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.
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.
,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
Stroke secondary to hemorrhage
Rationale: Stroke related to cerebral hemorrhage is major risk for 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.
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
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.
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
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.
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
6. 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.
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