1. 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.

Rationale: Diets rich in milk and cream stimulate gastric acid secretion

and should be avoided.

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, 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

Rationale: Stroke related to cerebral hemorrhage is major risk for

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uncontrolled hypertension.

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?

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.

a- Assume responsibility for placing the pillows while the UAP

completes another task.

b- Ask the UAP to use some of the pillows to prop the client in a side

lying position.

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

4. 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.

Rationale: Cymbalta is a selective serotonin and norepinephrine

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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

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?

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.

Rationale: An abdominal mass in a client with a family history for

ovarian cancer should be evaluated carefully

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?

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.

Rationale: Suctioning helps to clear secretions and maintain an open

airway, which is critical.

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?

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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

Rational: reservoir bag should not deflate completely during inspiration

and the client’s respiratory rate is within normal limits.

8. 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

Rationale: After the client falls, the nurse should immediately assess for

the possibility of injuries and provide first aid as needed

9. 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.

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

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