• 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 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
• 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”
• “I am having pain in my lower back when I move my legs”
• “My throat hurts when I swallow”
• “I feel sick to my stomach and am going to throw 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
•
• 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?
• 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?
• 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?
• 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?
• 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.
• 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 underwear 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.
• During shift report, the central electrocardiogram (EKG) monitoring
system alarms. Which client alarm should the nurse investigate firs?
• 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
• 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)?
• An 82-year-old client with Alzheimer’s disease newly-fractures
femur who has a Foley catheter and soft wrist restrains applied
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 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
• 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”
• “I am having pain in my lower back when I move my legs”
• “My throat hurts when I swallow”
• “I feel sick to my stomach and am going to throw 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
•
• 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?
• 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?
• 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?
• 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?
• 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.
• 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 underwear 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.
• During shift report, the central electrocardiogram (EKG) monitoring
system alarms. Which client alarm should the nurse investigate firs?
• 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
• 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)?
• An 82-year-old client with Alzheimer’s disease newly-fractures
femur who has a Foley catheter and soft wrist restrains applied
