dr.j
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 BPis
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 placingsoft 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 ofpillows.
4. An adolescent with major depressive disorder has been taking
duloxetine (Cymbalta) forthe 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)
,dr.j
smear results are negative. What information should the nurse
includein 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 respiratoryrate is 14 breaths / minute. What action
should the nurse implement?
• Document the assessment data
• Rational: reservoir bag should not deflate completely
during inspiration and theclient’s respiratory rate is within
normal limits.
8. During shift report, the central electrocardiogram (EKG)
monitoring system alarms.Which client alarm should the
nurse investigate firs?
• Respiratory apnea of 30 seconds
9. During a home visit, the nurse observed an elderly client with
diabetes slip and fall. What
action should the nurse take first?
• Check the client for lacerations or fractures
10. At 0600 while admitting a woman for a schedule repeat cesarean
section (C-Section), the
client tells the nurse that she drank a cup a coffee at 0400
because she wanted to avoidgetting a headache. Which action
should the nurse take first?
,dr.j
• Inform the anesthesia care provider
11. After placing a stethoscope as seen in the picture, the nurse
auscultates S1 and S2 heart
sounds. To determine if an S3 heart sound is present, what action
should the nurse takefirst?
• Listen with the bell at the same location
12. A 66-year-old woman is retiring and will no longer have a health
insurance through her
place of employment. Which agency should the client be
referred to by the employeehealth nurse for health insurance
needs?
• Medicare
13. A client who is taking an oral dose of a tetracycline complains of
gastrointestinal upset.What snack should the nurse instruct the
client to take with the tetracycline?
• Toasted wheat bread and jelly
14. Following a lumbar puncture, a client voices several
complaints. What complaintindicated to the nurse that the
client is experiencing a complication?
• “I have a headache that gets worse when I sit up”
• ―I am having pain in my lower back when I move my legs‖
• ―My throat hurts when I swallow‖
• “I feel sick to my stomach and am going to throw up”
15. Anelderly client seems confused and reports the onset of nausea,
dysuria, and urgencywith incontinence. Which action should the
nurse implement?
• Obtain a clean catch mid-stream specimen
16. The nurse is assisting the mother of a child with phenylketonuria
(PKU) to select foods that are in keeping with the child’s dietary
restrictions. Which foods are contraindicatedfor this child?
• Foods sweetened with aspartame
17. Before preparing a client for the first surgical case of the day, a
part-time scrub nurse asksthe circulating nurse if a 3 minute
, dr.j
surgical hand scrub is adequate preparation for this client. Which
response should the circulating nurse provide?
• Direct the nurse to continue the surgical hand scrub for a 5
minute duration
18. Which breakfast selection indicates that the client understands the
nurse’s instructions
about the dietary management of osteoporosis?
• Bagel with jelly and skim milk
19. Thecharge nurse of a critical care unit is informed at the
beginning of the shift that less than the optimal number of
registered nurses will be working that shift. In planning
assignments, which client should receive the most care hours by a
registered nurse (RN)?
• An 82-year-old client with Alzheimer’s disease newly-
fractures femur who has aFoley catheter and soft wrist
restrains applied
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 BPis
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 placingsoft 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 ofpillows.
4. An adolescent with major depressive disorder has been taking
duloxetine (Cymbalta) forthe 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)
,dr.j
smear results are negative. What information should the nurse
includein 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 respiratoryrate is 14 breaths / minute. What action
should the nurse implement?
• Document the assessment data
• Rational: reservoir bag should not deflate completely
during inspiration and theclient’s respiratory rate is within
normal limits.
8. During shift report, the central electrocardiogram (EKG)
monitoring system alarms.Which client alarm should the
nurse investigate firs?
• Respiratory apnea of 30 seconds
9. During a home visit, the nurse observed an elderly client with
diabetes slip and fall. What
action should the nurse take first?
• Check the client for lacerations or fractures
10. At 0600 while admitting a woman for a schedule repeat cesarean
section (C-Section), the
client tells the nurse that she drank a cup a coffee at 0400
because she wanted to avoidgetting a headache. Which action
should the nurse take first?
,dr.j
• Inform the anesthesia care provider
11. After placing a stethoscope as seen in the picture, the nurse
auscultates S1 and S2 heart
sounds. To determine if an S3 heart sound is present, what action
should the nurse takefirst?
• Listen with the bell at the same location
12. A 66-year-old woman is retiring and will no longer have a health
insurance through her
place of employment. Which agency should the client be
referred to by the employeehealth nurse for health insurance
needs?
• Medicare
13. A client who is taking an oral dose of a tetracycline complains of
gastrointestinal upset.What snack should the nurse instruct the
client to take with the tetracycline?
• Toasted wheat bread and jelly
14. Following a lumbar puncture, a client voices several
complaints. What complaintindicated to the nurse that the
client is experiencing a complication?
• “I have a headache that gets worse when I sit up”
• ―I am having pain in my lower back when I move my legs‖
• ―My throat hurts when I swallow‖
• “I feel sick to my stomach and am going to throw up”
15. Anelderly client seems confused and reports the onset of nausea,
dysuria, and urgencywith incontinence. Which action should the
nurse implement?
• Obtain a clean catch mid-stream specimen
16. The nurse is assisting the mother of a child with phenylketonuria
(PKU) to select foods that are in keeping with the child’s dietary
restrictions. Which foods are contraindicatedfor this child?
• Foods sweetened with aspartame
17. Before preparing a client for the first surgical case of the day, a
part-time scrub nurse asksthe circulating nurse if a 3 minute
, dr.j
surgical hand scrub is adequate preparation for this client. Which
response should the circulating nurse provide?
• Direct the nurse to continue the surgical hand scrub for a 5
minute duration
18. Which breakfast selection indicates that the client understands the
nurse’s instructions
about the dietary management of osteoporosis?
• Bagel with jelly and skim milk
19. Thecharge nurse of a critical care unit is informed at the
beginning of the shift that less than the optimal number of
registered nurses will be working that shift. In planning
assignments, which client should receive the most care hours by a
registered nurse (RN)?
• An 82-year-old client with Alzheimer’s disease newly-
fractures femur who has aFoley catheter and soft wrist
restrains applied
