• Following discharge teaching, a male client with duodenal ulcer tells the nu
m m m m m m m m m m m
rse the he will drink plenty of dairy products, such as milk, to help coat and
m m m m m m m m m m m m m m m m
protect his ulcer. What is the best follow-up action by the nurse?
m m m m m m m m m m m
• Review with the client the need to avoid foods that are rich in milk and
m m m m m m m m m m m m m m m
cream
• A 66-year-
m
old woman is retiring and will no longer have a health insurance through her
m m m m m m m m m m m m m
place of employment. Which agency should the client be referred to by the
m m m m m m m m m m m m m
employee health nurse for health insurance needs?
m m m m m m
• Medicare
• A client who is taking an oral dose of a tetracycline complains of gastroin
m m m m m m m m m m m m m
testinal upset. What snack should the nurse instruct the client to take with
m m m m m m m m m m m m m
the tetracycline?
m
• Toasted wheat bread and jelly m m m m
• Following a lumbar puncture, a client voices several complaints. Wh
m m m m m m m m m
at complaint indicated to the nurse that the client is experiencing a co
m m m m m m m m m m m m
mplication?
• “I have a headache that gets worse when I sit up”
m m m m m m m m m m
• “I am having pain in my lower back when I move my legs”
m m m m m m m m m m m m
• “My throat hurts when I swallow”
m m m m m
• “I feel sick to my stomach and am going to throw up”
m m m m m m m m m m m
• An elderly client seems confused and reports the onset of nausea, dysuria
m m m m m m m m m m m
, and urgency with incontinence. Which action should the nurse impleme
m m m m m m m m m m
nt?
• Obtain a clean catch mid-stream specimen
m m m m m
•
• A male client with hypertension, who received new antihypertensive prescr
m m m m m m m m m
, iptions at his last visit returns to the clinic two weeks later to evaluate his b
m m m m m m m m m m m m m m m
lood pressure (BP). His BP is 158/106 and he admits that he has not been ta
m m m m m m m m m m m m m m m
king the prescribed medication because the drugs make him “feel bad”. In
m m m m m m m m m m m m
explaining the need for hypertension control, the nurse should stress that an
m m m m m m m m m m m m
elevated BP places the client at risk for which pathophysiological condition
m m m m m m m m m m
?
• The nurse observes an unlicensed assistive personnel (UAP) positioning
m m m m m m m m m
a newly admitted client who has a seizure disorder. The client is supine a
m m m m m m m m m m m m m
nd the UAP is placing soft pillows along the side rails. What action shoul
m m m m m m m m m m m m m
d the nurse implement?
m m m
• The nurse observes an unlicensed assistive personnel (UAP) positioning
m m m m m m m m m
a newly admitted client who has a seizure disorder. The client is supine a
m m m m m m m m m m m m m
nd the UAP is placing soft pillows along the side rails. What action shoul
m m m m m m m m m m m m m
d the nurse implement?
m m m
• The nurse observes an unlicensed assistive personnel (UAP) positioning
m m m m m m m m m
a newly admitted client who has a seizure disorder. The client is supine a
m m m m m m m m m m m m m
nd the UAP is placing soft pillows along the side rails. What action shoul
m m m m m m m m m m m m m
d the nurse implement?
m m m
• The nurse observes an unlicensed assistive personnel (UAP) positioning
m m m m m m m m m
a newly admitted client who has a seizure disorder. The client is supine a
m m m m m m m m m m m m m
nd the UAP is placing soft pillows along the side rails. What action shoul
m m m m m m m m m m m m m
d the nurse implement?
m m m
• Instruct the UAP to obtain soft blankets to secure to the side rai
m m m m m m m m m m m m
ls instead of pillows.
m m m
• An adolescent with major depressive disorder has been taking duloxetine (
m m m m m m m m m m
Cymbalta) for the past 12 days. Which assessment finding requires immedi
m m m m m m m m m m
ate follow-up?
m
• Describes life without purpose m m m
• A 60-year-
m
old female client with a positive family history of ovarian cancer has devel
m m m m m m m m m m m m
oped an abdominal mass and is being evaluated for possible ovarian cancer
m m m m m m m m m m m
, . Her Papanicolau (Pap) smear results are negative. What information shou
m m m m m m m m m m
ld the nurse include in the client’s teaching plan?
m m m m m m m m
• Further evaluation involving surgery may be needed
m m m m m m
• A client who recently underwear a tracheostomy is being prepared for disch
m m m m m m m m m m m
arge to home. Which instructions is most important for the nurse to include
m m m m m m m m m m m m m
in the discharge plan?
m m m
• Teach tracheal suctioning techniques
m m m
• In assessing an adult client with a partial rebreather mask, the nurse notes that
m m m m m m m m m m m m m
m the oxygen
m
reservoir bag does not deflate completely during inspiration and the client’s
m m m m m m m m m m
respiratory rate is 14 breaths / minute. What action should the nurse imple
m m m m m m m m m m m m m
ment?
• Document the assessment data m m m
• Rational: reservoir bag should not deflate completely during inspir
m m m m m m m m
ation and the client’s respiratory rate is within normal limits.
m m m m m m m m m
• During shift report, the central electrocardiogram (EKG) monitoring sy
m m m m m m m m
stem alarms. Which client alarm should the nurse investigate firs?
m m m m m m m m m
, • Respiratory apnea of 30 seconds m m m m
• During a home visit, the nurse observed an elderly client with diabetes slip
m m m m m m m m m m m m m
and fall. What action should the nurse take first?
m m m m m m m m
• Check the client for lacerations or fractures
m m m m m m
• At 0600 while admitting a woman for a schedule repeat cesarean section (C-
m m m m m m m m m m m m
Section), the m
client tells the nurse that she drank a cup a coffee at 0400 because she w
m m m m m m m m m m m m m m m
anted to avoid getting a headache. Which action should the nurse take fir
m m m m m m m m m m m m
st?
• Inform the anesthesia care provider m m m m
• After placing a stethoscope as seen in the picture, the nurse auscultates S1 and
m m m m m m m m m m m m m
m S2 heartm
sounds. To determine if an S3 heart sound is present, what action should th
m m m m m m m m m m m m m
e nurse take first?
m m m
• Listen with the bell at the same location
m m m m m m m
• The nurse is assisting the mother of a child with phenylketonuria (PKU) t
m m m m m m m m m m m m
o select foods that are in keeping with the child’s dietary restrictions. Whic
m m m m m m m m m m m m
h foods are contraindicated for this child?
m m m m m m
• Foods sweetened with aspartame m m m
• Before preparing a client for the first surgical case of the day, a part-
m m m m m m m m m m m m m
time scrub nurse asks the circulating nurse if a 3 minute surgical hand scrub
m m m m m m m m m m m m m m
is adequate preparation for this client. Which response should the circulatin
m m m m m m m m m m
g nurse provide?
m m
• Direct the nurse to continue the surgical hand scrub for a 5 minute dura
m m m m m m m m m m m m m
tion
• Which breakfast selection indicates that the client understands the nurse’
m m m m m m m m m
s instructions about the dietary management of osteoporosis?
m m m m m m m
m m m m m m m m m m m
rse the he will drink plenty of dairy products, such as milk, to help coat and
m m m m m m m m m m m m m m m m
protect his ulcer. What is the best follow-up action by the nurse?
m m m m m m m m m m m
• Review with the client the need to avoid foods that are rich in milk and
m m m m m m m m m m m m m m m
cream
• A 66-year-
m
old woman is retiring and will no longer have a health insurance through her
m m m m m m m m m m m m m
place of employment. Which agency should the client be referred to by the
m m m m m m m m m m m m m
employee health nurse for health insurance needs?
m m m m m m
• Medicare
• A client who is taking an oral dose of a tetracycline complains of gastroin
m m m m m m m m m m m m m
testinal upset. What snack should the nurse instruct the client to take with
m m m m m m m m m m m m m
the tetracycline?
m
• Toasted wheat bread and jelly m m m m
• Following a lumbar puncture, a client voices several complaints. Wh
m m m m m m m m m
at complaint indicated to the nurse that the client is experiencing a co
m m m m m m m m m m m m
mplication?
• “I have a headache that gets worse when I sit up”
m m m m m m m m m m
• “I am having pain in my lower back when I move my legs”
m m m m m m m m m m m m
• “My throat hurts when I swallow”
m m m m m
• “I feel sick to my stomach and am going to throw up”
m m m m m m m m m m m
• An elderly client seems confused and reports the onset of nausea, dysuria
m m m m m m m m m m m
, and urgency with incontinence. Which action should the nurse impleme
m m m m m m m m m m
nt?
• Obtain a clean catch mid-stream specimen
m m m m m
•
• A male client with hypertension, who received new antihypertensive prescr
m m m m m m m m m
, iptions at his last visit returns to the clinic two weeks later to evaluate his b
m m m m m m m m m m m m m m m
lood pressure (BP). His BP is 158/106 and he admits that he has not been ta
m m m m m m m m m m m m m m m
king the prescribed medication because the drugs make him “feel bad”. In
m m m m m m m m m m m m
explaining the need for hypertension control, the nurse should stress that an
m m m m m m m m m m m m
elevated BP places the client at risk for which pathophysiological condition
m m m m m m m m m m
?
• The nurse observes an unlicensed assistive personnel (UAP) positioning
m m m m m m m m m
a newly admitted client who has a seizure disorder. The client is supine a
m m m m m m m m m m m m m
nd the UAP is placing soft pillows along the side rails. What action shoul
m m m m m m m m m m m m m
d the nurse implement?
m m m
• The nurse observes an unlicensed assistive personnel (UAP) positioning
m m m m m m m m m
a newly admitted client who has a seizure disorder. The client is supine a
m m m m m m m m m m m m m
nd the UAP is placing soft pillows along the side rails. What action shoul
m m m m m m m m m m m m m
d the nurse implement?
m m m
• The nurse observes an unlicensed assistive personnel (UAP) positioning
m m m m m m m m m
a newly admitted client who has a seizure disorder. The client is supine a
m m m m m m m m m m m m m
nd the UAP is placing soft pillows along the side rails. What action shoul
m m m m m m m m m m m m m
d the nurse implement?
m m m
• The nurse observes an unlicensed assistive personnel (UAP) positioning
m m m m m m m m m
a newly admitted client who has a seizure disorder. The client is supine a
m m m m m m m m m m m m m
nd the UAP is placing soft pillows along the side rails. What action shoul
m m m m m m m m m m m m m
d the nurse implement?
m m m
• Instruct the UAP to obtain soft blankets to secure to the side rai
m m m m m m m m m m m m
ls instead of pillows.
m m m
• An adolescent with major depressive disorder has been taking duloxetine (
m m m m m m m m m m
Cymbalta) for the past 12 days. Which assessment finding requires immedi
m m m m m m m m m m
ate follow-up?
m
• Describes life without purpose m m m
• A 60-year-
m
old female client with a positive family history of ovarian cancer has devel
m m m m m m m m m m m m
oped an abdominal mass and is being evaluated for possible ovarian cancer
m m m m m m m m m m m
, . Her Papanicolau (Pap) smear results are negative. What information shou
m m m m m m m m m m
ld the nurse include in the client’s teaching plan?
m m m m m m m m
• Further evaluation involving surgery may be needed
m m m m m m
• A client who recently underwear a tracheostomy is being prepared for disch
m m m m m m m m m m m
arge to home. Which instructions is most important for the nurse to include
m m m m m m m m m m m m m
in the discharge plan?
m m m
• Teach tracheal suctioning techniques
m m m
• In assessing an adult client with a partial rebreather mask, the nurse notes that
m m m m m m m m m m m m m
m the oxygen
m
reservoir bag does not deflate completely during inspiration and the client’s
m m m m m m m m m m
respiratory rate is 14 breaths / minute. What action should the nurse imple
m m m m m m m m m m m m m
ment?
• Document the assessment data m m m
• Rational: reservoir bag should not deflate completely during inspir
m m m m m m m m
ation and the client’s respiratory rate is within normal limits.
m m m m m m m m m
• During shift report, the central electrocardiogram (EKG) monitoring sy
m m m m m m m m
stem alarms. Which client alarm should the nurse investigate firs?
m m m m m m m m m
, • Respiratory apnea of 30 seconds m m m m
• During a home visit, the nurse observed an elderly client with diabetes slip
m m m m m m m m m m m m m
and fall. What action should the nurse take first?
m m m m m m m m
• Check the client for lacerations or fractures
m m m m m m
• At 0600 while admitting a woman for a schedule repeat cesarean section (C-
m m m m m m m m m m m m
Section), the m
client tells the nurse that she drank a cup a coffee at 0400 because she w
m m m m m m m m m m m m m m m
anted to avoid getting a headache. Which action should the nurse take fir
m m m m m m m m m m m m
st?
• Inform the anesthesia care provider m m m m
• After placing a stethoscope as seen in the picture, the nurse auscultates S1 and
m m m m m m m m m m m m m
m S2 heartm
sounds. To determine if an S3 heart sound is present, what action should th
m m m m m m m m m m m m m
e nurse take first?
m m m
• Listen with the bell at the same location
m m m m m m m
• The nurse is assisting the mother of a child with phenylketonuria (PKU) t
m m m m m m m m m m m m
o select foods that are in keeping with the child’s dietary restrictions. Whic
m m m m m m m m m m m m
h foods are contraindicated for this child?
m m m m m m
• Foods sweetened with aspartame m m m
• Before preparing a client for the first surgical case of the day, a part-
m m m m m m m m m m m m m
time scrub nurse asks the circulating nurse if a 3 minute surgical hand scrub
m m m m m m m m m m m m m m
is adequate preparation for this client. Which response should the circulatin
m m m m m m m m m m
g nurse provide?
m m
• Direct the nurse to continue the surgical hand scrub for a 5 minute dura
m m m m m m m m m m m m m
tion
• Which breakfast selection indicates that the client understands the nurse’
m m m m m m m m m
s instructions about the dietary management of osteoporosis?
m m m m m m m
