1. Folflowing discharge teaching, a male client with duodenal ulcer tells the nurse the he

will drink plenty of dairy products, such as smilk, to help coat and protect his ulcer. What

is the best follow-up action by the nurse? *milk produce more acids*

● Review with the client the need to avoid foods that are rich in milk and cream

2. 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, t he nurse

should stress that an elevated BP places the client at risk for which pathophysiological

condition?

● Stroke secondary to hemorrhage

3. 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?

● Instruct the UAP to obtain soft blankets to secure to the side rails instead of

pillows.

4. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for

the past 12 days. Which assessment finding requires immediate follow-up?

● Describes life without purpose

5. 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?

● Further evaluation involving surgery may be needed

6. A client who recently underwear a tracheostomy is being prepared for discharge to

home. Which instructions is most important for the nurse to include in the discharge

plan?

● Teach tracheal suctioning techniques

7. 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?

● Document the assessment data

● Rational: reservoir bag should not deflate completely during inspiration and the

client’s respiratory rate is within normal limits.

8. During shift report, the central electrocardiogram (EKG) monitoring system

alarms. Which client alarm should the nurse investigate firs?

● Respiratory apnea of 30 seconds

9. During a home visit, the nurse observed an elderly client with diabetes slip and fall. What

action should the nurse take first?

● Check the client for lacerations or fractures

10. 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?

● Inform the anesthesia care provider

11. 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?

● Listen with the bell at the same location

12. 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?

● Medicare

13. 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?

● Toasted wheat bread and jelly

14. Following a lumbar puncture, a client voices several complaints. What complaint

indicated to the nurse that the client is experiencing a complication?

● “I have a headache that gets worse when I sit up”

● “I am having pain in my lower back when I move my legs”

● “My throat hurts when I swallow”

● “I feelsick to my stomach and am going to throw up”

15. An elderly client seems confused and reports the onset of nausea, dysuria, and urgency

with incontinence. Which action should the nurse implement?

● Obtain a clean catch mid-stream specimen

16. The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods

that are in keeping with the child’s dietary restrictions. Which foods are contraindicated

for this child?

● Foods sweetened with aspartame

17. Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks

the circulating nurse if a 3 minute surgical hand scrub is adequate preparation for this

client. Which response should the circulating nurse provide?

● Direct the nurse to continue the surgical hand scrub for a 5 minute duration

18. Which breakfast selection indicates that the client understands the nurse’s instructions

about the dietary management of osteoporosis?

● Bagel with jelly and skim milk

19. The charge nurse of a critical care unit is informed at the beginning of the shift that less

than the optimal number of registered nurses will be working that shift. In planning

assignments, which client should receive the most care hours by a registered nurse (RN)?

● An 82-year-old client with Alzheimer’s disease newly-fractures femur who has a

Foley catheter and soft wrist restrains applied

20. A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the

pediatrician’s office. Upon inspection, the nurse notes that the nail went through the shoe

and pierced the bottom of the child’s foot. Which action should the nurse implement first?

● Cleanse the foot with soap and water and apply an antibiotic ointment

● Provide teaching about the need for a tetanus booster within the next 72 hours.

● have the mother check the child's temperature q4h for the next 24 hours

● transfer the child to the emergency department to receive a gamma globulin

injection