ANSWERS WITH RATIONALES (VERIFIED ANSWERS)
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?
a. Remind the client that it is also important to switch to decaffeinated coffee and tea.
b. Suggest that the client also plan to eat frequent small meals to reduce discomfort
c. Review with the client the need to avoid foods that are rich in milk and cream.
d. Reinforce this teaching by asking the client to list a dairy food that he might select.
Review with the client the need to avoid foods that are rich in milk and cream
Rationale: Diets rich in milk and cream stimulate gastric acid secretion and should be avoided.
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?
a. Blindness secondary to cataracts
b. Acute kidney injury due to glomerular damage
c. Stroke secondary to hemorrhage
d. Heart block due to myocardial damage
Stroke secondary to hemorrhage
Rationale: Stroke related to cerebral hemorrhage is major risk for uncontrolled hypertension.
Which type of Leukocyte is involved with allergic responses and the destruction of parasitic
worms?
a. Neutrophils
b. Lymphocytes
c. Eosinophils
d. Monocytes
,Eosinophils
Rationale: Eosinophils are involved in allergic responses and destruction of parasitic worms
The healthcare provider prescribes the antibiotic cephradine 500mg PO every 6 hours for a
client with a postoperative wound infection. Which foods should the nurse encourage this
client to eat
a. Vanilla-flavored yogurt
b. Low fat chocolate milk.
c. Calcium fortified juice
d. Cinnamon applesauce
d. Cinnamon applesauce
RATIONALE: Dairy products and calcium fortified dairy products decrease the absorption of
ciprofloxacin. Cinnamon applesauce contains no calcium, so this is the best snack selection.
Since other options contains calcium, these snacks should be avoided by a client who is taking
ciprofloxacin.
Several months after a foot injury, and adult woman is diagnosed with neuropathic pain. The
client describes the pain as severe and burning and is unable to put weight on her foot. She
asks the nurse when the pain will "finally go away." How should the nurse respond?
a. Explain the healing from injury can take many months
b. Assist the client in developing a goal of managing the pain.
c. Encourage the client to verbalize her fears about the pain
d. Complete an assessment of the client's functional ability.
Assist the client in developing a goal of managing the pain
Rationale: Neuropathic pain is chronic pain and the nurse should first help the client understand
the need to learn to manage the pain.
One day following an open reduction and internal fixation of a compound fracture of the leg,
a male client complains of "a tingly sensation" in his left foot. The nurse determines the
client's left pedal pulses are diminished. Based on these finding, what is the client's greatest
risk?
a. Reduce pulmonary ventilation and oxygenation related to fat embolism.
,b. Neurovascular and circulation compromise related to compartment syndrome.
c. Wound infection and delayed healing to fractured bone protrusion.
d. Venous stasis and thrombophlebitis related to postoperative immobility.
Neurovascular and circulation compromise related to compartment syndrome
Rationale: Inflammation from the traumatic injury produces swelling and edema inside the
closed space under the skin that produces pressure, which decreases blood flow to capillaries
and nerves, causing altered perfusion related to compartment syndrome
The nurse is completing a head to be assessment for a client admitted for observation after
falling out of a tree. Which finding warrants immediate intervention by the nurse?
a. Sluggish pupillary response to light
b. Clear fluid leaking from the nose.
c. Complaint of severe headache
d. Periorbital ecchymosis of right eye.
Clear fluid leaking from the nose
Rationale: Clear fluid from nose or ear may be cerebrospinal fluid related to a basilar skull
fracture and require immediate intervention.
A client with multiple sclerosis (MS) has decreased motor function after taking a hot bath
(Uhthoff's sign). Which pathophysiological mechanism supports this response
a. Arterial Constriction
b. Temporary vasodilation
c. Poor temperature control
d. Severe dehydration.
Temporary vasodilation
Rationale: Uhthoff's sign results from temporary vasodilation
While assessing a radial artery catheter, the client complains of numbness and pain distal to
the insertion site. What interventions should the nurse implement?
a. Determine of aspirin was given prior to radial artery catheter insertion.
b. Promptly remove the arterial catheter from the radial artery.
, c. Irrigate the arterial line using a syringe with sterile saline
d. Administer a PRN analgesic and assess numbness in 30 mints
Promptly remove the arterial catheter from the radial artery.
Rationale: The client is manifesting evidence of sensory dysfunction and ischemia distal to the
arterial catheter insertion site, so the arterial catheter should promptly be removed to minimize
tissue necrosis.
A client is admitted with an epidural hematoma that resulted from a skateboarding accident.
To differentiate the vascular source of the intracranial bleeding, which finding should the
nurse monitor?
a. Slow increasing intracranial pressure (ICP)
b. Decerebrate posturing
c. Rapid onset of decreased level of consciousness.
d. Coup contrecoup signs
Rapid onset of decreased level of consciousness.
Rationale: Epidural hematomas result from arterial bleeds that cause a rapid increase in ICP,
which initially manifested by an early and rapid onset of decreased consciousness. Slowly
increasing ICP is more likely to occur with a venous subdural hematoma.
The nurse finds a client at 33 weeks gestation in cardiac arrest. What adaptation to
cardiopulmonary resuscitation (CPR) should the nurse implement?
a. Apply oxygen by mask after opening the airway
b. Position a firm wedge to support pelvis and thorax at 30-degree tilt.
c. Give continuous compression with a ventilation ratio at 20:3
d. Apply less compression force to reduce aspiration
Position a firm wedge to support pelvis and thorax at 30-degree tilt.
Rationale: To relieve aortocaval compression caused by the gravid uterus, left lateral uterine
displacement (LUD) should be maximized using a firm wedge to support the pelvis and thorax at
30- degree tilt to optimize maternal hemodynamic during CPR. Maternal modification should
include ventilation with 100% oxygen, not A. Pregnant adults should be resuscitated using a
compression-ventilation ration of 30:2 not C without interruption of continuous compressions.
Effective chest compression should be forceful rhythmic application of pressure (fast and hard)