A 21-year-old primigravida has an emer...

The mother of a 1B-year-old girl calls the emergency department, suspecting her daughter’s abdominal pain may be appendicitis. In addition to pain, her daughter has a fever of 100°F (37.8℃) and has vomited twice. What should the nurse tell the mother

A. Give the daughter a laxative to rule out the possibility that constipation is causing the pain.
B. Gently press on the left lower quadrant of her daughter’s abdomen to test for rebound tenderness.
C. It’s most likely the flu because her daughter is too young to have appendicitis.
D. Immediately bring her daughter into the emergency department before the appendix has a chance to ruptur

单项选择题

A 69-year-old client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct

A. OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints.
B. OA and RA are very similar. OA affects the smaller joints, and RA affects the larger, weight-bearing joints.
C. OA affects joints on both sides of the body. RA is usually unilateral.
D. OA is more common in women. RA is more common in men.

单项选择题

A local elementary school has requested scoliosis screening for its students from the hospital’s community outreach program. The school should be informed that

A. these students are too young to screen; instead, older students should be screened.
B. these students are too old to screen and will no longer benefit from screening for scoliosis.
C. scoliosis screening requires sophisticated equipment and can’t be done in school.
D. this is an appropriate request and arrangements will be made as soon as possibl

单项选择题

The nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which of the following findings should the nurse consider abnormal

A. More back pain than the first postoperative day.
B. Paresthesia in the dermatomes near the wounds.
C. Urinary retention or incontinence.
D. Temperature of 99.2°F(37.3℃).

单项选择题

A 23-year-old primigravida client has a normal vaginal delivery. The next day, the nurse assesses the client’s lochia for color, amount, and the presence of clots. Which of the following best describes lochia on the first postpartum day

A. Dark red (loehia rubra), large amount, with many clots.
B. Pink (lochia serosa), moderate amount, no clots.
C. White (lochia alba), scant amount, no clots.
D. Dark red (lochia rubra), moderate amount, with a few small clots.

单项选择题

The child with rheumatic fever must have his heart rate measured while awake and while sleeping. Why are two readings necessary

A. To obtain a heart rate that isn’t affected by medication.
B. To eliminate interference from the jerky movements of chorea.
C. To ensure that the child can’t consciously raise or lower the heart rate.
D. To compensate for the effects of activity on the heart rat

单项选择题

A 28-year-old single female arrives at a mental health clinic complaining of depression. She states that she has been feeling numb and empty most of the time and has little energy to perform her usual activities. She has experienced these difficulties since the death of her best friend 6 months ago. Which of the following is the nurse’s best response

A. Tell the client that the physician will prescribe an antidepressant and she will feel better.
B. Encourage the client to get on with her life and stop feeling sorry for herself.
C. Advise the client that it isn’t unusual for grieving and loss to continue for quite some time.
D. Suggest that the client return in 3 months if the feelings persist.

单项选择题

A nurse instructs a prenatal class about the importance of doing Kegel exercises frequently. Kegel exercises help to

A. promote better breathing by strengthening the diaphragm muscle.
B. maintain good perineal muscle tone by tightening the pubococcygeus muscle.
C. minimize leg cramps by strengthening the calf muscles.
D. prepare the mother for pushing by strengthening the abdominal muscles.

单项选择题

The nurse is planning care for a female client diagnosed with acute hepatitis A virus (HAV). What’s the primary mode of transmission for HAV

A. Fecal contamination and oral ingestion.
B. Exposure to contaminated blood.
C. Sexual activity with an infected partner.
D. Sharing a contaminated needle or syring

单项选择题

A nurse is reviewing prenatal care with a client. Which of the following statements by the client best expresses adequate understanding of nutritional needs during pregnancy

A. "I expect to gain a few pounds each month at first. Then I’ll really get big and put on 20 pounds or so. "
B. "I guess I will get big and gain 20 to 30 pounds and look pregnant."
C. "Because I have to eat for two, I should eat whatever I want whenever I feel hungry. "
D. "I will need to eat more so that I will gain about 25 pounds, but I want to make sure I don’t fill up with junk food. "

单项选择题

An 8-year-old child enters a health care facility. During assessment, the nurse discovers that the child is experiencing the anxiety of separation from his parents. The nurse makes the nursing diagnosis of Fear related to separation from familiar environment and family. Which nursing intervention is most likely to help the child cope with fear and separation

A. Ask the parents not to visit the child until he has adjusted to the new environment.
B. Ask the physician to explain to the child why he needs to stay in the health care facility.
C. Explain to the child that he must act like an adult while he’s in the facility.
D. Have the parents stay with the child and participate in his car

单项选择题

Which intervention has the highest priority when providing skin care to a bedridden client

A. Changing the bed linens frequently for an incontinent client.
B. Keeping the skin clean and dry without using harsh soaps.
C. Gently massaging the skin around the pressure areas.
D. Rubbing moisturizing lotion over the pressure areas.

单项选择题

The nurse is teaching a client who is 28 weeks pregnant and has gestational diabetes how to control her blood glucose levels. Diet therapy alone has been unsuccessful in controlling her blood glucose levels, so she has started insulin therapy. The nurse should consider the teaching effective when the client says

A. "I won’t use insulin if I’m sick. "
B. "I need to use insulin each day. "
C. "If I give myself an insulin injection, I don’t need to watch what I eat. "
D. "I’ll monitor my blood glucose levels twice a week. "

单项选择题

A pregnant client is taking folic acid. During prenatal teaching, which of the following foods would the nurse recommend as high in folic acid

A. Egg yolks.
B. Fruit.
C. Bread.
D. Milk.

单项选择题

The mother of a hospitalized 3-year-old girl expresses concern because her daughter is wetting the bed. What should the nurse tell her

A. "It’s common for a child to exhibit regressive behavior when anxious or stressed. "
B. "Your child is probably angry about being hospitalized. This is her way of acting out. "
C. "Don’t worry. It’s common for a 3-year-olcl child to not be fully toilet-trained. "
D. "The nurses probably haven’t been answering the call light soon enough. They will try to respond more quickly. "

单项选择题

A client with antisocial personality disorder refuses to take a shower for 3 days. Which response by the nurse is best

A. "It’s policy here for all clients to bathe daily. "
B. "It’s time for your shower. I’ll help you with it. "
C. "Don’t worry about your shower until tomorrow. "
D. "Do you want people to make fun of you"

单项选择题

The physician prescribes a monoamine oxidase (MAO) inhibitor for a client. Which of the following nursing diagnostic categories would be most appropriate to focus on during client teaching

A. Risk for injury.
B. Disturbed thought processes.
C. Deficient fluid volume.
D. Disturbed sleep pattern.

单项选择题

The nurse is planning care for a client after a tracheostomy. One of the client’s goals is to overcome verbal communication impairment. Which of the following interventions should the nurse include in the care plan

A. Make an effort to read the client’s lips to foster communication.
B. Encourage the client’s communication attempts by allowing him time to select or write words.
C. Answer questions for the client to reduce his frustration.
D. Avoid using a tracheostomy plug because it blocks the airway.

单项选择题

The nurse is caring for a 10-year-old child with rheumatic fever. While obtaining the child’s health history from the mother, the nurse should ask if the child recently had which illness

A. Strep throat.
B. Influenza.
C. Chickenpox.
D. Mononucleosis.

单项选择题

During a routine follow-up examination, the nurse updates the client’s medication history. The client currently receives prednisone therapy. Concomitant use of an agent from which of the following classes could increase the risk of peptic ulcer disease

A. Antidiabetic agents, administered orally.
B. Nonsteroidal anti-inflammatory drugs (NSAIDs).
C. Beta-adrenergic blockers.
D. Contraceptive agents, administered orally.

单项选择题

Several children in a kindergarten class have been treated for pinworm. To prevent the spread of pinworm, the school nurse meets with the parents and explains that they should

A. tell the children not to bite their fingernails.
B. not let children share hairbrushes.
C. tell the children to cover their mouths and noses when they cough or sneeze.
D. have their children immunize

单项选择题

A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body

A. 9%.
B. 18%.
C. 27%.
D. 36%.

单项选择题

The nurse is caring for a comatose client who has suffered a closed head injury. What intervention should the nurse implement to prevent increases in intracranial pressure (ICP)

A. Suction the airway every hour and as needed.
B. Elevate the head of the bed 15 to 30 degrees.
C. Turn the client and change his position every 2 hours.
D. Maintain a well-lit room.

单项选择题

A registered nurse who usually works on a medical-surgical unit is told to report to the cardiac care unit (CCU) for the day because the CCU is short staffed and needs additional help to care for the clients. The nurse has never worked in the CCU. Which of the following responses is the most appropriate nursing action

A. Call the hospital lawyer.
B. Report to the CCU and identify tasks that she feels she can safely perform.
C. Speak to the nursing supervisor.
D. Refuse to go to the CCU.

单项选择题

The nurse is caring for a client who has had an above-the-knee amputation. The client refuses to look at the stump. When the nurse attempts to speak with the client about his surgery, he tells the nurse that he doesn’t wish to discuss it. The client also refuses to have his family visit. The nursing diagnosis that best describes the client’s problem is

A. hopelessness.
B. powerlessness.
C. disturbed body image.
D. fear.

单项选择题

The nurse is developing a care plan for a client in her 34th week of gestation who is experiencing premature labor. What nonpharmacologic intervention should the plan include to halt premature labor

A. Encouraging ambulation.
B. Serving a nutritious diet.
C. Promoting adequate hydration.
D. Performing nipple stimulation.

单项选择题

The nurse is planning care for a client admitted to the psychiatric unit with a diagnosis of paranoid schizophreni

a. Which nursing diagnosis should receive the highest priorityA. Risk for self- or other-directed violence.B. Imbalanced nutrition.C. Ineffective coping.D. Impaired verbal communication.

单项选择题

The nurse is providing care for a client who underwent mitral valve replacement. The best example of a measurable client outcome goal is to

A. change his own dressing.
B. walk in the hallway.
C. walk from his room to the end of the hall and back before discharge.
D. eat a special diet.

单项选择题

A child is sent to the school nurse because, according to his teacher, he’s constantly scratching his head. When the nurse assesses his hair and scalp, she finds evidence of lice. What did she probably see

A. Flaking of the scalp with pink, irritated skin exposed.
B. Small white spots that adhere to the hair shaft, close to the scalp.
C. Scaly, circumscribed patches on the scalp, with mild alopecia in these areas.
D. Multiple tiny pustules on the scalp with no abnormal findings on the hair shafts.

单项选择题

While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of what assessment parameters

A. Platelet count, prothrombin time (PT), and partial thromboplastin time (PTT).
B. Platelet count, blood glucose levels, and white blood cell (WBC) count.
C. Thrombin time, calcium levels, and potassium levels.
D. Fibrinogen level, WBC count, and platelet count.

单项选择题

A person’s psychosocial needs during the dying process of a relative may include

A. flexible visitation, participation in client care, and rest breaks.
B. flexible visitation, denial of imminent death, and rest breaks.
C. limited visitation, participation in client care, and rest breaks.
D. short, frequent, limited periods of visitation; participation in client care; and rest breaks.

单项选择题

Immediately after a 1-year-old client returns from a cardiac catheterization, the nurse notes that the pulse distal to the catheter insertion site is weak. The nurse should take which of the following actions

A. Remove the pressure bandage from the insertion site.
B. Perform passive exercises on the affected extremity.
C. Notify the physician of the assessment.
D. Record the data on the nursing notes and continue to evaluat

单项选择题

A child with type 1 diabetes mellitus develops diabetic ketoacidosis and receives a continuous insulin infusion. Which condition represents the greatest risk for this child

A. Hypercalcemia.
B. Hyperphosphatemia.
C. Hypokalemia.
D. Hypernatremi

单项选择题

The nurse is teaching breast self-examination (BSE) to a college student. The nurse knows that the client understands the best time to examine her breasts when she says:

A. "I’ll examine my breasts 1 week after my period starts. "
B. "I’ll perform a BSE just before my period starts. "
C. "I must examine my breasts the same time each day. "
D. "Every time I shower I’ll do a breast examination. "

单项选择题

A 21-year-old primigravida has an emergency cesarean delivery under general anesthesia because of unanticipated fetal distress. One postoperative intervention is to assist her to turn every 2 hours. Which of the following conditions is this intervention intended to prevent

A. Pressure ulcers.
B. Muscular stiffness.
C. Respiratory complications.
D. Venous stasis.

单项选择题

A 58-year-old client on a mental health unit has lost control, despite having been properly medicated, and is threatening to harm himself and others. He has been placed in four- point restraints. Which nursing measure should be taken next

A. Release one restraint every 15 minutes.
B. Have a staff member stay with the client at all times.
C. Leave the client alone to reduce his sensory stimulation and allow him to regain control.
D. Restrict fluids until the restraint period is over.

单项选择题

The nurse is developing a teaching plan for a client with diabetes mellitus. A client with diabetes mellitus should

A. use commercial preparations to remove corns.
B. cut toenails by rounding edges.
C. wash and inspect feet daily.
D. walk barefoot at least once each day.

单项选择题

The nurse is caring for a neonate with congenital clubfoot. The child has a cast to correct the defect. Before discharge, what should the nurse tell the parents

A. "The cast will be removed in 6 weeks. "
B. "A new cast is needed every 1 to 2 weeks. "
C. "A short leg cast is applied when the baby is ready to walk. "
D. "The cast will be removed when the baby begins to crawl. "

单项选择题

A 54-year-old female was found unconscious on the floor of her bathroom with self- inflicted wrist lacerations. An ambulance was called and the client was taken to the emergency department. When she was stable, the client was transferred to the inpatient psychiatric unit for observation and treatment with antidepressants. Now that the client is feeling better, which nursing intervention is most appropriate

A. Observing for extrapyramidal symptoms.
B. Beginning a therapeutic relationship.
C. Canceling any no-suicide contracts.
D. Continuing suicide precautions.

单项选择题

A client who has sustained a head injury is to receive mannitol (Osmitrol) by IV push. In evaluating the effectiveness of the drug, the nurse should expect to find

A. increased lung expansion.
B. decreased cerebral edema.
C. decreased cardiac workload.
D. increased cerebral circulation.

单项选择题

The nurse is giving home care instructions to a client who just had a cataract removed and an intraocular lens implanted. What should the nurse tell the client

A. Don’t sleep on the operated side.
B. Wear the eye shield continuously for 2 weeks.
C. Aspirin may be taken for mild pain.
D. Straining during bowel movements is allowe

单项选择题

The nurse is teaching a group of patient-care attendants about infection-control measures. The nurse tells the group that the first line of intervention for preventing the spread of infection is

A. wearing gloves.
B. administering antibiotics.
C. washing hands.
D. assigning private rooms for clients.

单项选择题

Which intervention will best help to prevent a client from falling

A. Monitor the client regularly or continually if his condition warrants it.
B. Keep the bed at a level where the nurse can easily provide care.
C. Make sure the side rails of the client’s bed are down.
D. Restrain the client to prevent him from getting out of bed and fallin

单项选择题

The nurse provides care for a client with chronic obstructive pulmonary disease (COPD). Administering high doses of oxygen may produce what result

A. Increased respiratory drive.
B. Diminished respiratory drive.
C. A mismatch between ventilation and perfusion.
D. A profound decrease in partial pressure of arterial carbon dioxide (PaCO₂).

单项选择题

A client with bicuspid aortic valve has severe stenosis and is scheduled for valve replacement. While teaching the client about his condition and upcoming surgery, the nurse shows him a heart illustration. Which valve will be replaced

A. A
B. B
C. C
D. D

单项选择题

A client is admitted to the labor and delivery unit in active labor. She has had no prenatal care but appears to be between 32 and 35 weeks’ gestation. History reveals that she’s gravida 5, para 1, abortus 3. She tells the nurse she thinks her friend gave her a cigarette containing crack cocaine. What should the nurse do next

A. Move the precipitant delivery cart to the labor room, and notify the neonatologist on call.
B. Teach the mother controlled breathing techniques.
C. Call a family member to come to the hospital.
D. Call the friend who gave the client the cigarette and find out exactly what the drug was.

单项选择题

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.

单项选择题

The physician inserts a chest tube into a client to treat a pneumothorax. The tube is connected to water-seal drainage. The nurse can prevent chest tube air leaks by

A. keeping the chest drainage system below the level of the chest.
B. keeping the head of the bed slightly elevated.
C. checking and taping all connections.
D. checking patency of the chest tub

单项选择题

The nurse is caring for a client in the manic phase of bipolar disorder who is ready for discharge from the psychiatric unit. As the nurse begins to terminate the nurse-client relationship, which client response is most appropriate

A. Expressing feelings of anxiety.
B. Displaying anger, shouting, and banging the table.
C. Withdrawing from the nurse in silence.
D. Rationalizing the termination, saying that everything comes to an en

单项选择题

A 28-year-old accountant is admitted to the neurologic unit after a sudden onset of blindness the day before an important project is due for her boss. After preliminary evaluation and testing yields no positive findings, the physician’s initial reaction is that the client may be demonstrating which defense mechanism

A. Repression.
B. Transference.
C. Reaction formation.
D. Conversion.

单项选择题

A female client is being treated for genital herpes. The client should receive teaching on the

A. prevention of outbreaks of lesions.
B. need to abstain from sexual contact.
C. need to keep the perineal area moist.
D. need to wear tight-fitting nylon underwear.

单项选择题

A neonate of a client with type 1 diabetes mellitus is at high risk for hypoglycemi

a. An initial sign the nurse should recognize as indicating hypoglycemia in a neonate isA. peripheral acrocyanosis.B. bradycardia.C. lethargy.D. jaundic

单项选择题

A 32-year-old client is admitted to the unit. She states, "I’m a well-known, wealthy designer," and begins to order the nurses to prepare her bath while she orders her tray and telephones her colleagues. Her husband states that she’s too busy to eat and sleep and is losing weight. Her admitting diagnosis is bipolar disorder, manic phase. For which of the following events should the nurse plan

A. Erratic and unpredictable behavior if challenged.
B. Boredom and the need for minute-to-minute activities.
C. Rapid mood changes from elation to depression.
D. One-to-one treatment to occupy the client’s tim

单项选择题

A first-time mother-to-be is in the labor room, her husband at her bedside. The client states that her contractions began 6 hours ago. Which of the following assessment findings would confirm that the client is in true labor

A. Discomfort located chiefly in the abdomen.
B. Constant intensity of contractions.
C. Contractions occurring every 10 to 15 minutes and lasting 20 to 30 seconds.
D. Cervix that is 100% effaced and 2 cm dilate

单项选择题

The nurse is speaking to grieving parents after a sudden infant death syndrome (SIDS) death. What should the nurse emphasize to the parents

A. The death couldn’t have been prevented and isn’t the parents’ fault.
B. The parents must allow an autopsy to confirm the diagnosis.
C. The parents are still young and can have more children.
D. The parents should place other infants on their backs to sleep.

单项选择题

Hyperthyroidism is caused by increased levels of thyroxine in blood plasm

a. A client with this endocrine dysfunction would experienceA. heat intolerance and systolic hypertension.B. weight gain and heat intolerance.C. diastolic hypertension and widened pulse pressure.D. anorexia and hyperexcitability.

单项选择题

A client on an inpatient psychiatric unit at a community mental health center is pacing up and down the hallway. The client has a history of aggression. Which response by the nurse would be best when approaching the client

A. "If you can’t relax, you could go to your room. "
B. "Would you like your antianxiety medication now"
C. "You’re pacing. What’s going on"
D. "Let’s go play a game of pool. "

单项选择题

The nurse is providing care for a pregnant client with gestational diabetes. The client asks the nurse if her gestational diabetes will affect her delivery. The nurse should know that

A. the delivery may need to be induced early.
B. the delivery must be by cesarean.
C. the mother will carry to term safely.
D. it’s too early to tell.

单项选择题

The nurse is providing breast cancer education at a community facility. The American Cancer Society recommends that women get mammograms

A. yearly after age 40.
B. after the birth of the first child and every 2 years thereafter.
C. after the first menstrual period and annually thereafter.
D. every 3 years between ages 20 and 40 and annually thereafter.

单项选择题

A client in the manic phase of bipolar disorder constantly belittles other clients and demands special favors from the nurses. Which nursing intervention would be most appropriate for this client

A. Ask other clients and staff members to ignore the client’s behavior.
B. Set limits with consequences for belittling or demanding behavior.
C. Offer the client an antianxiety drug when belittling or demanding behavior occurs.
D. Offer the client a variety of stimulating activities to distract him from belittling or making demands of others.

单项选择题

A 2-year-old client returns from surgery after a bowel resection as a result of Hirschsprung’s disease. A temporary colostomy is in place. Which immediate postoperative nursing intervention takes priority

A. Changing the surgical dressing.
B. Suctioning the nasopharynx frequently to remove secretions.
C. Irrigating the colostomy with 100 ml of normal saline solution.
D. Auscultating lung sounds.

单项选择题

While making rounds in a senior citizens’ housing complex, the visiting nurse discovers one of her clients sobbing in her darkened apartment. On questioning the client, an 85- year-old widow, the nurse learns that her pet cat of 15 years had been put to sleep the day before. What’s the nurse’s best response

A. "It shouldn’t be hard to find another cat. You’ll feel better once you have another pet. "
B. "It was only a cat. Why are you allowing yourself to be so upset It would be different if it were a person. "
C. "I’m so sorry that your pet had to be put to sleep. I know how important your cat was to you. "
D. "It’s probably best for the cat because it was so old and ill. "

单项选择题

A 2-week postpartum client inquires about alcohol use during lactation. She tells the nurse she has heard that a small glass of wine or beer before nursing will increase her milk supply and be good for the baby. What’s the nurse’s best response

A. "It’s true that a little alcohol before breast-feeding will help your milk supply because it will help you relax. "
B. "Research has shown that it actually decreases the amount of milk the baby will get, perhaps because it affects the taste of your milk. "
C. "A little alcohol will help you to relax and the small amount that will pass through the milk may just help the baby relax. "
D. "You shouldn’t even consider drinking alcohol while you are nursing a baby. "

单项选择题

The nurse is assessing a client diagnosed with appendicitis. Which of the following signs or symptoms should the nurse expect to find

A. Rigid abdomen, Levine’s sign, pain relief leaning forward.
B. Rebound tenderness, McBurney’s sign, low-grade fever.
C. Right lower quadrant pain, Chvostek’s sign, muscle guarding.
D. Periumbilical pain, Trousseau’s sign, pain relief with pressur

单项选择题

A child, age 3, is brought to the emergency department in respiratory distress caused by acute epiglottiditis. Which clinical manifestations should the nurse expect to assess

A. Severe sore throat, drooling, leaning forward to breathe.
B. Low-grade fever, stridor, barking cough.
C. Pulmonary congestion, productive cough, fever.
D. Sore throat, fever, general malais

单项选择题

The nurse is providing preoperative care to a client scheduled for an appendectomy. Which statement regarding pain control is most appropriate

A. "There’s no need to ask for pain medication, you’ll receive it on a schedule. "
B. "Take your pain medication after walking so that you won’t feel dizzy. "
C. "Take your pain medication before your pain becomes intense. "
D. "Use as little pain medication as possible to avoid addiction. "

单项选择题

The nurse is developing a teaching plan for a client diagnosed with osteoarthritis. To minimize injury to the osteoarthritic client, the nurse should instruct the client to

A. install safety devices in his home.
B. wear comfortable shoes.
C. get help when lifting objects.
D. wear protective devices when exercisin

单项选择题

The nurse in the emergency department is assessing a 64-year-old client experiencing substernal chest pain. The client’s electrocardiogram shows evidence of myocardial ischemi

a. Which statement should indicate to the nurse that the client may be a candidate for thrombolytic therapyA. "I have had chest pain for 2 days. "B. "My chest pain started 3 hours ago. "C. "My chest pain stops when I take a nitroglycerin pill. "D. "I have had chest pain on and off all week. "

单项选择题

What is the normal pH range for arterial blood

A. 7.00 to 7.49.
B. 7.35 to 7.45.
C. 7.50 to 7.60.
D. 7.55 to 7.65.

单项选择题

The nurse is caring for a client who is on ritodrine therapy to halt premature labor. What condition indicates an adverse reaction to ritodrine therapy

A. Hypoglycemia.
B. Crackles.
C. Bradycardia.
D. Hyperkalemi

单项选择题

A mother brings her 5-month-old female child to the pediatric clinic. The child has had recurrent middle-ear infections since she was 3 months old. Which of the following areas is most important to assess

A. How well the client eats.
B. The client’s weight gain since her last visit.
C. Whether the client received all of her prescribed antibiotic at the time of the last infection.
D. The client’s temperatur

单项选择题

An 8-month-old boy is admitted to the pediatric unit following a fall from his high chair. The child is awake, alert, and crying. The nurse should know that a brain injury is more severe in children because of

A. increased myelination.
B. intracranial hypotension.
C. cerebral hyperemia.
D. a slightly thicker cranium.

单项选择题

The nurse is working in a support group for clients with acquired immunodeficiency syndrome (AIDS). Which point is most important for the nurse to stress

A. Avoiding the use of recreational drugs and alcohol.
B. Refraining from telling anyone about the diagnosis.
C. Following safer-sex practices.
D. Telling potential sex partners about the diagnosis, as required by law.

单项选择题

A 13-year-old visits the school nurse because he’s experiencing back pain, fatigue, and dyspne

a. The nurse suspects that the child may have scoliosis. The nurse should firstA. send the child home to recover.B. inspect the child for uneven shoulder height or uneven hip height.C. arrange for the child to have spinal X-rays as soon as possible.D. ask the child’s parent to take him to a physician immediately.

单项选择题

The nurse is caring for a bedridden, elderly adult. To prevent pressure ulcers, which intervention should the nurse include in the care plan

A. Turn and reposition the client a minimum of every 8 hours.
B. Vigorously massage lotion into bony prominences.
C. Post a turning schedule at the client’s bedside.
D. Slide the client, rather than lift, when turnin

单项选择题

A hospitalized client taking 30 mg of tranylcypromine (Parnate) twice per day complains of a stiff neck and headache. Which action would be best for the nurse to take

A. Note the complaints as usual adverse effects.
B. Withhold the next dose of medication.
C. Administer an analgesic, as needed and as prescribed.
D. Help the client relax.

单项选择题

Two family members are arguing in a child’s room. They start to hit each other and the child is crying. What’s the most appropriate nursing action

A. Call security to come and intervene.
B. Remove the child from the room.
C. Ask one of the family members to leave the room.
D. Try to reason with both family members.

单项选择题

A female client is discharged from the hospital after having an episode of heart failure. She’s prescribed daily oral doses of digoxin (Lanoxin) and furosemide (Lasix). Two days later, she tells her community health nurse that she feels weak and frequently feels her heart "flutter. " What action should the nurse take

A. Tell the client to rest more often.
B. Tell the client to stop taking the digoxin, and call the physiciarn.
C. Call the physician, report the symptoms, and request to draw a blood sample to determine the client’s potassium level.
D. Tell the client to avoid foods that contain caffein

单项选择题

The nurse is assessing a pregnant woman in the clinic. In the course of the assessment, the nurse learns that this woman smokes one pack of cigarettes per day. The first step the nurse should take to help the woman stop smoking is to

A. assess the client’s readiness to stop.
B. suggest that the client reduce the daily number of cigarettes smoked by one-half.
C. provide the client with the telephone number of a formal smoking cessation program.
D. help the client develop a plan to stop.

单项选择题

A client has a boggy uterus during stage IV of her delivery. Four hours postpartum, the nurse is preparing to administer methylergonovine maleate (Methergine) 0.2mg PO as prescribed every 6 hours. The client’s vital signs are; temperature, 100.4°F (38℃); pulse, 60 beats/minute; respirations, 14 breaths/minute; blood pressure, 140/90mmHg. Which is the most appropriate intervention

A. Immediately administer the drug.
B. Administer the drug and call the physician.
C. Administer the drug and recheek vital signs.
D. Don’t administer the dru

单项选择题

A gravida 2, para 1 with pregnancy-induced hypertension is receiving magnesium sulfate IV, 2g/hour via infusion pump. In assessing the client, the nurse notes a decrease in respirations from 16 to 12 breaths/minute and slightly pink-tinged urine (output is 25mL/hour). The client still complains of feeling sleepy. The nurse’s action should include

A. checking the most recent serum level of magnesium sulfate and notifying the physician of the results.
B. turning the client on her left side and taking vital signs again.
C. flushing the client’s indwelling urinary catheter with sterile normal saline solution to see if it’s draining properly.
D. instructing the client to turn, cough, and deep breathe every 30 minutes.

单项选择题

The nurse is about to administer a medication to a client with whom the nurse is unfamiliar. To verify the client’s identity, the nurse should

A. ask the client his name.
B. check the name posted outside the client’s room.
C. ask a family member the identity of the client.
D. check the client’s identification bracelet.

单项选择题

When caring for a client with the nursing diagnosis Impaired swallowing related to neuromuscular impairment, the nurse should

A. position the client in a supine position.
B. elevate the head of the bed 90 degrees during meals.
C. encourage the client to remove dentures.
D. encourage thin liquids for dietary intak

单项选择题

The nurse is teaching a female client with osteoporosis about her prescribed diet. Which of the following foods is the best source of calcium

A. 1 cup of low-fat yogurt.
B. 1 cup of skim milk.
C. 1 oz of cheddar cheese.
D. 1 cup of ice cream.

单项选择题

What laboratory finding is the primary diagnostic indicator for pancreatitis

A. Elevated blood urea nitrogen (BUN).
B. Elevated serum lipase.
C. Elevated aspartate aminotransferase (AST).
D. Increased lactate dehydrogenase (LD).

单项选择题

For a client with bulimia, which assessment is least important in the care plan

A. Observe the client after eating for 1 hour.
B. Note the client’s intake.
C. Note changes in appetite.
D. Note changes in respiratory rat

单项选择题

The nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is

A. helping him communicate.
B. keeping his airway patent.
C. encouraging him to perform activities of daily living.
D. preventing him from developing an infection.

单项选择题

The nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice

A. Straw-colored urine.
B. Reduced hematocrit.
C. Clay-colored stools.
D. Elevated urobilinogen in the urin

单项选择题

The nurse is planning care for a 10-year-old child in the acute phase of rheumatic fever. Which activity would be most appropriate for the nurse to schedule in the care plan

A. Playing ping-pong.
B. Reading books.
C. Climbing on play equipment in the playroom.
D. Unrestricted ambulation.

问答题

Directions: The question below is followed by six choices numbered 260-265. If a choice is correct, mark A in the space provided. If a choice is not correct, mark B. Blacken one circle on your answer sheet for each number.
A client is diagnosed with gout. Which foods should the nurse instruct the client to avoid
Green leafy vegetables.

答案： B

单项选择题

The nurse is developing a teaching plan for a client with genital herpes. She should include information about

A. acyclovir (Zovirax).
B. penicillin.
C. doxycycline.
D. tetracyclin

单项选择题

A woman in labor shouts to the nurse, "My baby is coming right now! I feel like I have to push!" An immediate nursing assessment reveals that the head of the fetus is crowning. After asking another staff member to notify the physician and setting up for delivery, which nursing intervention is most appropriate

A. Gently pulling at the neonate’s head as it’s delivered.
B. Holding the neonate’s head back until the physician arrives.
C. Applying gentle pressure to the neonate’s head as it’s delivered.
D. Placing the mother in a Trendelenburg position until the physician arrives.

单项选择题

The nurse is teaching a group of women to perform breast self-examination. The nurse should explain that the purpose of performing the examination is to discover

A. cancerous lumps.
B. areas of thickness or fullness.
C. changes from previous self-examinations.
D. fibrocystic masses.

问答题

Directions: The question below is followed by six choices numbered 260-265. If a choice is correct, mark A in the space provided. If a choice is not correct, mark B. Blacken one circle on your answer sheet for each number.
A client is diagnosed with gout. Which foods should the nurse instruct the client to avoid
Liver.

答案： A

问答题

Directions: The question below is followed by six choices numbered 260-265. If a choice is correct, mark A in the space provided. If a choice is not correct, mark B. Blacken one circle on your answer sheet for each number.
A client is diagnosed with gout. Which foods should the nurse instruct the client to avoid
Chocolate.

答案： B

问答题

Directions: The question below is followed by six choices numbered 260-265. If a choice is correct, mark A in the space provided. If a choice is not correct, mark B. Blacken one circle on your answer sheet for each number.
A client is diagnosed with gout. Which foods should the nurse instruct the client to avoid
Sardines.

答案： A

单项选择题

A nurse needs assistance transferring an elderly, confused client to bed. The nurse leaves the client to find someone to assist her with the transfer. While the nurse is gone, the client falls and hurts herself. The nurse is at fault because she hasn’t

A. properly educated this client about safety measures.
B. restrained the client.
C. documented that she left the client.
D. arranged for continual care of the client.

问答题

Directions: The question below is followed by six choices numbered 260-265. If a choice is correct, mark A in the space provided. If a choice is not correct, mark B. Blacken one circle on your answer sheet for each number.
A client is diagnosed with gout. Which foods should the nurse instruct the client to avoid
Cod.

答案： A

问答题

Directions: The question below is followed by six choices numbered 260-265. If a choice is correct, mark A in the space provided. If a choice is not correct, mark B. Blacken one circle on your answer sheet for each number.
A client is diagnosed with gout. Which foods should the nurse instruct the client to avoid
Eggs.

答案： B

单项选择题

The nurse is caring for a 45-year-old male client admitted with a retinal detachment in his left eye. What symptoms would the nurse expect to find during assessment

A. Flashing lights in the visual field.
B. Sudden eye pain.
C. Loss of color vision.
D. Colored halos around lights.

单项选择题

A mother complains to the nurse that her 4-year-old son often lies. What’s the nurse’s best response

A. Let the child know that he’ll be punished for lying.
B. Ask him why he isn’t telling the truth.
C. It’s probably due to his vivid imagination and creativity.
D. Acknowledge him by saying, "That’s a pretend story. "

单项选择题

The nurse is caring for an 85-year-old client. For which important factor directly influencing this client’s mental health should the nurse be most aware

A. The client’s attitude toward life circumstances.
B. The client’s age, education level, social status, and economic level.
C. The number of children and grandchildren in the family and the client’s relationship with them.
D. Grief issues related to loss, role changes, and physical stamin

单项选择题

A psychiatric client who was voluntarily admitted now wishes to be discharged from the hospital, against medical advice. What’s the most important assessment the nurse should make of the client

A. Ability to care for himself.
B. Degree of danger to self and others.
C. Level of psychosis.
D. Intended compliance with aftercar

单项选择题

A client has severe pruritus from hepatitis B. Which of the following nursing measures would best enhance the client’s comfort

A. Use hot water to increase vasodilation.
B. Use cold water to decrease itching sensation.
C. Give tepid water baths.
D. Avoid lotions and creams.

单项选择题

The nurse should anticipate which psychological reactions during the second trimester of pregnancy

A. Self-centeredness and concentration on the behavior and appearance of children.
B. Extroversion and emotional lability.
C. Ambivalence and uncertainty.
D. Dismay over body image and readiness for the end of pregnancy.

单项选择题

The nurse is caring for a client with a fractured left femur. What signs indicate potential fat emboli

A. Increased partial pressure of arterial oxygen (PaO₂), reduced sensation in left leg or foot.
B. Left leg pain, dyspnea.
C. Bradycardia, skin bruises.
D. Cyanosis, decreased PaO₂.

单项选择题

A client on an inpatient psychiatric unit at a community mental health center is pacing the hallway and appears agitated. When the nurse approaches him, he says loudly, "Leave me alone. " What’s the nurse’s best approach

A. Say nothing and pace with the client.
B. Say "You sound upset. I’d like to help. "
C. Say "okay" and walk away.
D. Summon help in case the client becomes aggressiv

单项选择题

The major goal of therapy in crisis intervention is to

A. withdraw from the stress.
B. resolve the immediate problem.
C. decrease anxiety.
D. provide documentation of events.

单项选择题

While admitting a client with pneumonia, the nurse notes multiple bruises in various stages of healing. The client has Alzheimer’s disease and a history of multiple fractures. Legally, the most important action for the nurse to take is to

A. document findings thoroughly.
B. question the client about the bruising.
C. inform appropriate local authorities.
D. tell the client’s physician.

单项选择题

The nurse is teaching a client who has been prescribed allopurinol for the treatment of gout. Which instruction would the nurse give to the client

A. Increase alcohol intake while taking the drug.
B. Avoid foods that are rich in purine.
C. Take aspirin for pain.
D. Take the drug between meals to promote absorption.

单项选择题

Conjunctivitis may be caused by bacteria, viruses, allergens, or irritants. What signs and symptoms differentiate bacterial conjunctivitis from other types

A. Subacute onset, severe pain, and preauricular adenopathy.
B. Recurrent onset, no pain, and clear discharge.
C. Acute onset, moderate pain, and purulent discharge.
D. Acute onset, mild pain, and clear discharg

单项选择题

During afternoon rounds, the nurse finds a male client using a pencil to scratch inside his knee-to-toe cast. The client is complaining of severe itching in the ankle are

a. Which action should the nurse takeA. Allow him to continue to scratch inside the cast with a pencil.B. Give him a sterile metal object to use for scratching instead of the pencil.C. Encourage him to avoid scratching, and obtain an order for diphenhydramine (Benadryl) if severe itching persists.D. Obtain an order for a sedative, such as diazepam (Valium), to prevent him from scratchin

单项选择题

The parents of a 4-year-old with sickle cell anemia tell the nurse that they would like to have other children, but they’re concerned about passing sickle cell anemia on to them. Which health care team member would be the most appropriate person for the nurse to refer them to

A. Clergy.
B. Social worker.
C. Certified nurse midwife.
D. Genetic counselor.

单项选择题

A client is 22 weeks pregnant with her first child. Her weight gain is normal, but she complains of constipation. What’s the most effective recommendation the nurse can make

A. "Take a mild laxative daily. "
B. "Increase intake of fluids and high-fiber foods. "
C. "Relax when trying to move the bowels. "
D. "Start a strenuous exercise program. "

单项选择题

A mother brings her 15-month-old male child to the ambulatory care clinic for well-child care. He’s crying and pulling at his left ear, which appears erythematous. Which of the following actions should the nurse take first

A. Ask the mother to leave the room because her anxiety is increasing the child’s distress.
B. Examine the ear with the child supine because this aids visualization of the tympanic membrane.
C. Examine the affected ear last in order to minimize distress early in the examination.
D. Examine the left ear first in order to assess what may be physically wrong with the chil

A 21-year-old primigravida has an emergency cesarean delivery under general anesthesia because of unanticipated fetal distress. One postoperative intervention is to assist her to turn every 2 hours. Which of the following conditions is this intervention intended to prevent

你可能感兴趣的试题

The mother of a 1B-year-old girl calls the emergency department, suspecting her daughter’s abdominal pain may be appendicitis. In addition to pain, her daughter has a fever of 100°F (37.8℃) and has vomited twice. What should the nurse tell the mother

A 69-year-old client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct

A local elementary school has requested scoliosis screening for its students from the hospital’s community outreach program. The school should be informed that

The nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which of the following findings should the nurse consider abnormal

A 23-year-old primigravida client has a normal vaginal delivery. The next day, the nurse assesses the client’s lochia for color, amount, and the presence of clots. Which of the following best describes lochia on the first postpartum day

The child with rheumatic fever must have his heart rate measured while awake and while sleeping. Why are two readings necessary

A nurse instructs a prenatal class about the importance of doing Kegel exercises frequently. Kegel exercises help to

The nurse is planning care for a female client diagnosed with acute hepatitis A virus (HAV). What’s the primary mode of transmission for HAV

A nurse is reviewing prenatal care with a client. Which of the following statements by the client best expresses adequate understanding of nutritional needs during pregnancy

Which intervention has the highest priority when providing skin care to a bedridden client

A pregnant client is taking folic acid. During prenatal teaching, which of the following foods would the nurse recommend as high in folic acid

The mother of a hospitalized 3-year-old girl expresses concern because her daughter is wetting the bed. What should the nurse tell her

A client with antisocial personality disorder refuses to take a shower for 3 days. Which response by the nurse is best

The physician prescribes a monoamine oxidase (MAO) inhibitor for a client. Which of the following nursing diagnostic categories would be most appropriate to focus on during client teaching

The nurse is planning care for a client after a tracheostomy. One of the client’s goals is to overcome verbal communication impairment. Which of the following interventions should the nurse include in the care plan

The nurse is caring for a 10-year-old child with rheumatic fever. While obtaining the child’s health history from the mother, the nurse should ask if the child recently had which illness

During a routine follow-up examination, the nurse updates the client’s medication history. The client currently receives prednisone therapy. Concomitant use of an agent from which of the following classes could increase the risk of peptic ulcer disease

Several children in a kindergarten class have been treated for pinworm. To prevent the spread of pinworm, the school nurse meets with the parents and explains that they should

A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body

The nurse is caring for a comatose client who has suffered a closed head injury. What intervention should the nurse implement to prevent increases in intracranial pressure (ICP)

The nurse is developing a care plan for a client in her 34th week of gestation who is experiencing premature labor. What nonpharmacologic intervention should the plan include to halt premature labor

The nurse is planning care for a client admitted to the psychiatric unit with a diagnosis of paranoid schizophreni

The nurse is providing care for a client who underwent mitral valve replacement. The best example of a measurable client outcome goal is to

A child is sent to the school nurse because, according to his teacher, he’s constantly scratching his head. When the nurse assesses his hair and scalp, she finds evidence of lice. What did she probably see

While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of what assessment parameters

A person’s psychosocial needs during the dying process of a relative may include

Immediately after a 1-year-old client returns from a cardiac catheterization, the nurse notes that the pulse distal to the catheter insertion site is weak. The nurse should take which of the following actions

A child with type 1 diabetes mellitus develops diabetic ketoacidosis and receives a continuous insulin infusion. Which condition represents the greatest risk for this child

The nurse is teaching breast self-examination (BSE) to a college student. The nurse knows that the client understands the best time to examine her breasts when she says:

A 21-year-old primigravida has an emergency cesarean delivery under general anesthesia because of unanticipated fetal distress. One postoperative intervention is to assist her to turn every 2 hours. Which of the following conditions is this intervention intended to prevent

A 58-year-old client on a mental health unit has lost control, despite having been properly medicated, and is threatening to harm himself and others. He has been placed in four- point restraints. Which nursing measure should be taken next

The nurse is developing a teaching plan for a client with diabetes mellitus. A client with diabetes mellitus should

The nurse is caring for a neonate with congenital clubfoot. The child has a cast to correct the defect. Before discharge, what should the nurse tell the parents

A client who has sustained a head injury is to receive mannitol (Osmitrol) by IV push. In evaluating the effectiveness of the drug, the nurse should expect to find

The nurse is giving home care instructions to a client who just had a cataract removed and an intraocular lens implanted. What should the nurse tell the client

The nurse is teaching a group of patient-care attendants about infection-control measures. The nurse tells the group that the first line of intervention for preventing the spread of infection is

Which intervention will best help to prevent a client from falling

The nurse provides care for a client with chronic obstructive pulmonary disease (COPD). Administering high doses of oxygen may produce what result

A client with bicuspid aortic valve has severe stenosis and is scheduled for valve replacement. While teaching the client about his condition and upcoming surgery, the nurse shows him a heart illustration. Which valve will be replaced

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

The physician inserts a chest tube into a client to treat a pneumothorax. The tube is connected to water-seal drainage. The nurse can prevent chest tube air leaks by

The nurse is caring for a client in the manic phase of bipolar disorder who is ready for discharge from the psychiatric unit. As the nurse begins to terminate the nurse-client relationship, which client response is most appropriate

A female client is being treated for genital herpes. The client should receive teaching on the

A neonate of a client with type 1 diabetes mellitus is at high risk for hypoglycemi

A first-time mother-to-be is in the labor room, her husband at her bedside. The client states that her contractions began 6 hours ago. Which of the following assessment findings would confirm that the client is in true labor

The nurse is speaking to grieving parents after a sudden infant death syndrome (SIDS) death. What should the nurse emphasize to the parents

Hyperthyroidism is caused by increased levels of thyroxine in blood plasm

A client on an inpatient psychiatric unit at a community mental health center is pacing up and down the hallway. The client has a history of aggression. Which response by the nurse would be best when approaching the client

The nurse is providing care for a pregnant client with gestational diabetes. The client asks the nurse if her gestational diabetes will affect her delivery. The nurse should know that

The nurse is providing breast cancer education at a community facility. The American Cancer Society recommends that women get mammograms

A client in the manic phase of bipolar disorder constantly belittles other clients and demands special favors from the nurses. Which nursing intervention would be most appropriate for this client

A 2-year-old client returns from surgery after a bowel resection as a result of Hirschsprung’s disease. A temporary colostomy is in place. Which immediate postoperative nursing intervention takes priority

A 2-week postpartum client inquires about alcohol use during lactation. She tells the nurse she has heard that a small glass of wine or beer before nursing will increase her milk supply and be good for the baby. What’s the nurse’s best response

The nurse is assessing a client diagnosed with appendicitis. Which of the following signs or symptoms should the nurse expect to find

A child, age 3, is brought to the emergency department in respiratory distress caused by acute epiglottiditis. Which clinical manifestations should the nurse expect to assess

The nurse is providing preoperative care to a client scheduled for an appendectomy. Which statement regarding pain control is most appropriate

The nurse is developing a teaching plan for a client diagnosed with osteoarthritis. To minimize injury to the osteoarthritic client, the nurse should instruct the client to

The nurse in the emergency department is assessing a 64-year-old client experiencing substernal chest pain. The client’s electrocardiogram shows evidence of myocardial ischemi

What is the normal pH range for arterial blood

The nurse is caring for a client who is on ritodrine therapy to halt premature labor. What condition indicates an adverse reaction to ritodrine therapy

A mother brings her 5-month-old female child to the pediatric clinic. The child has had recurrent middle-ear infections since she was 3 months old. Which of the following areas is most important to assess

An 8-month-old boy is admitted to the pediatric unit following a fall from his high chair. The child is awake, alert, and crying. The nurse should know that a brain injury is more severe in children because of

The nurse is working in a support group for clients with acquired immunodeficiency syndrome (AIDS). Which point is most important for the nurse to stress

A 13-year-old visits the school nurse because he’s experiencing back pain, fatigue, and dyspne

The nurse is caring for a bedridden, elderly adult. To prevent pressure ulcers, which intervention should the nurse include in the care plan

A hospitalized client taking 30 mg of tranylcypromine (Parnate) twice per day complains of a stiff neck and headache. Which action would be best for the nurse to take

Two family members are arguing in a child’s room. They start to hit each other and the child is crying. What’s the most appropriate nursing action

The nurse is assessing a pregnant woman in the clinic. In the course of the assessment, the nurse learns that this woman smokes one pack of cigarettes per day. The first step the nurse should take to help the woman stop smoking is to

The nurse is about to administer a medication to a client with whom the nurse is unfamiliar. To verify the client’s identity, the nurse should

When caring for a client with the nursing diagnosis Impaired swallowing related to neuromuscular impairment, the nurse should

The nurse is teaching a female client with osteoporosis about her prescribed diet. Which of the following foods is the best source of calcium

What laboratory finding is the primary diagnostic indicator for pancreatitis

For a client with bulimia, which assessment is least important in the care plan

The nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is

The nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice

The nurse is planning care for a 10-year-old child in the acute phase of rheumatic fever. Which activity would be most appropriate for the nurse to schedule in the care plan

The nurse is developing a teaching plan for a client with genital herpes. She should include information about

The nurse is teaching a group of women to perform breast self-examination. The nurse should explain that the purpose of performing the examination is to discover