisting Bthe Bmother Bof Ba Bchild Bwith Bphenylketonuria B(PKU) Bto Bselect
Bfoods Bthat Bare Bin Bkeeping Bwith Bthe Bchild’s Bdietary Brestrictions. BWhich Bfoods Bare
Bcontraindicated Bfor Bthis Bchild?
Foods Bsweetened Bwith Baspartame
17. Before Bpreparing Ba Bclient Bfor Bthe Bfirst Bsurgical Bcase Bof Bthe Bday, Ba Bpart-time Bscrub
Bnurse Basks Bthe Bcirculating Bnurse Bif Ba B3 Bminute Bsurgical Bhand Bscrub Bis Badequate
Bpreparation Bfor Bthis Bclient. BWhich Bresponse Bshould Bthe Bcirculating Bnurse Bprovide?
Direct Bthe Bnurse Bto Bcontinue Bthe Bsurgical Bhand Bscrub Bfor Ba B5 Bminute Bduration
18. Which Bbreakfast Bselection Bindicates Bthat Bthe Bclient Bunderstands Bthe Bnurse’s
Binstructions Babout Bthe Bdietary Bmanagement Bof Bosteoporosis?
Bagel Bwith Bjelly Band Bskim Bmilk
19. The Bcharge Bnurse Bof Ba Bcritical Bcare Bunit Bis Binformed Bat Bthe Bbeginning Bof Bthe Bshift Bthat
Bless Bthan Bthe Boptimal Bnumber Bof Bregistered Bnurses Bwill Bbe Bworking Bthat Bshift. BIn
Bplanning Bassignments, Bwhich Bclient Bshould Breceive Bthe Bmost Bcare Bhours Bby Ba
Bregistered Bnurse B(RN)?
An B82-year-old Bclient Bwith BAlzheimer’s Bdisease Bnewly-fractures Bfemur Bwho
, has Ba BFoley Bcatheter Band Bsoft Bwrist Brestrains Bapplied
B
