segtheghegwillgdrinkgplentygofgdairygproducts,gsuchgasgmilk,gtoghelpgcoatgandgpr
otectghisgulcer.gWhatgisgthegbestgfollow-upgactiongbygthegnurse?
• Reviewgwithgthegclientgthegneedgtogavoidgfoodsgthatgaregrichgingmilkgandgc
ream
• Ag66-year-
oldgwomangisgretiringgandgwillgnoglongerghavegaghealthginsurancegthroughgher
placegofgemployment.gWhichgagencygshouldgthegclientgbegreferredgtogbygthege
mployeeghealthgnursegforghealthginsurancegneeds?
• Medicare
• Agclientgwhogisgtakinggangoralgdosegofgagtetracyclinegcomplainsgofggastroint
estinalgupset.gWhatgsnackgshouldgthegnurseginstructgthegclientgtogtakegwithgth
egtetracycline?
• Toastedgwheatgbreadgandgjelly
• Followinggaglumbargpuncture,gagclientgvoicesgseveralgcomplaints.gWh
atgcomplaintgindicatedgtogthegnursegthatgthegclientgisgexperiencinggagco
mplication?
• “IghavegagheadachegthatggetsgworsegwhengIgsitgup”
• “IgamghavinggpaingingmyglowergbackgwhengIgmovegmyglegs”
• “MygthroatghurtsgwhengIgswallow”
• “Igfeelgsickgtogmygstomachgandgamggoinggtogthrowgup”
• Angelderlygclientgseemsgconfusedgandgreportsgthegonsetgofgnausea,gdysuria,g
andgurgencygwithgincontinence.gWhichgactiongshouldgthegnursegimplement?
• Obtaingagcleangcatchgmid-streamgspecimen
•
• Agmalegclientgwithghypertension,gwhogreceivedgnewgantihypertensivegprescri
ptionsgatghisglastgvisitgreturnsgtogthegclinicgtwogweeksglatergtogevaluateghisgblo
, odgpressureg(BP).gHisgBPgisg158/106gandghegadmitsgthatgheghasgnotgbeengtakin
ggthegprescribedgmedicationgbecausegthegdrugsgmakeghimg“feelgbad”.gIngexpl
aininggthegneedgforghypertensiongcontrol,gthegnursegshouldgstressgthatgangelev
atedgBPgplacesgthegclientgatgriskgforgwhichgpathophysiologicalgcondition?
• Thegnursegobservesgangunlicensedgassistivegpersonnelg(UAP)gpositioningg
agnewlygadmittedgclientgwhoghasgagseizuregdisorder.gThegclientgisgsupinega
ndgthegUAPgisgplacinggsoftgpillowsgalonggthegsidegrails.gWhatgactiongshould
thegnursegimplement?
g
• Thegnursegobservesgangunlicensedgassistivegpersonnelg(UAP)gpositioningg
agnewlygadmittedgclientgwhoghasgagseizuregdisorder.gThegclientgisgsupinega
ndgthegUAPgisgplacinggsoftgpillowsgalonggthegsidegrails.gWhatgactiongshould
thegnursegimplement?
g
• Thegnursegobservesgangunlicensedgassistivegpersonnelg(UAP)gpositioningg
agnewlygadmittedgclientgwhoghasgagseizuregdisorder.gThegclientgisgsupinega
ndgthegUAPgisgplacinggsoftgpillowsgalonggthegsidegrails.gWhatgactiongshould
thegnursegimplement?
g
• Thegnursegobservesgangunlicensedgassistivegpersonnelg(UAP)gpositioningg
agnewlygadmittedgclientgwhoghasgagseizuregdisorder.gThegclientgisgsupinega
ndgthegUAPgisgplacinggsoftgpillowsgalonggthegsidegrails.gWhatgactiongshould
thegnursegimplement?
g
• InstructgthegUAPgtogobtaingsoftgblanketsgtogsecuregtogthegsidegrail
sginsteadgofgpillows.
• Angadolescentgwithgmajorgdepressivegdisorderghasgbeengtakinggduloxetineg(
Cymbalta)gforgthegpastg12gdays.gWhichgassessmentgfindinggrequiresgimmedia
tegfollow-up?
• Describesglifegwithoutgpurpose
• Ag60-year-
oldgfemalegclientgwithgagpositivegfamilyghistorygofgovariangcancerghasgdevel
opedgangabdominalgmassgandgisgbeinggevaluatedgforgpossiblegovariangcancer.
HergPapanicolaug(Pap)gsmeargresultsgaregnegative.gWhatginformationgshould
g
thegnursegincludegingthegclient’sgteachinggplan?
g
, • Furthergevaluationginvolvinggsurgerygmaygbegneeded
• Agclientgwhogrecentlygunderweargagtracheostomygisgbeinggpreparedgforgdisch
argegtoghome.gWhichginstructionsgisgmostgimportantgforgthegnursegtogincludegi
ngthegdischargegplan?
• Teachgtrachealgsuctioninggtechniques
• Ingassessinggangadultgclientgwithgagpartialgrebreathergmask,gthegnursegnotesgthatgt
hegoxygen
reservoirgbaggdoesgnotgdeflategcompletelygduringginspirationgandgthegclient’sg
respiratorygrategisg14gbreathsg/gminute.gWhatgactiongshouldgthegnursegimplem
ent?
• Documentgthegassessmentgdata
• Rational:greservoirgbaggshouldgnotgdeflategcompletelygduringginspira
tiongandgthegclient’sgrespiratorygrategisgwithingnormalglimits.
• Duringgshiftgreport,gthegcentralgelectrocardiogramg(EKG)gmonitoringgsy
stemgalarms.gWhichgclientgalarmgshouldgthegnurseginvestigategfirs?
, • Respiratorygapneagofg30gseconds
• Duringgaghomegvisit,gthegnursegobservedgangelderlygclientgwithgdiabetesgslipga
ndgfall.gWhatgactiongshouldgthegnursegtakegfirst?
• Checkgthegclientgforglacerationsgorgfractures
• Atg0600gwhilegadmittinggagwomangforgagschedulegrepeatgcesareangsectiong(C-
Section),gthe
clientgtellsgthegnursegthatgshegdrankgagcupgagcoffeegatg0400gbecausegshegwa
ntedgtogavoidggettinggagheadache.gWhichgactiongshouldgthegnursegtakegfirst?
• Informgtheganesthesiagcaregprovider
• Aftergplacinggagstethoscopegasgseengingthegpicture,gthegnursegauscultatesgS1gandg
S2gheart
sounds.gTogdeterminegifgangS3gheartgsoundgisgpresent,gwhatgactiongshouldgthe
nursegtakegfirst?
g
• Listengwithgthegbellgatgthegsameglocation
• Thegnursegisgassistinggthegmothergofgagchildgwithgphenylketonuriag(PKU)gto
selectgfoodsgthatgaregingkeepinggwithgthegchild’sgdietarygrestrictions.gWhichg
g
foodsgaregcontraindicatedgforgthisgchild?
• Foodsgsweetenedgwithgaspartame
• Beforegpreparinggagclientgforgthegfirstgsurgicalgcasegofgthegday,gagpart-
timegscrubgnursegasksgthegcirculatinggnursegifgag3gminutegsurgicalghandgscrubgi
sgadequategpreparationgforgthisgclient.gWhichgresponsegshouldgthegcirculatingg
nursegprovide?
• Directgthegnursegtogcontinuegthegsurgicalghandgscrubgforgag5gminutegdurati
on
• Whichgbreakfastgselectiongindicatesgthatgthegclientgunderstandsgthegnurse’s
instructionsgaboutgthegdietarygmanagementgofgosteoporosis?
g
• Bagelgwithgjellygandgskimgmilk