QUESTIONS AND ANSWERS WITH
SOLUTIONS 2024
1.UFollowingUdischargeUteaching,UaUmaleUclientUwithUduodenalUulcerUtellsUtheUnurseUtheUheUwillUdrinkUplen
tyUofUdairyUproducts,UsuchUasUmilk,UtoUhelpUcoatUandUprotectUhisUulcer.UWhatUisUtheUbestUfollow-
upUactionUbyUtheUnurse?
A)URemindUtheUclientUthatUitUisUalsoUimportantUtoUswitchUtoUdecaffeinatedUcoffeeUandUtea.U
B)USuggestUthatUtheUclientUalsoUplanUtoUeatUfrequentUsmallUmealsUtoUreduceUdiscomfort.U
C)UReviewUwithUtheUclientUtheUneedUtoUavoidUfoodsUthatUareUrichUinUmilkUandUcream.U
D)UReinforceUthisUteachingUbyUaskingUtheUclientUtoUlistUaUdairyUfoodUthatUheUmightUselect.U-
UANSWERUC)UReviewUwithUtheUclientUtheUneedUtoUavoidUfoodsUthatUareUrichUinUmilkUandUcream.U
Rationale:UDietsUrichUinUmilkUandUcreamUstimulateUgastricUacidUsecretionUandUshouldUbeUavoided.
2.UAUmaleUclientUwithUhypertension,UwhoUreceivedUnewUantihypertensiveUprescriptionsUatUhisUlastUvisitUret
urnsUtoUtheUclinicUtwoUweeksUlaterUtoUevaluateUhisUbloodUpressureU(BP).UHisUBPUisU158/106UandUheUadmits
UthatUheUhasUnotUbeenUtakingUtheUprescribedUmedicationUbecauseUtheUdrugsUmakeUhimU"feelUbad".UInUexp
lainingUtheUneedUforUhypertensionUcontrol,UtheUnurseUshouldUstressUthatUanUelevatedUBPUplacesUtheUclient
UatUriskUforUwhichUpathophysiologicalUcondition?U
A)UBlindnessUsecondaryUtoUcataractsU
B)UAcuteUkidneyUinjuryUdueUtoUglomerularUdamageU
C)UStokeUsecondaryUtoUhemorrhageU
D)UHeartUblockUdueUtoUmyocardialUdamageU-UANSWERUC)UStokeUsecondaryUtoUhemorrhageU
,Rationale:UStrokeUrelatedUtoUcerebralUhemorrhageUisUmajorUriskUforUuncontrolledUhypertension.
3.UTheUnurseUobservesUanUunlicensedUassistiveUpersonnelU(UAP)UpositioningUaUnewlyUadmittedUclientUwho
UhasUaUseizureUdisorder.UTheUclientUisUsupineUandUtheUUAPUisUplacingUsoftUpillowsUalongUtheUsideUrails.UWh
atUactionUshouldUtheUnurseUimplement?U
A)UEnsureUthatUtheUUAPUhasUplacedUpillowsUeffectivelyUtoUprotectUtheUclient.U
B)UInstructUtheUUAPUtoUobtainUsoftUblanketsUtoUsecureUtoUtheUsideUrailsUinsteadUofUpillows.U
C)UAssumeUresponsibilityUforUplacingUtheUpillowsUwhileUtheUUAPUcompletesUanotherUtask.U
D)UAskUtheUUAPUtoUuseUsomeUofUtheUpillowsUtoUpropUtheUclientUinUaUsideUlyingUposition.U-
UANSWERUB)UInstructUtheUUAPUtoUobtainUsoftUblanketsUtoUsecureUtoUtheUsideUrailsUinsteadUofUpillows.U
Rationale:UTheUnurseUshouldUinstructUtheUUAPUtoUpadUtheUsideUrailsUwithUsoftUblanketsUbecauseUtheUuseUo
fUpillowsUcouldUresultUinUsuffocationUandUwouldUneedUtoUbeUremovedUatUtheUonsetUofUseizure.UTheUnurseU
CANUdelegateUpaddingUtheUsideUrailsUtoUtheUUAP.
4.UAnUadolescentUwithUmajorUdepressiveUdisorderUhasUbeenUtakingUduloxetineU(Cymbalta)UforUtheUpastU12
Udays.UWhichUassessmentUrequiresUimmediateUfollow-up?
A)UDescribesUlifeUwithoutUpurposeU
B)UComplainsUofUnauseaUandUlossUofUappetite
C)UStatesUisUoftenUfatiguedUandUdrowsy
D)UExhibitsUanUincreaseUinUsweatingU-UANSWERUA)UDescribesUlifeUwithoutUpurposeU
,Rationale:UCymbaltaUisUaUselectiveUserotoninUandUnorepinephrineUreuptakeUinhibitorUthatUisUknownUtoUinc
reaseUtheUriskUofUsuicidalUthinkingUinUadolescentsUandUyoungUadultsUwithUmajorUdepressiveUdisorder.UB,UC
UandUDUareUsideUeffects.
5.UAU60-year-
oldUfemaleUclientUwithUaUpositiveUfamilyUhistoryUofUovarianUcancerUhasUdevelopedUanUabdominalUmassUan
dUisUbeingUevaluatedUforUpossibleUovarianUcancer.UHerUpapanicolauU(pap)UsmearUresultsUareUnegative.UWh
atUinformationUshouldUtheUnurseUincludeUinUtheUclient'sUteachingUplan?U
A)UFurtherUevaluationUinvolvingUsurgeryUmayUbeUneeded
B)UAUpelvicUexamUisUalsoUneededUbeforeUcancerUisUruledUout
C)UPapUsmearUevaluationUshouldUbeUcontinuedUeveryUsixUmonth
D)UOneUadditionalUnegativeUpapUsmearUinUsixUmonthsUisUneededU-
UANSWERUA)UFurtherUevaluationUinvolvingUsurgeryUmayUbeUneeded
Rationale:UAnUabdominalUmassUinUaUclientUwithUfamilyUhistoryUforUovarianUcancerUshouldUbeUevaluatedUca
refully.
6.UAUclientUwhoUrecentlyUunderwearUaUtracheostomyUisUbeingUpreparedUforUdischargeUtoUhome.UWhichUin
structionsUisUmostUimportantUforUtheUnurseUtoUincludeUinUtheUdischargeUplan?
A)UExplainUhowUtoUuseUcommunicationUtools.
B)UTeachUtrachealUsuctioningUtechniques
C)UEncourageUself-careUandUindependence.
D)UDemonstrateUhowUtoUcleanUtracheostomyUsite.U-UANSWERUB)UTeachUtrachealUsuctioningUtechniques
, Rationale:USuctioningUhelpsUtoUclearUsecretionsUandUmaintainUanUopenUairway,UwhichUisUcritical.
7.UInUassessingUanUadultUclientUwithUaUpartialUrebreatherUmask,UtheUnurseUnotesUthatUtheUoxygenUreservoi
rUbagUdoesUnotUdeflateUcompletelyUduringUinspirationUandUtheUclient'sUrespiratoryUrateUisU14UbreathsU/Umi
nute.UWhatUactionUshouldUtheUnurseUimplement?
A)UEncourageUtheUclientUtoUtakeUdeepUbreaths
B)URemoveUtheUmaskUtoUdeflateUtheUbag
C)UIncreaseUtheUliterUflowUofUoxygen
D)UDocumentUtheUassessmentUdataU-UANSWERUD)UDocumentUtheUassessmentUdataU
Rational:UreservoirUbagUshouldUnotUdeflateUcompletelyUduringUinspirationUandUtheUclient'sUrespiratoryUrat
eUisUwithinUnormalUlimits.
8.UDuringUaUhomeUvisit,UtheUnurseUobservedUanUelderlyUclientUwithUdiabetesUslipUandUfall.UWhatUactionUsh
ouldUtheUnurseUtakeUfirst?
A)UGiveUtheUclientU4UouncesUofUorangeUjuice
B)UCallU911UtoUsummonUemergencyUassistance
C)UCheckUtheUclientUforUlacerationsUorUfractures
D)UAssesUclientsUbloodUsugarUlevelU-UANSWERUC)UCheckUtheUclientUforUlacerationsUorUfractures
Rationale:UAfterUtheUclientUfalls,UtheUnurseUshouldUimmediatelyUassessUforUtheUpossibilityUofUinjuriesUandU
provideUfirstUaidUasUneeded