1. Following discharge teaching, a maleclient 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
i i i i i i i i i i i i
milk and cream.
i
d. Reinforce this teaching by asking theclient to list a dairy food that hemight
select.
Rationale: Diets rich in milk and cream stimulate gastric acid secretion
i i i i i i i i i i
and should be avoided.
i i i
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 med-ication i
because the drugs make him “feel bad”. In explaining the needfor
hypertension control, the nurse should stress that an elevated BP places
the client at risk for which pathophysiological condition?
a. Blindness secondaryto cataracts
b. Acute kidney injury dueto glomerular damage
c. Stroke secondary to hemorrhage
i i i
d. Heart block dueto myocardial damage
Rationale: Stroke related to cerebral hemorrhage is major risk for
i i i i i i i i i
uncontrolled hypertension.
i
3. The nurse observes an unlicensed assistive personnel (UAP) posi-
tioning 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
i i i i i i i i i i i i
, instead of pillows. i i
a. Assume responsibility for placing the pillows while the UAP
completes another task.
b. Ask the UAPto use some of the pillows to prop the client in aside
lying position.
Rationale: The nurse should instruct the UAP to pad the side rails with
i i i i i i i i i i i i
soft blankest because the use of pillows could result in suffocation and
i i i i i i i i i i i
would need to be removed at the onset of the seizure. The nurse can
i i i i i i i i i i i i i
delegate paddling the side rails to the UAP
i i i i i i i
4. An adolescent with major depressive disorder has been taking du-
loxetine (Cymbalta) for the past 12 days. Which assessment find-
ing requires immediate follow-up?
a. Describes life without purpose i i i
b. Complains of nausea and loss of appetite
c. States is often fatigued and drowsy
d. Exhibits an increase in sweating.
Rationale: Cymbalta is a selective serotonin and norepinephrine
i i i i i i i
reuptake inhibitor that is known to increase the risk of suicidal
i i i i i i i i i i i
i thinking in adolescents and young adults with major depressive
i i i i i i i i
, disorder. B, C and D are side effects
i i i i i i i
5. A 60-year-old female client with a positive family history of ovar-
ian cancer has developed an abdominal mass and is being evaluat-
ed for possible ovarian cancer. Her Papanicolau (Pap) smear re-
sults are negative. What information should the nurse include in the
client‟s teaching plan?
a. Further evaluation involving surgery may be needed
i i i i i i
b. Apelvic exam is also needed before cancer is ruled out
c. Pap smear evaluation should becontinued every six month
d. One additional negative pap smear in six months is needed.
Rationale: An abdominal mass in a client with a family history for
i i i i i i i i i i i
ovarian cancer should be evaluated carefully
i i i i i i
6. A client who recently underwear a tracheostomy is being pre-
pared for discharge to home. Which instructions is most impor-
tant for the nurse to include in the discharge plan?
a. Explain how to use communication tools.
b. Teach tracheal suctioningtechniques c-
i i i
Encourage self-care and independence.
d- Demonstrate how to clean tracheostomysite.
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
i i i i i i i i i i i i
milk and cream.
i
d. Reinforce this teaching by asking theclient to list a dairy food that hemight
select.
Rationale: Diets rich in milk and cream stimulate gastric acid secretion
i i i i i i i i i i
and should be avoided.
i i i
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 med-ication i
because the drugs make him “feel bad”. In explaining the needfor
hypertension control, the nurse should stress that an elevated BP places
the client at risk for which pathophysiological condition?
a. Blindness secondaryto cataracts
b. Acute kidney injury dueto glomerular damage
c. Stroke secondary to hemorrhage
i i i
d. Heart block dueto myocardial damage
Rationale: Stroke related to cerebral hemorrhage is major risk for
i i i i i i i i i
uncontrolled hypertension.
i
3. The nurse observes an unlicensed assistive personnel (UAP) posi-
tioning 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
i i i i i i i i i i i i
, instead of pillows. i i
a. Assume responsibility for placing the pillows while the UAP
completes another task.
b. Ask the UAPto use some of the pillows to prop the client in aside
lying position.
Rationale: The nurse should instruct the UAP to pad the side rails with
i i i i i i i i i i i i
soft blankest because the use of pillows could result in suffocation and
i i i i i i i i i i i
would need to be removed at the onset of the seizure. The nurse can
i i i i i i i i i i i i i
delegate paddling the side rails to the UAP
i i i i i i i
4. An adolescent with major depressive disorder has been taking du-
loxetine (Cymbalta) for the past 12 days. Which assessment find-
ing requires immediate follow-up?
a. Describes life without purpose i i i
b. Complains of nausea and loss of appetite
c. States is often fatigued and drowsy
d. Exhibits an increase in sweating.
Rationale: Cymbalta is a selective serotonin and norepinephrine
i i i i i i i
reuptake inhibitor that is known to increase the risk of suicidal
i i i i i i i i i i i
i thinking in adolescents and young adults with major depressive
i i i i i i i i
, disorder. B, C and D are side effects
i i i i i i i
5. A 60-year-old female client with a positive family history of ovar-
ian cancer has developed an abdominal mass and is being evaluat-
ed for possible ovarian cancer. Her Papanicolau (Pap) smear re-
sults are negative. What information should the nurse include in the
client‟s teaching plan?
a. Further evaluation involving surgery may be needed
i i i i i i
b. Apelvic exam is also needed before cancer is ruled out
c. Pap smear evaluation should becontinued every six month
d. One additional negative pap smear in six months is needed.
Rationale: An abdominal mass in a client with a family history for
i i i i i i i i i i i
ovarian cancer should be evaluated carefully
i i i i i i
6. A client who recently underwear a tracheostomy is being pre-
pared for discharge to home. Which instructions is most impor-
tant for the nurse to include in the discharge plan?
a. Explain how to use communication tools.
b. Teach tracheal suctioningtechniques c-
i i i
Encourage self-care and independence.
d- Demonstrate how to clean tracheostomysite.
