单选题The nurse is developing a plan of care for a client with iron-deficiency anemia. Which of the following would be an appropriate nursing diagnosis of the client? A. Excess fluid volume related to anemia. B. Imbalanced nutrition related to nausea. C. Activity intolerance related to fatigue. D. Impaired home maintenance related to neurological impairment.
单选题Thenurseiscaringfora-year-oldmaleclientwithtetralogyofFallot.Whichassessmentfindingsshouldthenurseexpect?A.Aorticstenosis,atrialseptaldefect,overridingaorta,leftventricularhypertrophy.B.Pulmonaryarterystenosis,intraventricularseptaldefect,overridingaorta,rightventricularhypertrophy.C.Pulmonaryarterystenosis,patentductusarteriosus,overridingaorta,rightventricularhypertrophy.D.Transpositionofthegreatvessels,intraventricularseptaldefect,rightventricularhypertrophy,patentductusarteriosus.
单选题When helping the client who has had a cerebrovascular accident (CVA) learn self-care skills, the nurse should use which of the following interventions to help him learn to dress himself? A. Encourage the client to wear clothing designed especially for people who have had a CVA. B. Dress the client, explaining each step of the process as it is completed. C. Teach the client to put on clothing on the affected side first. D. Encourage the client to ask his wife for help when dressing.
单选题The nurse is administering neostigmine to a client with myasthenia gravis. Which nursing intervention should the nurse implement? A. Give the medication on an empty stomach. B. Warn the client that he'll experience mouth dryness. C. Schedule the medication before meals. D. Administer the medication for complaints of muscle weakness or difficulty swallowing.
单选题A client is brought to the hospital after vomiting bright red blood and is admitted through the emergency department with a diagnosis of bleeding duodenal ulcer. While the client is bleeding, it will be essential for the nurse to assess frequently for signs of early shock. Which one of the following is an important indicator of early shock? A. Tachycardia. B. Dry, flushed skin. C. Increased urine output. D. Loss of consciousness.
单选题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.
单选题A child, age 5, with an IQ of 65 is admitted to the hospital for evaluation. When planning care, the nurse should keep in mind that this child is A. within the lower range of normal intelligence. B. mildly retarded but educable. C. moderately retarded but trainable. D. completely dependent on others for care.
单选题A client is scheduled to have a descending colostomy. He's very anxious and has many questions concerning the surgical procedure, care of a stoma, and lifestyle changes. It would be most appropriate for the nurse to make a referral to which member of the health care team? A. Social worker. B. Registered dietitian. C. Occupational therapist. D. Enterostomal nurse therapist.
单选题A male client with a total hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, he complains of severe pain in the surgical wound. Which action should the nurse take（）
单选题A client with a seizure disorder has been prescribed phenytoin
(Dilantin). Which of the following should the nurse include in the teaching
plan?
A. It will be necessary for the client to take potassium supplements to
prevent hypokalemia.
B. The client should use a soft toothbrush and floss teeth daily.
C. The use of phenytoin can lead to the development of diabetes.
D. It is appropriate to substitute various brands of phenytoin as long as
the dosage is the same.
单选题Which outcome would indicate successful treatment of diabetes insipidus? A. Fluid intake of less than 2,500 mL in 24 hours. B. Urine output of more than 200 mL/hour. C. Blood pressure of 90/50 mmHg. D. Pulse rate of 126 beats/minute.
单选题A client is diagnosed with hyperthyroidism. The nurse should expect clinical manifestations similar to
单选题A client with an incomplete small bowel obstruction is to be treated with a Cantor tube. Which of the following measures would most likely be included in the client's care once the Cantor tube has passed into the duodenum? A. Maintain bed rest with bathroom privileges. B. Advance the tube 2 to 4 inches at specified times. C. Provide frequent mouth care. D. Provide ice chips for the client to suck.
单选题A client who has been using crutches at home for t week reports that he is having trouble using the crutches because his armpits hurt and his fingers tingle. What would be the nurse's most appropriate response? A. "You need to do more arm exercises. It sounds like your muscles need strengthening. " B. "That's normal. As you adjust to the crutches, the discomfort will diminish. " C. "Be sure to take your pain medication before ambulating. That will help your discomfort. " D. "Let me watch you ambulate. Your crutches or technique may need some adjustment. /
单选题A client is experiencing an early postpartum hemorrhage. Which action is inappropriate
单选题The nurse is caring for a toddler in respiratory arrest. The nurse will assist with endotracheal intubation and use an uncurled tube because the
单选题Which one of the following clients is at the greatest risk for aspiration? A. A stroke client with dysarthria. B. An ambulatory client with Alzheimer's disease. C. A 92-year-old client who needs help with activities of daily living (ADLs). D. A client with severe, deforming rheumatoid arthritis.
单选题The family of a patient who has just died requests to be alone with the body and asks for supplies to wash the body. You know that the mortician usually washes the body. Your best response is A．Inform the family that there is no need for them to wash the body since the mortician does this B．Explain that hospital policy forbids their being alone with the deceased patient and that hospital supplies are only to be used by hospital personnel C．Give the supplies but watch the family so that nothing unusual happens D．Provide the requested supplies and ask if this request is linked to their religious or cultural customs and if there is anything else you can do to be of assistance
单选题Which of the following would the nurse do for a 4-year-old girl who has just had a lumbar puncture
单选题The client was admitted with severe head injury resulting from a motor
vehicle accident. The client is presently unconscious. To facilitate
rehabilitation when the client's condition allows, the nurse should
A. maintain limbs in the position of function.
B. apply restraints to arms and legs to control spasms.
C. exercise just the arms as the legs maintain their tone longer.
D. notify physical therapy as soon as the physician orders passive range of
motion.