REAL EXAM AND PRACTICE QUESTIONS AND
SOLUTIONS| CURRENTLY TESTING VERSION |
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The nurse is caring for a client diagnosed with gastroesophageal reflux disease (GERD).
Which client outcomes suggest that treatment has been effective? Select all that apply.
A. Experiences flatulence nightly
B. Absence of cough or hoarseness
C. Reports decreased epigastric pain
D. Experiences belching only after meals
E. Eats a well-balanced diet with no regurgitation
B. Absence of cough or hoarseness
C. Reports decreased epigastric pain
E. Eats a well-balanced diet with no regurgitation
A client is in the hospital for complications after surgery of the gastrointestinal tract. The
nurse reviews the clients chart and learns that the client has lost 15lbs since the surgery.
Labs reveal low albumin, prealbumin, and transferrin levels. What should the nurse do
next?
A. Ask the client about their usual daily intake and preferences
B. Ask the unlicensed assistive personnel to feed the client
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,C. Request the provider prescribe enteral tube feedings
D. Provide nutritional supplements between each meal
A. Ask the client about their usual daily intake and preferences
A client is admitted to the medical floor with a 4-day history of diarrheal vomiting and poor
appetite. You review the following documentation from the patients chart:
"1700: Mucous membranes pale and dry. Skin warm and dry to touch. Poor turgor with
tenting present. Bowel sounds hyperactive x 4 quadrants. Client states, "I am unable
to keep anything down." Vital signs: BP 96/68, HR 96, Temp 101.1F, and spO2 94% on
room air."
What is the priority intervention by the nurse?
A. Administer an antipyretic for the fever
B. Provide the client with oral fluids
C. Ensure a patent IV and start IV fluids
D. Administer an antiemetic for the vomiting
C. Ensure a patent IV and start IV fluids
(Note: Managing the fever is not a priority action. Oral fluids are not correct because
the patient is vomiting. Administering an antiemetic for the vomiting should happen,
but is not the priority. The patient is experiencing dehydration. The priority action
would be IV and IV fluids.)
Total parenteral nutrition (TPN) is being administered to a client. What is an appropriate
nursing intervention?
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,A. Checking blood glucose levels
B. Adding electrolytes to the TPN bag
C. Ensuring the bag is replaced every 8 hours
D. Setting the rate of the fat emulsion at 0.20 g/kg/hour
A. Checking blood glucose levels
A client was admitted with an upper gastrointestinal bleed and the nurse provides
discharge teaching to the client. What statement by the client indicates further teaching is
needed?
A. I understand that I should get some help to stop drinking alcohol.
B. Ill contact my health care provider before I start taking any herbal remedies.
C. I know it will be important to continue taking my daily aspirin to prevent a heart attack
D. I will need to change my pain medication from naproxen to acetaminophen
C. I know it will be important to continue taking my daily aspirin to prevent a heart attack
(Note: Aspirin is an NSAID. This is the response needing further teaching.)
A client presents to the emergency department with a 6 hour history of vomiting that is
'dark brown in appearance.' The client reports a history of gastric ulcers; hypertension;
diabetes; and chronic pain for which naproxen is taken. What is a priority nursing action?
A. Assess the clients abdomen for hardness, tenseness, and rigidity.
B. Insert an indwelling urinary catheter
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, C. Place an IV and start lactated ringers
D. Prepare to start intravenous administration of a proton pump inhibitor
A. Assess the clients abdomen for hardness, tenseness, and rigidity.
An elderly resident is brought to the emergency department via ambulance. The client is
barely able to stand because of weakness and reports several episodes of diarrhea in the
past 2 days. The client describes stools as watery and very foul-smelling. What is the
priority action by the nurse?
A. Collect a stool sample
B. Start an IV
C. Place the client on contact isolation
D. Administer an antidiarrheal agent
C. Place the client on contact isolation
(Note: Client symptoms relate to C-Diff)
The nurse is caring for a client taking clopidogrel after having an embolic event. The client
shares that since starting the medication he has noticed that his stools are darker in color.
What is an appropriate response by the nurse?
A. That is typical with this medication
B. Tell me what you mean by darker?
C. Often dietary changes cause this
D. When is the last time you had a BM?
B. Tell me what you mean by darker?
(Note: Side-effects of this medication does not include dark stools.)
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