单选题A 10-month-old girl with bronchitis is taken out of the 30% oxygen tent for breakfast because she refuses to eat unless in a high chair. During the feeding, the nurse notes that the child's respiratory rate has increased, she is becoming more irritable, and she is using accessory muscles to breathe. Which of the following should be the nurse's first action? A. Perform postural drainage then complete the feeding. B. Suction the child's nose with a bulb syringe. C. Discontinue the feeding and place the child back in the tent. D. Assess the pulse rate and respirations and notify the physician.
单选题A client undergoes extracorporeal shock wave lithotripsy (ESWL) to break up and remove renal calculi. Which of the following nursing measures is appropriate for the postoperative care of this client? A. Maintain client on strict bed rest for 48 hours after the procedure. B. Instruct client to anticipate a decrease in urinary output. C. Instruct client to anticipate hematuria for about 24 hours after the procedure. D. Limit fluid intake to 1000 mL/day until all stone fragments have been passed.
单选题The nurse is teaching parents how to reduce the spread of impetigo. The nurse should encourage parents to A. teach children to cover mouths and noses when they sneeze. B. have their children immunized against impetigo. C. teach children the importance of proper hand washing. D. isolate the child with impetigo from other members of the family.
单选题The nurse is giving instructions to a client who is going home with a cast on his leg. Which point is most critical? A. Using crutches properly. B. Exercising joints above and below the cast, as ordered. C. Avoiding walking on a leg cast without the physician's permission. D. Reporting signs of impaired circulation.
单选题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.
单选题Following coronary artery bypass grafting, a client begins having chest "fullness" and anxiety. The nurse suspects cardiac tamponade and prints a lead Ⅱ electrocardiograph (ECG) strip for interpretation. In looking at the strip, the change in the QRS complex that would most support her suspicion is A. narrowing complex. B. widening complex. C. amplitude increase. D. amplitude decrease.
单选题The immobile adolescent with a recent fractured femur suddenly complains chest pain, dyspnea, diaphoresis, and tachycardia. Which of the following would the nurse suspect? A. Atelectasis. B. Pneumonia. C. Pulmonary edema. D. Pulmonary emboli.