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发布时间:2024-04-25 23:13:25

[单项选择]An elderly client with Alzheimer's disease begins supplemental tube feedings through a gastrostomy tube to provide adequate calorie intake. The nurse should be concerned most with the potential for ().
A. hypoglycemia.
B. fluid volume excess.
C. aspiration.
D. constipation.

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[单项选择]A client with coronary artery disease reports intermittent chest pain that occurs with exertion. The physician prescribes sublingual nitroglycerin. When teaching the client about nitroglycerin administration, the nurse should include which instruction ?()
A. "Be careful after taking nitroglycerin because it may cause dizziness. "
B. "Make sure you replace your nitroglycerin tablets every 6 months to ensure potency. "
C. "A burning sensation after taking nitroglycerin indicates medication potency. "
D. "When you experience chest pain, take one tablet every 30 minutes until the pain is relieved. "
[单项选择]The nurse evaluates the client's understanding of myasthenia gravis. The nurse would judge that the client has formed a realistic concept of her condition when she says
A. "By taking medication and pacing activities, I will live longer, but ultimately the disease will cause my death. "
B. "By taking medication and pacing activities, my fatigue will be relieved, but I should expect occasional periods of muscle weakness. "
C. "By taking medication and pacing activities, my symptoms will be controlled and eventually the disease will be cured. "
D. "By taking medication and pacing activities, I should be able to control the disease and enjoy a healthy lifestyle. "
[单项选择]During a client's chemotherapy regimen for breast cancer, which is important for the nurse to include in her plan of care
A. Instruct the client to consume plenty of raw fruits and vegetables.
B. Take rectal temperatures for greater accuracy.
C. Tell the client to avoid crowds and infected individuals.
D. Ask friends and relatives not to visit during the course of chemotherapy.
[单项选择]A representative from the client's firm will oversee the work to ensure that all ______ of the project are met.
A. specified
B. specifications
C. specifying
D. specifies
[单项选择]To prevent external rotation of the client's hips while he is lying on his back, it would be best for the nurse to place
A. firm pillows under the length of his legs.
B. sandbags alongside his legs from knees to ankles.
C. troehanter rolls alongside his legs from ilium to midthigh.
D. a footboard that supports his feet in the normal anatomic position.
[单项选择]While suctioning a client's laryngectomy tube, the nurse should insert the catheter
A. about 1 to 2 inches.
B. as the client exhales.
C. until resistance is met, then withdraw it 1 to 2 cm.
D. until the client begins coughing.
[单项选择]Which of these signs suggests that a client with syndrome of inappropriate antidiuretic hormone (SIADH) secretion has developed complications
A. Tetanic contractions.
B. Neck vein distention.
C. Weight loss.
D. Polyuria.
[单项选择]The nurse is irrigating a client's colostomy when the client complains of abdominal cramping after receiving about 100 mL of the irrigating solution. What should the nurse do first
A. Stop the flow of solution temporarily.
B. Reposition the client on to her right side.
C. Remove the irrigation tube.
D. Massage the abdomen gently.
[单项选择]The nurse identifies a client's responses to actual or potential health problems during which step of the nursing process
A. Assessment.
B. Analysis.
C. Planning.
D. Evaluation.
[单项选择]The nurse notices that a client's abdominal wound has eviscerated. Which of the following would the nurse do first
[单项选择]The nurse assesses the client's urinary stoma regularly for edema. Which of the following signs and symptoms might indicate excessive stomal edema
A. Elevated temperature.
B. Urine output below 30 mL/hour.
C. Urine dribbling from the stoma.
D. Complaints of discomfort around the stoma.
[单项选择]The nurse observes that the client's total parenteral nutrition (TPN) solution is infusing too slowly. The nurse calculates that the client has received 300 mL less than was ordered for the day. What should the nurse do next
[单项选择]When prioritizing a client's care plan based on Maslow's hierarchy of needs, the nurse's first priority would be ().
A. allowing the family to see a newly admitted client.
B. ambulating the client in the hallway.
C. administering pain medication.
D. placing wrist restraints on the client.
[单项选择]Which of the following findings in a client's history would be most likely to predispose her to renal calculi
A. The client takes large doses of vitamin E.
B. The client drinks one to two glasses of fluid daily.
C. The client had a urinary tract infection within the last 6 months.
D. The client eats a diet that meets the daily requirements for calcium.
[单项选择]The nurse is delivering the client's 10 AM medications. The client is away from his room for a diagnostic study. Which action is the most appropriate for the nurse to take ?()
A. Leave the medications on the client's bedside table.
B. Ask the client's roommate to keep the medications for the client until he returns.
C. Lock the medications in the medicine preparation area until the client returns.
D. Have the client skip that dose of medication.
[单项选择]The nurse inspects a client's back and notices small hemorrhagic spots. The nurse documents that the client has
A. extravasation.
B. osteomalacia.
C. petechiae.
D. uremia.
[单项选择]The nurse is reviewing a client's arterial blood gas (ABG) report. Which ABG value reflects the acid concentration in the blood
A. pH
B. PaO2
C. PaCO2
[单项选择]The nurse notices that the client's pupils are fixed and dilated. What does this finding indicate
A. The client is permanently paralyzed.
B. The client is going to be blind as a result of an injury.
C. The client probably has meningitis.
D. The client has received a significant brain injury.
[单项选择]When bandaging the burned client's hand, the nurse should pay more attention about which of the following
A. The bandage is free of elastic.
B. The bandage material is moistened with sterile normal saline solution.
C. The hand and finger surfaces do not touch.
D. The hand and fingers are not elevated above heart level.

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