1. Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drinkÂÂ
plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-upÂÂ
action by the nurse?
• Review with the client the need to avoid foods that are rich in milk and creamÂÂ
2. A male client with hypertension, who received new antihypertensive prescriptions at his last visit returnsÂÂ
to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that heÂÂ
has not been taking the prescribed medication because the drugs make him “feel badâ€Â. In explaining theÂÂ
need for hypertension control, the nurse should stress that an elevated BP places the client at risk for whichÂÂ
pathophysiological condition?ÂÂ
• Stroke secondary to hemorrhageÂÂ
3. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted clientÂÂ
who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the sideÂÂ
rails. What action should the nurse implement?ÂÂ
4. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12ÂÂ
days. Which assessment finding requires immediate follow-up?ÂÂ
• Describes life without purposeÂÂ
5. A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominalÂÂ
mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative.ÂÂ
What information should the nurse include in the client’s teaching plan?ÂÂ
• Further evaluation involving surgery may be neededÂÂ
6. A client who recently underwear a tracheostomy is being prepared for discharge to home. WhichÂÂ
instructions is most important for the nurse to include in the discharge plan?ÂÂ
• Teach tracheal suctioning techniquesÂÂ
7. In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygenÂÂ
reservoir bag does not deflate completely during inspiration and the client’s respiratory rate is 14ÂÂ
breaths / minute. What action should the nurse implement?ÂÂ
•
• Rational: reservoir bag should not deflate completely during inspiration and the client’s respiratoryÂÂ
rate is within normal limits.
8. During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which clientÂÂ
alarm should the nurse investigate firs?ÂÂ
• Respiratory apnea of 30 seconds