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