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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
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? - ✔✔Stroke secondary to hemorrhage
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? - ✔✔Instruct
the UAP to obtain soft blankets to secure to the side rails instead of pillows
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,An adolescent with major depressive disorder has been taking duloxetine (Cymbalta)
for the past 12 days. Which assessment finding requires immediate follow-up -
✔✔Describes life without purpose
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 - ✔✔Further evaluation involving surgery may be
needed
A client who recently underwent 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
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 -
✔✔Document the assessment data
Rational: reservoir bag should not deflate completely during inspiration and the client's
respiratory rate is within normal limits.
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,During shift report, the central electrocardiogram (EKG) monitoring system alarms.
Which client alarm should the nurse investigate first? - ✔✔Respiratory apnea of 30
seconds
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
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 avoid
getting a headache. Which action should the nurse take first? - ✔✔Inform the anesthesia
care provider
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 take
first - ✔✔Listen with the bell at the same location
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 employee
health nurse for health insurance needs? - ✔✔Medicare
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
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, Following a lumbar puncture, a client voices several complaints. What complaint
indicated to the nurse that the client is experiencing a complication? - ✔✔"I have a
headache that gets worse when I sit up"
An elderly client seems confused and reports the onset of nausea, dysuria, and urgency
with incontinence. Which action should the nurse implement - ✔✔Obtain a clean catch
mid-stream specimen
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 contraindicated
for this child? - ✔✔Foods sweetened with aspartame
Before preparing a client for the first surgical case of the day, a part-time scrub nurse
asks the circulating nurse if a 3 minute 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
Which breakfast selection indicates that the client understands the nurse's instructions
about the dietary management of osteoporosis? - ✔✔Bagel with jelly and skim milk
The charge 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)
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