Review with the client the need to avoid foods that are rich in milk and cream
Rationale: Diets rich in milk and cream stimulate gastric acid secretion and should be
avoided.
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?
a. Remind the client that it is also important
to switch to decaffeinated coffee and tea.
b. Suggest that the client also plan to eat
frequent small meals to reduce discomfort
c. Review with the client the need to avoid
foods that are rich in milk and cream.
d. Reinforce this teaching by asking the
client to list a dairy food that he might select.
Stroke secondary to hemorrhage
Rationale: Stroke related to cerebral hemorrhage is major risk for uncontrolled
hypertension.
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?
a. Blindness secondary to cataracts
b. Acute kidney injury due to glomerular
damage
c. Stroke secondary to hemorrhage
d. Heart block due to myocardial damage
, Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows
Rationale: The nurse should instruct the UAP to pad the side rails with soft blankest
because the use of pillows could result in suffocation and would need to be removed at
the onset of the seizure. The nurse can delegate paddling the side rails to the UAP
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?
a. Ensure that the UAP has placed the
pillows effectively to protect the client.
b. Instruct the UAP to obtain soft blankets to
secure to the side rails instead of pillows.
c. Assume responsibility for placing the
pillows while the UAP completes another
task.
d. Ask the UAP to use some of the pillows to
prop the client in a side lying position.
Describes life without purpose
Rationale: Cymbalta is a selective serotonin and norepinephrine reuptake inhibitor that
An adolescent with major depressive is known to increase the risk of suicidal thinking in adolescents and young adults with
disorder has been taking duloxetine major depressive disorder. B, C and D are side effects
(Cymbalta) for the past 12 days. Which
assessment finding requires immediate
follow-up
a. Describes life without purpose
b. Complains of nausea and loss of appetite
c. States is often fatigued and drowsy
d. Exhibits an increase in sweating.
Further evaluation involving surgery may be needed
Rationale: An abdominal mass in a client with a family history for ovarian cancer should
be evaluated carefully
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
a. Further evaluation involving surgery may
be needed
b. A pelvic exam is also needed before
cancer is ruled out
c. Pap smear evaluation should be
continued every six month
d. One additional negative pap smear in six
months is needed.
, Teach tracheal suctioning techniques
Rationale: Suctioning helps to clear secretions and maintain an open airway, which is
A client who recently underwent a
critical.
tracheostomy is being prepared for
discharge to home. Which instructions is
most important for the nurse to include in the
discharge plan?
a. Explain how to use communication tools.
b. Teach tracheal suctioning techniques
c. Encourage self-care and independence.
d. Demonstrate how to clean tracheostomy
site.
Document the assessment data
Rational: reservoir bag should not deflate completely during inspiration and the client's
respiratory rate is within normal limits.
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
a. Encourage the client to take deep breaths
b. Remove the mask to deflate the bag
c. Increase the liter flow of oxygen
d. Document the assessment data
Respiratory apnea of 30 seconds
Rationale: The priority is the client whose alarm indicating respiratory apnea that
During shift report, the central
electrocardiogram (EKG) monitoring system should be assessed first.
alarms. Which client alarm should the nurse
investigate first?
a. Respiratory apnea of 30 seconds
b. Oxygen saturation rate of 88%
c. Eight premature ventricular beats every
minute
d. Disconnected monitor signal for the last 6
minutes.
Check the client for lacerations or fractures
During a home visit, the nurse observed an Rationale: After the client falls, the nurse should immediately assess for the possibility
elderly client with diabetes slip and fall. What of injuries and provide first aid as needed
action should the nurse take first?
a. Give the client 4 ounces of orange juice
b. Call 911 to summon emergency
assistance
c. Check the client for lacerations or
fractures
d. Asses clients blood sugar level
, Inform the anesthesia care provider
Rationale: Surgical preoperative instruction includes NPO after midnight the day of
At 0600 while admitting a woman for a surgery to decrease the risk of aspiration should vomiting occur during anesthesia.
schedule repeat cesarean section (C- While it is possible the C-section will be done on schedule or rescheduled for later in
Section), the client tells the nurse that she the day, the anesthesia provider should be notified first.
drank a cup a coffee at 0400 because she
wanted to avoid getting a headache. Which
action should the nurse take first?
a. Ensure preoperative lab results are
available
b. Start prescribed IV with lactated Ringer's
c. Inform the anesthesia care provider
d. Contact the client's obstetrician.
Listen with the bell at the same location
After placing a stethoscope as seen in the Rationale: The nurse uses the bell of the stethoscope to hear low-pitched sounds such
picture, the nurse auscultates S1 and S2 as S3 and S4. The nurse listens at the same site using the diaphragm the diaphragm
heart sounds. To determine if an S3 heart and bell before moving systematically to the next sites.
sound is present, what action should the
nurse take first
a. Side the stethoscope across the sternum.
b. Move the stethoscope to the mitral site
c. Listen with the bell at the same location
d. Observe the cardiac telemetry monitor
Medicare
Rationale: Title XVII of the social security Act of 1965 created Medicare Program to
A 66-year-old woman is retiring and will no provide medical insurance for person more than 65 years or older, disable or with
longer have a health insurance through her permeant kidney failure, WIC provides supplemental nutrition to meet the needs of
place of employment. Which agency should pregnant of breastfeeding woman, infants and children up to age of 6. Medicaid
the client be referred to by the employee provides financial assistance to pay for medical services for poor older adults, blind,
health nurse for health insurance needs? disable and families with dependent children. COBRA(D) health benefit provisions is a
limited insurance plan for those who has been laid off or become unemployed.
a. Woman, Infant, and Children program
b. Medicaid
c. Medicare
d. Consolidated Omnibus Budget
Reconciliation Act provision.
Toasted wheat bread and jelly
A client who is taking an oral dose of a Rationale: Dairy products decrease the effect of tetracycline, so the nurse instructs the
tetracycline complains of gastrointestinal client to eat a snack such as toast, which contains no dairy products and may decrease
upset. What snack should the nurse instruct GI symptoms.
the client to take with the tetracycline?
a. Fruit-flavored yogurt.
b. Cheese and crackers.
c. Cold cereal with skim milk.
d. Toasted wheat bread and jelly
Rationale: Diets rich in milk and cream stimulate gastric acid secretion and should be
avoided.
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?
a. Remind the client that it is also important
to switch to decaffeinated coffee and tea.
b. Suggest that the client also plan to eat
frequent small meals to reduce discomfort
c. Review with the client the need to avoid
foods that are rich in milk and cream.
d. Reinforce this teaching by asking the
client to list a dairy food that he might select.
Stroke secondary to hemorrhage
Rationale: Stroke related to cerebral hemorrhage is major risk for uncontrolled
hypertension.
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?
a. Blindness secondary to cataracts
b. Acute kidney injury due to glomerular
damage
c. Stroke secondary to hemorrhage
d. Heart block due to myocardial damage
, Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows
Rationale: The nurse should instruct the UAP to pad the side rails with soft blankest
because the use of pillows could result in suffocation and would need to be removed at
the onset of the seizure. The nurse can delegate paddling the side rails to the UAP
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?
a. Ensure that the UAP has placed the
pillows effectively to protect the client.
b. Instruct the UAP to obtain soft blankets to
secure to the side rails instead of pillows.
c. Assume responsibility for placing the
pillows while the UAP completes another
task.
d. Ask the UAP to use some of the pillows to
prop the client in a side lying position.
Describes life without purpose
Rationale: Cymbalta is a selective serotonin and norepinephrine reuptake inhibitor that
An adolescent with major depressive is known to increase the risk of suicidal thinking in adolescents and young adults with
disorder has been taking duloxetine major depressive disorder. B, C and D are side effects
(Cymbalta) for the past 12 days. Which
assessment finding requires immediate
follow-up
a. Describes life without purpose
b. Complains of nausea and loss of appetite
c. States is often fatigued and drowsy
d. Exhibits an increase in sweating.
Further evaluation involving surgery may be needed
Rationale: An abdominal mass in a client with a family history for ovarian cancer should
be evaluated carefully
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
a. Further evaluation involving surgery may
be needed
b. A pelvic exam is also needed before
cancer is ruled out
c. Pap smear evaluation should be
continued every six month
d. One additional negative pap smear in six
months is needed.
, Teach tracheal suctioning techniques
Rationale: Suctioning helps to clear secretions and maintain an open airway, which is
A client who recently underwent a
critical.
tracheostomy is being prepared for
discharge to home. Which instructions is
most important for the nurse to include in the
discharge plan?
a. Explain how to use communication tools.
b. Teach tracheal suctioning techniques
c. Encourage self-care and independence.
d. Demonstrate how to clean tracheostomy
site.
Document the assessment data
Rational: reservoir bag should not deflate completely during inspiration and the client's
respiratory rate is within normal limits.
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
a. Encourage the client to take deep breaths
b. Remove the mask to deflate the bag
c. Increase the liter flow of oxygen
d. Document the assessment data
Respiratory apnea of 30 seconds
Rationale: The priority is the client whose alarm indicating respiratory apnea that
During shift report, the central
electrocardiogram (EKG) monitoring system should be assessed first.
alarms. Which client alarm should the nurse
investigate first?
a. Respiratory apnea of 30 seconds
b. Oxygen saturation rate of 88%
c. Eight premature ventricular beats every
minute
d. Disconnected monitor signal for the last 6
minutes.
Check the client for lacerations or fractures
During a home visit, the nurse observed an Rationale: After the client falls, the nurse should immediately assess for the possibility
elderly client with diabetes slip and fall. What of injuries and provide first aid as needed
action should the nurse take first?
a. Give the client 4 ounces of orange juice
b. Call 911 to summon emergency
assistance
c. Check the client for lacerations or
fractures
d. Asses clients blood sugar level
, Inform the anesthesia care provider
Rationale: Surgical preoperative instruction includes NPO after midnight the day of
At 0600 while admitting a woman for a surgery to decrease the risk of aspiration should vomiting occur during anesthesia.
schedule repeat cesarean section (C- While it is possible the C-section will be done on schedule or rescheduled for later in
Section), the client tells the nurse that she the day, the anesthesia provider should be notified first.
drank a cup a coffee at 0400 because she
wanted to avoid getting a headache. Which
action should the nurse take first?
a. Ensure preoperative lab results are
available
b. Start prescribed IV with lactated Ringer's
c. Inform the anesthesia care provider
d. Contact the client's obstetrician.
Listen with the bell at the same location
After placing a stethoscope as seen in the Rationale: The nurse uses the bell of the stethoscope to hear low-pitched sounds such
picture, the nurse auscultates S1 and S2 as S3 and S4. The nurse listens at the same site using the diaphragm the diaphragm
heart sounds. To determine if an S3 heart and bell before moving systematically to the next sites.
sound is present, what action should the
nurse take first
a. Side the stethoscope across the sternum.
b. Move the stethoscope to the mitral site
c. Listen with the bell at the same location
d. Observe the cardiac telemetry monitor
Medicare
Rationale: Title XVII of the social security Act of 1965 created Medicare Program to
A 66-year-old woman is retiring and will no provide medical insurance for person more than 65 years or older, disable or with
longer have a health insurance through her permeant kidney failure, WIC provides supplemental nutrition to meet the needs of
place of employment. Which agency should pregnant of breastfeeding woman, infants and children up to age of 6. Medicaid
the client be referred to by the employee provides financial assistance to pay for medical services for poor older adults, blind,
health nurse for health insurance needs? disable and families with dependent children. COBRA(D) health benefit provisions is a
limited insurance plan for those who has been laid off or become unemployed.
a. Woman, Infant, and Children program
b. Medicaid
c. Medicare
d. Consolidated Omnibus Budget
Reconciliation Act provision.
Toasted wheat bread and jelly
A client who is taking an oral dose of a Rationale: Dairy products decrease the effect of tetracycline, so the nurse instructs the
tetracycline complains of gastrointestinal client to eat a snack such as toast, which contains no dairy products and may decrease
upset. What snack should the nurse instruct GI symptoms.
the client to take with the tetracycline?
a. Fruit-flavored yogurt.
b. Cheese and crackers.
c. Cold cereal with skim milk.
d. Toasted wheat bread and jelly
