1. 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? ANS >>
Review with the client the need to avoid foods that are rich in milk and cream
2. 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 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? ANS >> Stroke secondary to hemorrhage
3. 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 placing soft pillows along the side rails. What action should the
nurse implement? ANS >> Instruct the UAP to obtain soft blankets to secure to the
side rails instead of pillows.
4. 4. An adolescent with major depressive disorder has been taking duloxetine
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10
, (Cymbalta) for the past 12 days. Which assessment finding requires immediate
follow-up? ANS >> Describes life without purpose
5. 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) smear results are negative. What information
should the nurse include in the client's teaching plan? ANS >> Further
evaluation involving surgery may be needed
6. 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? ANS >> Teach tracheal suctioning techniques
7. 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 respiratory rate is 14 breaths / minute. What action should the
nurse implement? ANS >> Document the assessment data
8. 8. During shift report, the central electrocardiogram (EKG) monitoring sys-
tem alarms. Which client alarm should the nurse investigate firs? ANS >>
Respiratory apnea of 30 seconds
9. 9. During a home visit, the nurse observed an elderly client with diabetes slip
and fall. What action should the nurse take first? ANS >> Check the client for
lacerations or fractures
10. 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
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10
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? ANS >>
Review with the client the need to avoid foods that are rich in milk and cream
2. 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 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? ANS >> Stroke secondary to hemorrhage
3. 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 placing soft pillows along the side rails. What action should the
nurse implement? ANS >> Instruct the UAP to obtain soft blankets to secure to the
side rails instead of pillows.
4. 4. An adolescent with major depressive disorder has been taking duloxetine
mailto:https://www.stuvia.com/en-us/user/techgrades 1/
10
, (Cymbalta) for the past 12 days. Which assessment finding requires immediate
follow-up? ANS >> Describes life without purpose
5. 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) smear results are negative. What information
should the nurse include in the client's teaching plan? ANS >> Further
evaluation involving surgery may be needed
6. 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? ANS >> Teach tracheal suctioning techniques
7. 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 respiratory rate is 14 breaths / minute. What action should the
nurse implement? ANS >> Document the assessment data
8. 8. During shift report, the central electrocardiogram (EKG) monitoring sys-
tem alarms. Which client alarm should the nurse investigate firs? ANS >>
Respiratory apnea of 30 seconds
9. 9. During a home visit, the nurse observed an elderly client with diabetes slip
and fall. What action should the nurse take first? ANS >> Check the client for
lacerations or fractures
10. 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
mailto:https://www.stuvia.com/en-us/user/techgrades 2/
10
