answers
Following discharge teaching, a male client with duodenal ulcer
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tells the nurse the he will drink plenty of dairy products, such as
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milk, to help coat and protect his ulcer. What is the best follow-
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up action by the nurse?
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a. Remind the client that it is also important to switch to
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decaffeinated coffee and tea. |\ |\ |\
b. Suggest that the client also plan to eat frequent small meals
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to reduce discomfort
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c. Review with the client the need to avoid foods that are rich in
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milk and cream. |\ |\
d. Reinforce this teaching by asking the client to list a dairy food
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that he might select. - CORRECT ANSWERS ✔✔c. Review with the
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client the need to avoid foods that are rich in milk and cream.
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The nurse observes an unlicensed assistive personnel (UAP)
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positioning a newly admitted client who has a seizure disorder. |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
The client is supine and the UAP is placing soft pillows along the
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side rails. What action should the nurse implement?
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a. Ensure that the UAP has placed the pillows effectively to
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protect the client. |\ |\
b. Instruct the UAP to obtain soft blankets to secure to the side
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rails instead of pillows.
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c. Assume responsibility for placing the pillows while the UAP
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completes another task. |\ |\
,d. Ask the UAP to use some of the pillows to prop the client in a
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side lying position. - CORRECT ANSWERS ✔✔b. Instruct the UAP
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to obtain soft blankets to secure to the side rails instead of
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pillows.
A male client with hypertension, who received new
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antihypertensive prescriptions at his last visit returns to the clinic |\ |\ |\ |\ |\ |\ |\ |\ |\
two weeks later to evaluate his blood pressure (BP). His BP is
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158/106 and he admits that he has not been taking the
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prescribed medication because the drugs make him "feel bad". In
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explaining the need for hypertension control, the nurse should
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stress that an elevated BP places the client at risk for which
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pathophysiological condition? |\
a. Blindness secondary to cataracts
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b. Acute kidney injury due to glomerular damage
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c. Stroke secondary to hemorrhage
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d. Heart block due to myocardial damage - CORRECT ANSWERS
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✔✔c. Stroke secondary to hemorrhage
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An adolescent with major depressive disorder has been taking
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duloxetine (Cymbalta) for the past 12 days. Which assessment
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finding requires immediate follow-up|\ |\ |\
a. Describes life without purpose
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b. Complains of nausea and loss of appetite
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c. States is often fatigued and drowsy
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d. Exhibits an increase in sweating. - CORRECT ANSWERS ✔✔a.
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Describes life without purpose |\ |\ |\
,A 60-year-old female client with a positive family history of
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ovarian cancer has developed an abdominal mass and is being
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evaluated for possible ovarian cancer. Her Papanicolau (Pap)
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smear results are negative. What information should the nurse
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include in the client's teaching plan
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a. Further evaluation involving surgery may be needed
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b. A pelvic exam is also needed before cancer is ruled out
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c. Pap smear evaluation should be continued every six month
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d. One additional negative pap smear in six months is needed. -
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CORRECT ANSWERS ✔✔a. Further evaluation involving surgery
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may be needed |\ |\
A client who recently underwent a tracheostomy is being
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prepared for discharge to home. Which instructions is most
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important for the nurse to include in the discharge plan?
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a. Explain how to use communication tools.
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b. Teach tracheal suctioning techniques
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c. Encourage self-care and independence.
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d. Demonstrate how to clean tracheostomy site. - CORRECT
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ANSWERS ✔✔b. Teach tracheal suctioning techniques |\ |\ |\ |\ |\
In assessing an adult client with a partial rebreather mask, the
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nurse notes that the oxygen reservoir bag does not deflate
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completely during inspiration and the client's respiratory rate is
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14 breaths / minute. What action should the nurse implement
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a. Encourage the client to take deep breaths
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b. Remove the mask to deflate the bag
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c. Increase the liter flow of oxygen
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, d. Document the assessment data - CORRECT ANSWERS ✔✔d.
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Document the assessment data |\ |\ |\
During shift report, the central electrocardiogram (EKG)
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monitoring system alarms. Which client alarm should the nurse
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investigate first? |\
a. Respiratory apnea of 30 seconds
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b. Oxygen saturation rate of 88%
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c. Eight premature ventricular beats every minute
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d. Disconnected monitor signal for the last 6 minutes. - CORRECT
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ANSWERS ✔✔a. Respiratory apnea of 30 seconds
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During a home visit, the nurse observed an elderly client with
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diabetes slip and fall. What action should the nurse take first?
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a. Give the client 4 ounces of orange juice
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b. Call 911 to summon emergency assistance
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c. Check the client for lacerations or fractures
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d. Asses clients blood sugar level - CORRECT ANSWERS ✔✔c.
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Check the client for lacerations or fractures
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At 0600 while admitting a woman for a schedule repeat cesarean
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section (C-Section), the client tells the nurse that she drank a
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cup a coffee at 0400 because she wanted to avoid getting a
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headache. Which action should the nurse take first?
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a. Ensure preoperative lab results are available
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b. Start prescribed IV with lactated Ringer's
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