单选题Which assessment would the nurse perform to validate that the membranes are ruptured? A. Observe for a pink, mucus vaginal discharge. B. Test the leaking fluid with nitrazine paper. C. Assess the client's temperature, pulse, and blood pressure. D. Send a urine specimen from the client to be cultured.
单选题Which of the following signs and symptoms would alert the nurse to possible internal bleeding in a client who has undergone pulmonary lobectomy? A. Increased blood pressure and decreased pulse and respiratory rates. B. Sanguineous drainage from the chest tube at a rate of 50 mL per hour during the past 3 hours. C. Restlessness and shortness of breath. D. Urine output of 180 mL during the past 3 hours.
单选题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.
单选题The nurse suspects that a 68-year-old client has digoxin toxicity. The nurse should assess for A. hearing loss. B. vision changes. C. decreased urine output. D. gait instability.
单选题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.
单选题A client who is a gravida 1 para 0 has been admitted to the perinatal admission unit and is in early labor. The client's cervical examination would reveal which of the following? A. 2 cm dilated; 100% effaced at 0 station. B. 4 to 5 cm dilated; 80% effaced at -1 station. C. 2 cm dilated; 50% effaced at +1 station. D. 3 cm dilated; 50% effaced at 0 station.
单选题When Tommy's mother hides his favorite toy under a blanket, he acts as though it no longer exists and makes no attempt to retrieve it. Tommy is clearly in Piaget's stage: A．Sensorimotor B．Preoperational C．Formal operational D．Concrete operational
单选题When caring for children who are sick, who have sustained traumas, or
who are suffering from nutritional inadequacies, the nurse should know the
correct hemoglobin (Hb) values for children. Which of the following
ranges would be inaccurate?
A. Neonates. 10.6 to 16.5.
B. 3 months. 10.6 to 16.5.
C. 3 years. 9.4 to 15.5.
D. 10 years. 10.7 to 15.5.
单选题A client diagnosed with schizoaffective disorder is suffering from schizophrenia with elements of which of the following disorders? A. Thought disorder. B. Amnestic disorder. C. Personality disorder. D. Mood disorder.
单选题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 area. Which action should the nurse take?
A. 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 scratching.
单选题The mother of a 9-month-old asks about adding new foods to his diet. The child is being breast-fed and takes formula and cereal when at the sitter's. Which of the following would the nurse instruct the mother to do? A. Mix new foods with formula or breast milk. B. Mix new foods with more familiar foods. C. Offer new foods one at a time. D. Offer new foods after giving formula or breast milk.
单选题The nurse is providing postoperative care for a client recovering from abdominal surgery. The client is receiving morphine through a client-controlled analgesia pump. Which finding would indicate that the client is obtaining adequate pain relief? A. Awakening several times during the night to redose. B. Respiratory rate of 10 breaths/minute. C. Pain rating of 2 or 3 on a scale of 0 to 10. D. Complaint of itching as an adverse effect of the analgesia.
单选题You are caring for a comatose patient whose primary diagnosis is breast cancer but who has suffered multiple complications and who is now in the end stages of her illness. She has been in the medical intensive care unit for 3 weeks. Her husband tells you that he and his wife often talked about the end of her life and that she was very clear about not wanting aggressive treatment that would merely prolong her dying. You both agree that this seems to be all that therapy is now doing for her. Which of the following orders would you recommend the husband speak to her physician about A．Comfort-measures-only B．Do-not-hospitalize C．Do-not-resuscitate D．Slow-code-only
单选题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（）
单选题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
单选题A term neonate's mother is O-negative, and cord studies indicate that the neonate is A-positive. Which of the following would be least likely if the neonate developed neonate hemolytic disease? A. Lethargy or irritability. B. Poor feeding patterns including vomiting. C. Weight loss greater than 10%. D. Signs of kernicterus.
单选题A client has had a total gastrectomy for gastric cancer. Which one of
the following is the most appropriate expected outcomes about nutrition?
A. The client will learn to self-administer enteral feedings every 4
hours.
B. The client will maintain adequate nutrition through oral or parenteral
feedings.
C. The client will regain any weight lost within 4 weeks of the surgical
procedure.
D. The client will eat three full meals a day without experiencing gastric
complications.
单选题The group of medications most often used in the treatment of schizophrenia is A．Antichoinergics B．Phenothiazines C．Thioxanthenes D．Antidepressants
单选题After a gastrectomy, the client will have a nasogastric tube in place for several days postoperatively. The nurse explains to the client that the nasogastric tube is for which of the following reasons? A. Prevent excessive pressure on suture lines. B. Prevent the development of ascites. C. Provide enteral feedings in the immediate postoperative period. D. Enable administration of antacids to promote healing of the anastomosis.
单选题The employer of a client on the psychiatric unit calls the nursing station inquiring about the client's progress. The nurse doesn't know if the client has given consent to allow the staff to give information out to callers on the phone. Which of the following would be the nurse's best response? A. "I'm not permitted to discuss her progress. " B. "I'll give you the name and telephone number of her physician. " C. "I'll have her call you. " D. "I can't confirm whether your employee is a client here. /