• Avoids eye contact.
• Has a disheveled appearance.
157. A client in the postanesthesia care unit (PACU) has an eight (8) on the Aldrete postanesthesia scoring system. What intervention should nurse implement?
• Transfer the client to the surgical floor.
158. In caring for the body of a ...
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?
• 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, the 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 theemployee
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 feel sick 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?
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• 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
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