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 nur
...
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.
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?
a. Ensure that the UAP has placed the pillows effectively to protect the client.
b. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.
c. Assume responsibility for placing the pillows while the UAP completes another task.
d. Ask the UAP to use some of the pillows to prop the client in a side lying position.
Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows
Rationale: The nurse should instruct the UAP to pad the side rails with soft blankest
because the use of pillows could result in suffocation and would need to be removed at
the onset of the seizure. The nurse can delegate paddling the side rails to the UAP
An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for
the past 12 days. Which assessment finding requires immediate follow-up
a. Describes life without purpose
b. Complains of nausea and loss of appetite
c. States is often fatigued and drowsy
d. Exhibits an increase in sweating.
Describes life without purpose
Rationale: Cymbalta is a selective serotonin and norepinephrine reuptake inhibitor that
is known to increase the risk of suicidal thinking in adolescents and young adults with
major depressive disorder. B, C and D are side effects
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
a. Further evaluation involving surgery may be needed
b. A pelvic exam is also needed before cancer is ruled out
c. Pap smear evaluation should be continued every six month
d. One additional negative pap smear in six months is needed.
Further evaluation involving surgery may be needed
Rationale: An abdominal mass in a client with a family history for ovarian cancer should
be evaluated carefully
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?
a. Explain how to use communication tools.
b. Teach tracheal suctioning techniques
c. Encourage self-care and independence.
d. Demonstrate how to clean tracheostomy site.
Teach tracheal suctioning techniques
Rationale: Suctioning helps to clear secretions and maintain an open airway, which is
critical.
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
a. Encourage the client to take deep breaths
b. Remove the mask to deflate the bag
c. Increase the liter flow of oxygen
d. Document the assessment data
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 first?
a. Respiratory apnea of 30 seconds
b. Oxygen saturation rate of 88%
c. Eight premature ventricular beats every minute
d. Disconnected monitor signal for the last 6 minutes.
Respiratory apnea of 30 seconds
Rationale: The priority is the client whose alarm indicating respiratory apnea that should
be assessed first.
During a home visit, the nurse observed an elderly client with diabetes slip and fall.
What action should the nurse take first?
a. Give the client 4 ounces of orange juice
b. Call 911 to summon emergency assistance
c. Check the client for lacerations or fractures
d. Asses clients blood sugar level
Check the client for lacerations or fractures
Rationale: After the client falls, the nurse should immediately assess for the possibility of
injuries and provide first aid as needed
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?
a. Ensure preoperative lab results are available
b. Start prescribed IV with lactated Ringer's
c. Inform the anesthesia care provider
d. Contact the client's obstetrician.
Inform the anesthesia care provider
Rationale: Surgical preoperative instruction includes NPO after midnight the day of
surgery to decrease the risk of aspiration should vomiting occur during anesthesia.
While it is possible the C-section will be done on schedule or rescheduled for later in the
day, the anesthesia provider should be notified first.
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
a. Side the stethoscope across the sternum.
b. Move the stethoscope to the mitral site
c. Listen with the bell at the same location
d. Observe the cardiac telemetry monitor
Listen with the bell at the same location
Rationale: The nurse uses the bell of the stethoscope to hear low-pitched sounds such
as S3 and S4. The nurse listens at the same site using the diaphragm the diaphragm
and bell before moving systematically to the next sites.
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?
a. Woman, Infant, and Children program
b. Medicaid
c. Medicare
d. Consolidated Omnibus Budget Reconciliation Act provision.
Medicare
Rationale: Title XVII of the social security Act of 1965 created Medicare Program to
provide medical insurance for person more than 65 years or older, disable or with
permeant kidney failure, WIC provides supplemental nutrition to meet the needs of
pregnant of breastfeeding woman, infants and children up to age of 6. Medicaid
provides financial assistance to pay for medical services for poor older adults, blind,
disable and families with dependent children. COBRA(D) health benefit provisions is a
limited insurance plan for those who has been laid off or become unemployed.
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?
