阶段测试3
b
Following a group therapy session, a client approaches a nurse and verbalizes a need for seclusion because of uncontrollable feelings. the most appropriate nursing action would be to A inform the client that seclusion has not been prescribed. B obtain an informed consent. C call the client `s family D place the client in seclusion immediately.
a
The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure? A side-lying, with legs pulled up and head bent down onto chest B side-lying, with the pillow under the hip C prone, in slight Trendelenburg's position D prone, with a pillow under the abdomen
b
The client with myasthenia gravis having difficulty speaking the speech is dysarthritic and has a nasal tone the nurse would avoid using which of the following communication strategies when working with this client ? A Repeating a what the client said to verify the message B encouraging the client to speak quickly C using a communication board when necessary D asking yes and no questions when able
a
The client with pheochromocytoma is scheduled for surgery and says to the nurse, "I `m not sure that surgery is the best thing to do ?" the most appropriate response by the nurse is which of the following ? A "you have concerns about the surgical treatment for your condition." B "there is no reason to worry .your doctor is a wonderful surgeon." C "you are very ill .your physician has made the corrent decision." D "I think you are making the right decision to have the surgery."
d
The community health nurse visits a client at home .the client states, " I haven`t slept at all the last couple of nights." Which response by the nurse illustrates the most therapeutic communication technique for this client? A " go on..... B "sleeping? C " the last couple of nights" D "you`ve having difficulty sleeping?
d
The family of a client with a spinal cord injury rushes to the nursing station saying that the client needs immedicate help. On entering the room, the nurse notes that the client is diaphoretic with a flushed face and neck and complains of a severe the headache. The pulse rate is 40 beats per minute and blood pressure is 230/100 mm Hg. The nurse acts quickly,knowing that the client is experiencing A spinal shock B malignant hypertension C pulmonary embolism D autonomic dysreflexia
c
The mother arrived at the clinic with her 3-year -old child .the mother tells the nurse that the child has had a fever and a cough for the past 2 days and that this morning the child began to wheeze.viral pneumonia is diagnosed.based on the diabosis ,the nurse anticipates that which of the following will be a component of the treatment plan? A orally administered antibiotics B hospitalization and intravenously administered antibiotics. C supportive treatment D intravenous fluid administration
c
The nurse completes the initial assessment of a client admitted to the mental health unit .the nurse analyzes the data obtained on assessment and determines that which of the following presents a priority concern? A the presence of bruises on the client`s body B the client`s report of not eating or sleeping C the client`s report of suicidal thoughts D the significant other`s disapproving of the treatment
a
The nurse has interted a nasogastric tube to the level of the oropharynx and has repositioned the client`s head in a flexed-forward position .the client has been asked to begin swallowing. the nurse starts slowly to advance the nasogastric tube with each swallow. the client begins to cough, gag ,and choke .which nursing action would least likely result in proper tube insertion and promote client relaxation? A continuing to advance the tube to the desired distance. B pulling the tube back slightly C checking the back of the pharynx using a tongue blade and flashlight D instructing the client to breathe slowly and take sips of water
b
The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client about 24 hours following a laparotomy .which of the following findings would indicate the need to notify the physician? A light yellowish brown drainage B dark red drainage C dark brown drainage D green-tinged drainage
c
The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis .which of the following laboratory results would the nurse expect to note if the client indeed has appendicitis? A leukopenia with a shift to the right B leukocytosis with a shift to the right. C leukocytosis with a shift to the left. D leukopenia with a shift to the left .
b
The nurse is caring for a client receiving bolus feedings via levin-type nasogastric tube .as the nurse is finishing the feeding ,the client asks for the bed to be positioned falt to sleep .the nurse understands that most appropriate position for this client at this time is which of the following 、 A.head of the bed flat with the client in the supine position for at least 30minutes. B head of the bed elevated 30to 45 degree with the client in the right lateral position for 60 minutes C head of the bed elevated 45 to 60 degree with the client in the supine position for 9o minutes D.head of the bed in semi-fowler position with the client in the left lateral position for 60 minutes
b
The nurse is caring for a client who is on strict bedrest .the nurse is develops a plan of care and develops goals related to the prevention of deep vein thrombosis and pulmonary emboli .which of the following nursing actions would be most helpful to prevent these disorders from developing? A applying a heating pad to the lower extremities. B encouraging active range of motion exercises C placing a pillow under the knees D restricting fliuds
d
The nurse is caring for a client whose magnesium level is 3.5mg/dl which assessment sign symptom would the nurse most likely expect to note in the client based on this magnesium level? A tetany B twitches C positive trousseau`s sign D loss of deep tendon reflexes
c
The nurse is caring for a client with a nasogastric tube connected to continuous suction. during the assessment ,the nurse observes that the client is mouth breathing has dry mucous membranes, and has a foul breath odor .in planning care ,which of the following would be most appropriate to maintain the integrity of this client`s oral mucosa? A offer small sips of water frequently B encourage sucking on sour ,hard candy C brush teeth frequently;use mouthwash and water D use lemon-glycerin swabs to provide oral hygiene.
d
The nurse is developing a plan of care for the client experiencing anxiety following the loss of a job .the client is verbalizing concerns regarding the ability to meet role expectations and financial obligations .the most appropriate nursing diagnosis for this client is A dysfunctional family process. B disturbed thought process. C risk for anxiety D ineffective coping.
c
The nurse is employed in a prenatal clinic and is performing prenatal assessments on clients who are in their first trimester of pregnancy .the nurse is concerned with identifying clients who may be at risk for the development of postpartum complications. Which of the following clients would be least likely at risk for the development of thromboembolitic disorders in the postpartum period ? A a 39-year-old woman who reports that she smokes. B a 37 -year -old woman in her fourth pregnancy who is overweight. C a 26 -year-old woman with a family history of thrombophlebitis. D a woman who is 22years old with a first pragnancy and who states that oral contraceptives taken in the past have caused thrombophlebitis.
a
The nurse is evaluating the respiratory outcomes for the client with Guillian-barre syndrome. the nurse would evaluate that which of the following is the least optimal outcome for the client? A adventitious breath sounds B spontaneous breathing C oxygen saturation 98% D vital capacity within normal range
b
The nurse is monitoring the chest tube drainage system in a client with a chest tube .the nurse notes intermittent bubbing in the water seal compartment .which of the following is the most appropriate action? A change the chest tube drainage system. B.document the findings Ccheck for an airleak. D notify the physician.
a
The nurse is performing an initial assessment on a large -for-gestational-age newborn infant .which physical assessment technique would the nurse perform to assess for the evidence of birth trauma? A palpate the clavicles for a fracture B auscultate the heart for a cardiac defect C blanch the skin for evidence of jaundice D perform the ortolani maneuver for hip dislocation.
b
The nurse is planning care for the client with hemiparesis of the right arm and leg. The nurse incorporates in the care plan to place objects A within the client's reach on the right side B within the client's reach on the left side C just out of the client's reach on the right side D just out of the client's reach on the left side
c
The nurse is preparing the client for the termination phase of the nurse -client relationship .the nurse prepares to implement which nursing task that is most appropriate for this phase? A identifying expected outcomes B planning short-term goals C making appropriate referrals D developing realistic solutions
c
The nurse is preparing to discontinue a client`s nasogastric tube .the client is positioned properly, and the tube has been flushed with 15ml of air to clear secretion. before removing the tube ,the nurse makes which statement to the client? A " take a deep breath when I tell you and breathe normally while I remove the tube." B " take the deep breath when I tell you and bear down while I remove the tube." C "take a deep breath when I tell you and slowly exhale while I remove the tube." D "take a deep breath when I tell you and hold it while I remove the tube."
b
The nurse is preparing to perform an otoscopic examination on an adult client .the nurse does which of the following to perform this examination? A pulls the pinna up and back before inserting the speculum B pulls the earlobe down and back before inserting the speculum C uses the smallest speculum available to decrease the discomfort of the examination D tilts the clients head forward and down before insering the speculum
b
The nurse is providing care to a client admitted to the hospital with a diagnosis of acute anxiety disorder. The nurse is conversing with the client .the client says to the nurse , " I have a secret that I want to tell you .you won`t tell anyone about it ,will you? A "no I won`t tell anyone. B "I can`t promise to keep a secret C if you tell me the secret ,I will tell it to your doctor." D" if you tell me the secret, I will need to document it in your record
d
The nurse is working with a client who has sought counseling after trying to rescue a neighbor involved in a house fire .in spite of the client`s efforts, the neighbor died. which action does the nurse engage in with the client during the working phase of the nurse-client relationship? A exploring the client `s potential for self-harm B exploring about the client `s perception or appraisal of the neighbor`s death C inquiring about the client`s perception or appraisal of the neighbor`s death D inquiring about and examining the client`s feelings that may block adaptive coping
a
The nurse notes that the infant with a diagnosis of hydrocephalus has a head that is heavier than the average infant .the nurse determines that special safety precautions are need when moving the infant .which statement would the nurse include in the discharge teaching with the parents to reflect this safety need? A "when picking up your infant, support the infant `s neck and head with the open palm of your hand. B feed your infant in a side-lying position. C place a helmet on your infant when in bed.' D hyperextend your infant `s head with a rolled blanket under the neck area."
b
The nursing has administered about half of the enema solution when the client complains of pain and cramping .which nursing action is the most appropriate? A raise the enema bag so that the solution can be completed quickly. B clamp the tubing for 30 seconds and restart the flow at a slower rate. C reassure the client and continue the flow D diacontinue the enema and notify the physician
d
The supervisor reprimands the nurse in charge of the nursing unit because the charge nurse has not adhered to the unit budget .later that afternoon ,the charge nurse accuses the nursing staff of wasting supplies. This behavior is an example of A denial B repression C suppression D displacement.
d
A client who has a gastrostomy tube for feeding refuses to participate in the plan of care, will not make eye contact, and dose not speak to the family or visitors. the nurse assess that this client is using which type of coping mechanism? A self -control B problem-solving C accepting responsibility D distancing
c
A community health nurse is working with disaster relief following a tornado .the nurse`s goal with the overall community is to prevent as much injury and death as possible from the uncontrollable event .finding safe housing for survivors, providing support to families ,organizing counseling, and securing physical care when needed are examples of which type of prevention? A the primary level of prevention B the secondary level of prevention C the tertiary level of prevention D aggregate care pervention
a
A pregnant client is seen in the health care clinic and asks the nurse what causes the breasts to change in size and appearance during pregnancy.the nurse plans to base the response on which of the following ? A the breast changes are due to the secretion of estrogen and progesterone. B the breasts become stretched because of the weight gain. C the increased metabolic rate cause the breasts to become larger. D cortisol secreted by the adrenal glands play a factor in increasing the size and appearance of the breasts.
d
A transcutaneous electrical nerve stimulation is prescribed for a client with pain, and the nurse instructs the client about the purpose of the transcutaneous electrical nerve stimulation unit .which statement by the client indicates the need for further instructions? A "electrodes are attached to the skin." B the unit relieves pain C " the unit will reduce the need for analgesics." D "hospitalization is required because the unit is not portable."
a
An 85-year-old client is hospitalized for a right fracture hip. during the postoperative period,the client`s appetite is poor and the client refuses to get out of bed .which nursing statement would be most appropriate to make to the bone.' A "it is important for you to get out of bed so that calcium will go back into the bone." B "we need to increase your calcium intake because you are spending too much time in bed." C "we need to give you iodine so that it will help in hemoglobin synthesis." D "you need to remenber to turn yourself in bed every two hours to keep from getting so stiff."
a
Methenamine mandelate (mandelamine) is prescribed for the client a gram-positive urinary tract infection .which of the following conditions ,if noted in the client`s record ,would alert the nurse to question the order for this prescribed medication ? A cirrhosis of the liver B diabetes mellitus C peripheral vascular disease D hypothyroidism
d
The 32-year -old female client has a history of fibrocystic disorder of the breasts. the nurse interviewing the client asks whether the breast lumps are more noticeable A in the spring months B in the autumn. C after menses D before menses.
c
The nurse caring for a client with addison`s disease would expect to note which of the following on assessment of the client ? A obesity B. edema C hypotension D.hirsutism
d
.A client with a small-bowel obstruction asks the nurse to explain the purpose of the nasogastric tube and continuous gastric suction. after the teaching is completed ,the nurse determines that the client understands if the client states that the purpose of the continuous gastric suction is to A provide nourishment B relieve the bronchi of mucus C withdraw gastric contents for laboratory analysis. D remove gas and fluids from the stomach and intestine.
b
.Levothyroxine (synthroid) is prescribed for a client diagnosed with hypothyroidism. the nurse reviews the client `s record and notes that the client presently is taking warfarin(coumadin).the nurse contacts the physician, anticipating that the physician will prescribe which of the following ? A an increased dosage of warfarin B a decrease dosage of warfarin C an increase dosage of levothyroxine D a decrease dosage of levothyroxine.
d
An inebriated client is brought to the emergency department by the local police. The client is told that the physician will be in t see the client in about 30 minutes. The client because loud and offensive and wants to be seen by physician immediately .the most appropriate nursing intervention is which of the following? A attempt to talk with the client to deescalate behavior. B watch the behavior escalate before intervening C inform the client that the client will be asked to leave if the behavior continues. D offer to take the client to an examination room until the client can be treated.
b
Cinoxacin(cinobac), a urinary antiseptic ,is prescribed for the client .the nurse checks the client`s record knowing that this medication is used with caution In which of the following disorders? A hepatic disease B renal disease C diabetes insipidus D congestive heart failure
a
Cromolyn sodium (intal) is prescribed for the client with alleric asthma. the nurse understands that this medication acts to A inhibit the release of mediators from mast cells after exposure to an antigen. B promote the migration of eosinophils into the inflammatory site. C increase the number of eosinophils. D dilate the bronchi.
b
During the termination phase of the nurse -client relationship ,the clinic nurse observes that the client continuously demonstrates bursts of anger.the most appropriate interpretation of the behavior is that client A requires further treament and is not ready to be discharged. B is displaying typical behaviors that can occur during termination C needs to be admitted to the hospital'. D needs to be referred to the psychiatrist as soon as possible.
c
The cient with heart disease is provided instructions regarding a low-fat diet .the nurse determines that the client understands the diet if the client states that a food item to avoid is A apples. B oranges. C avocado. D cherries.
a
The client has an impairment of cranial nerve 2 .specific to this impairment the nurse would plan to do which of the following to ensure client safety? A Provide a clear path for ambulation without obstacles B Test the temperature of the shower water C Speak loudly to the client D Check the temperature of the food on the dietary tray
d
The client is scheduled for an upper gastrointestinal endoscopy. which assessment is essential to include in the plan of care following the procedure? A monitoring for rectal bleeding B assessing pulses C monitoring urine output D assessing for the presence of the gag reflex
a
The client recovering from a head injury is arousable and participating in care .The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observed the client doing which of the following activities? A exhaling during repositioning B isometric exercises C blowing nose D coughing vigorously
a
The nurse provides instructions to a malnourished client regarding iron supplementation during pregnancy .which statement if made by the client would indicate an understanding of the instructions? A "the iron is best absorbed if taken with orange juice." B "meat dose not provide iron and should be avoided." C "iron supplements will give me diarrhea.; D "my body has all the iron it needs and I don`t need to take supplements."
b
The client who suffered a crush injury to the leg has a highly positive urine myoglobin level. the nurse assess this particilar client carefully for signs of A cerebrovascular accident. B acute tubular necrosis C respiratory failure D myocardial infarction.
d
A 4 year - lod child is diagnosed with otitis media.the mother asks the nurse about the causes of this illness .the nurse responds ,knowing that which of the following is an unassociated risk factor related to otitis media? A household smoking B bottle-feeding C exposure to illness in other children D a history of urinary tract infections
c
A client arrives in the emergency room in a crisis state, the client demonstrates signs of profound anxiety and is unable to focus on anything but the object of the crisis and the impact on self. the initial nursing assessment would focus on A the object of the crisis B the presence of support systems C the physical condition of the client. D the client`s coping mechanisms
c
The client is diagnosed with glaucoma. which of the following identifies a risk factor associated with this eye disorder? A a history of migraine headaches B frequent urinary tract infections C cardiovascular disease D frequent upper respiratory infections
c
The client is return to the nursing unit following thoracic surgery with chest tubes in place .during the first few hours postoperatively, the nurse assesses for drainage and expects to note that it is A serous B serosanguinous C bloody D bloody with frequent small clots
c
A nurse enters a client `s room, and the client is demanding release from the hospital .the nurse reviews the client`s record and notes that the client was admitted 2 days ago for treatment of an anxiety disorder and that the admission was a voluntary admission. which of the following actions will the nurse take? A tell the client that discharge is not possible at this time . B call the client`s family C contact the physician. D persuade the client to stay a few more days.
a
The client seen in the health care clinic has tested positive for gonorrhea .the nurse anticipates that which medication will be precribed for the client based on this finding ? A ceftriaxone(pocephin) B penicillin G benzathine(bicillin) C acyclovir(zovirax) D azithromycin(zithromax)
880
A nurse is calculating a client`s fluid intake for an 8-hour period .the client drank 8 oz of tea and 4 oz orange juice for breakfast, 4oz of water at 10am and 1pm when taking his medications,and 6oz of iced tea at lunch ,at 8 am and again at 2 pm ,the client received his antibiotics intravenously in 50ml of narmal saline what is the client`s total intake in milliliters? Answer_______ml__
c
A nasogastric tube has been inserted into a client, and the physician prescribes that the tube be attached to intermittent suction. The nurse attaches the suction, noting that the pressure should not exceed A 10mmhg B 20mmhg C 25 mmhg D 30mmhg
1342
A client in the labor room delivers a 7-lb girl. the obstetrician hands the newborn infant to the delivery room nurse .prioritize and number the nursing actions in caring for the newborn infant in the order in which they would be performed .(number 1 would indicate the first action.) A performs an apgar score B checks the newborn infant`s temperture C hands the newborn infant to the father D dries the infant
a
A client is seen in the health care clinic and is diagnosed with mild anemia .the anemia is believed to result from the menstrual period. the woman asks the nurse how much blood is lost during a menstrual period.the nurse plans to base the response on which of the following amounts of blood lost during this time? A 40ml B 60ml C 80ml D 100ml
b
The emergency room nurse is caring for a client admitted with diabetic ketoacidosis. the physician prescribes intravenous insulin. the nurse plans to prepare which type of insulin for the client? A NPH B regular C lente D ultralente
