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.
单选题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.
单选题The client is taking lithium (Lithobid). Which instruct should the nurse give to the client? A. Drink at least six to eight glasses of water per day and to avoid caffeine. B. Limit the use of salt in his diet. C. Discontinue medicine when feeling better. D. Increase the amount of sodium in his diet.
单选题The physician prescribes several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question
单选题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 malaise.
单选题Aclienthospitalizedwithapneumothoraxhasthefollowingarterialbloodgas(ABG)analysis:pH,7.19;partialpressureofarterialcarbondioxide(PaCO2),63mmHg;and,22mEq/L.Achesttubewasinsertedandoxygenadministeredat4L/minbynasalcannula.Onehouraftertheinitiationoftreatment,ABGanalysisreveals:pH,7.28;PaCO2,52mmHg;and,22mEq/L.ThischangeinABGanalysisindicatesA.respiratoryalkalosis.B.impendingrespiratoryarrest.C.theneedforintubation.D.improvedrespiratorystatus.
单选题The nurse is caring for a 35-year-old multipara who delivered a full-term infant by cesarean delivery because of a breech presentation. The nurse recognizes that which of the following events would be the most important contribution to preventing thromboembolism? A. Increasing oral fluid intake. B. Providing oxygen therapy. C. Encouraging frequent ambulation. D. Administering pain medications as needed.
单选题The nurse has assisted a multigravida with a precipitous delivery of a viable neonate in a local grocery store. Because a precipitous delivery can lead to decreased uterine tone, which of the following nursing actions would help to prevent this complication? A. Place the neonate on the client's fundus. B. Place the mother in a supine position. C. Encourage the mother to breast-feed the infant. D. Massage the client's fundus continuously.
单选题When caring for a client with a 3-cm stage 1 pressure ulcer on the coccyx, which of the following actions can the nurse institute independently? A. Using a povidone-iodine wash on the ulceration three times per day. B. Using a normal saline solution and applying a protective dressing as necessary. C. Applying an antibiotic cream to the area three times per day. D. Massaging the area with an astringent every 2 hours.
单选题Which of the following findings would indicate that the goals for total parenteral nutrition (TPN) are being achieved for the client? A. Serum glucose level of 96. B. Weight gain of 0.5 pounds/day. C. Urine negative for glucose. D. Serum potassium level of 4 mEq/L.
单选题The client with cirrhosis is put on a sodium-restricted diet and a diuretic. The nurse would expect to administer a potassium-sparing diuretic. Which of the follow is a potassium-sparing diuretic? A. Furosemide (Lasix). B. Spironolactone (Aldactone). C. Hydrochlorothiazide (HydroDIURIL). D. Ethacrynic acid (Edecrin).
单选题Following a unilateral adrenalectomy, the nurse would assess for hyperkalemia shown by which of the following? A. Muscle weakness. B. Tremors. C. Diaphoresis. D. Constipation.
单选题Theophylline ethylenediamide is administered to a client with COPD. The nurse knows that the medication is for which of the following purpose
单选题A client has been diagnosed with type A hepatitis. What special precautions should the nurse take when caring for this client? A. Put on a mask and gown before entering the client's room. B. Wear gloves and a gown when removing the client's bedpan. C. Prevent the droplet spread of the organism. D. Use caution when bringing food to the client.
单选题When preparing to give a neonate the first feeding by nipple, the nurse uses a 5 mL feeding of sterile water first. Which of the following is the reason for doing so? A. Ensure that the neonate has the energy to take oral feedings. B. Ensure that the mother will be able to feed the neonate. C. Ascertain the patency of the neonate's esophagus. D. Determine if the neonate can retain the feeding.
单选题The development of laryngeal cancer is most clearly linked to which of the following factors? A. High-fat, low-fiber diet. B. Alcohol and tobacco use. C. Low socioeconomic status. D. Overuse of artificial sweeteners.
单选题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. "
单选题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.
单选题When assessing the fetal heart rate tracing, the nurse becomes concerned about the fetal heart rate pattern. In response to the loss of variability, the nurse repositions the client to her left side and administers oxygen. These actions are likely to improve which of the following? A. Fetal hypoxia. B. Maternal comfort. C. The contraction pattern. D. The status of a trapped cord.