I. Physiological Adaptation
1. Question: Following discharge teaching, a male client with a duodenal ulcer
states he will drink plenty of dairy products like milk to protect his ulcer.
What is the best follow-up action by the nurse?
o Answer: Review with the client the need to avoid foods that are rich
in milk and cream because they stimulate gastric acid secretion.
2. Question: A male client with hypertension, not taking prescribed
medication due to feeling unwell, has a BP of 158/106. What risk should the
nurse stress regarding uncontrolled hypertension?
o Answer: Stroke secondary to hemorrhage.
3. Question: The nurse sees a UAP positioning a client with a seizure disorder
supine with pillows along the side rails. What action should the nurse take?
o Answer: Instruct the UAP to obtain soft blankets to secure to the side
rails instead of pillows to prevent suffocation during a seizure.
4. Question: An adolescent with major depressive disorder has been taking
duloxetine (Cymbalta) for 12 days. Which assessment finding requires
immediate follow-up?
o Answer: Describes life without purpose, as Cymbalta can increase the
risk of suicidal thinking in this population.
5. Question: A 60-year-old female with a positive family history of ovarian
cancer has an abdominal mass and negative Pap smear. What information
should the nurse include in the teaching plan?
o Answer: Further evaluation involving surgery may be needed.
, 6. Question: A client post-tracheostomy is being prepared for discharge.
Which instruction is most important?
o Answer: Teach tracheal suctioning techniques to maintain a clear
airway.
7. Question: Assessing an adult with a partial rebreather mask, the reservoir
bag doesn't deflate completely during inspiration, and the respiratory rate is
14. What action should the nurse take?
o Answer: Document the assessment data, as these findings are within
expected parameters for this mask.
8. Question: During shift report, a central EKG monitor alarms. Which client
alarm should the nurse investigate first?
o Answer: Respiratory apnea of 30 seconds due to the immediate threat
to life.
9. Question: During a home visit, an elderly client with diabetes slips and
falls. What action should the nurse take first?
o Answer: Check the client for lacerations or fractures.
10.Question: At 0600, admitting a woman for a repeat C-section, the client
reports drinking coffee at 0400 (NPO after midnight). What action should
the nurse take first?
o Answer: Inform the anesthesia care provider.
11.Question: After placing a stethoscope to auscultate S1 and S2, what action
should the nurse take first to determine if an S3 heart sound is present?
o Answer: Listen with the bell at the same location, as the bell detects
low-pitched sounds like S3.
12.Question: A 66-year-old woman retiring and losing employer health
insurance needs a referral. Which agency is most appropriate?
o Answer: Medicare, for individuals 65 and older.