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单项选择题

The nurse notices that a client’s abdominal wound has eviscerated. Which of the following would the nurse do first

A. Notify the client’s physician immediately.
B. Reinsert the protruding viscera into the abdominal cavity.
C. Place the client in reverse Trendelenburg’s position.
D. Cover the wound with sterile saline-moistened dressings.
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单项选择题

A client is admitted with a diagnosis of delusions of grandeur. This diagnosis reflects the client has a belief that he is

A. highly important or famous.
B. being persecuted.
C. connected to events unrelated to himself.
D. responsible for the evil in the worl
单项选择题

Which of the following discharge instructions should the nurse give the parents of an infant with a temporary colostomy

A. Flush the stoma with tap water at least once a day.
B. Allow the diaper to absorb the colostomy drainage.
C. Give the infant plenty of liquids to drink.
D. Expect the stoma to become dusky red within 2 weeks.
单项选择题

Which of the following would lead the nurse to suspect that a neonate with an infection is developing septic shock

A. Axillary temperature is 99.8°F(37.7℃).
B. Blood pressure is 45/25 mmHg.
C. Heart rate during sleep is 205 beats per minute.
D. Respiratory rate while awake is 32 breaths per minut
单项选择题

The most effective health-promotion measure related to glaucoma that the nurse could teach clients is which of the following

A. Appropriate blood pressure control.
B. Prompt treatment of all eye infections.
C. Avoidance of extended-wear contact lenses by older people.
D. Annual intraocular pressure measurements for people older than 40 years.
单项选择题

For a child receiving steroids in therapeutic doses over a long period, the nurse should pay more attention on which of the following

A. Monitor the child’s serum glucose level.
B. Decrease the child’s ingestion of potassium-rich foods.
C. Give the drug on an empty stomach.
D. Monitor the child’s temperature to assess for infection.
单项选择题

A client with multiple sclerosis has been prescribed baclofen. The nurse teaches the client about the action of the drug. Which of the following is an accurate instruction regarding this drug’s action

A. "Baclofen will decrease your fatigue and help increase your energy levels. "
B. "Baclofen will help relieve the muscle spasms that you have been experiencing. "
C. "It is an antibiotic that will help treat your urinary tract infection. "
D. "Taking this drug will help decrease the visual problems you have been having. "
单项选择题

A client, a gravida 3 para 2 at 35 weeks’ gestation, comes in to the antepartum clinic for a check-up. She has been experiencing backaches after standing all day at her job as a grocery clerk. Which of the following exercise would the nurse suggest to relieve backache

A. The pelvic tilt.
B. Squatting.
C. Stretching.
D. Walkin
单项选择题

Which of the following home regimens should the nurse suggest to relieve itching in children with chicken pox

A. Generous amounts of fine baby powder.
B. Oatmeal preparation baths.
C. Terrycloth towels moistened with hydrogen peroxide.
D. Cool compresses moistened with a weak salt solution.
单项选择题

Which of the following methods would the nurse use to feed an infant after surgical repair of cleft lip

A. Gastric gavage.
B. Intravenous fluids.
C. Rubber-tipped medicine dropper.
D. Bottle with a lamb’s nippl
单项选择题

Which of the following would be best to help prepare a preschool-aged child for an injection

A. Having an older child explain that shots do not hurt.
B. Helping the child to imagine she is in a different place.
C. Giving the child a play syringe and a bandage to give a doll injections.
D. Giving the child a pounding board to encourage expressions of anger.
单项选择题

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.
单项选择题

Which of the following would be most important to teach a client older than 65 years to prevent a recurrence of bacterial pneumonia

A. Change current diet habits.
B. Seek prompt antibiotic therapy for viral infections.
C. Receive prophylactic antibiotic therapy.
D. Obtain annual influenza and pneumococcal vaccines.
单项选择题

When preparing to give a child with insulin-dependent diabetes his dose of regular and NPH humulin insulin, which of the following actions would be most appropriate

A. Taking the premixed insulin out of the refrigerator, then withdrawing the amount into in one syringe.
B. Using two syringes, one for each type of insulin, and giving two injections.
C. Withdrawing the NPH insulin first, then withdrawing the regular insulin into one syringe.
D. Withdrawing the regular insulin first, then withdrawing the NPH insulin into one syring
单项选择题

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.
单项选择题

The nurse is caring for a client who is experiencing sinus bradycardia with a pulse rate of 40 beats/minute. His blood pressure is 80/50 mmHg and he complains of dizziness. Which medication would be used to treat his bradycardia

A. Atropine.
B. Dobutamine (Dobutrex).
C. Bretylium (Bretylol).
D. Lidocaine (Xylocaine).
单项选择题

A client with a history of panic attacks seeks to increase social interaction. Each time the client tries to go to the dayroom, she begins to perspire and becomes short of breath. Which action by the nurse will help ease the client’s feelings of panic

A. Have other clients volunteer to accompany the client.
B. Tell the client she has to overcome her fear.
C. Allow the client to stay in her room.
D. Walk with the client and stay with her while she’s in the dayroom.
单项选择题

What is the nurse’s most important role in caring for a client with a mental health disorder

A. To offer advice.
B. To know how to solve the client’s problems.
C. To establish trust and rapport.
D. To set limits with the client.
单项选择题

During a private conversation, a client with borderline personality disorder asks the nurse to "keep my secret" and then displays multiple self-inflicted, superficial lacerations on the forearms. What is the nurse’s best response

A. "This type of behavior requires you to be on suicide precautions. "
B. "I’m going to tell your physician. Do you want to tell me why you did that"
C. "Tell me what type of instrument you used. I’m concerned about infection. "
D. "Whenever something important occurs in treatment, the team needs to know about it. I’ll have to tell the others, but let’s talk about it first. "
单项选择题

A client reports a severe headache shortly after a lumbar puncture for a myelogram. What would be the nurse’s best response

A. Increase the client’s fluid intake.
B. Administer prescribed antihypertensives.
C. Offer roll lenses to the client.
D. Place cooling packs over the lumbar puncture sit
单项选择题

Which event may trigger pain in the client with trigeminal neuralgia

A. Walking in the mall.
B. Sitting in the sun.
C. Eating lunch.
D. Sleepin
单项选择题

During a shock state, the renin-angiotensin-aldosterone system exerts which effect on renal function

A. Decreased urine output, increased reabsorption of sodium and water.
B. Decreased urine output, decreased reabsorption of sodium and water.
C. Increased urine output, increased reabsorption of sodium and water.
D. Increased urine output, decreased reabsorption of sodium and water.
单项选择题

The nurse preparing to give a child an intramuscular injection chooses to give the injection into the gluteal muscle. The site is acceptable because which of the following reasons

A. The child has been walking for 1 year.
B. The child has small deltoid muscles.
C. The child is older than 2 years.
D. The child weighs more than 25 pounds.
单项选择题

Which of the following nursing diagnoses would be most appropriate for a client newly diagnosed with non-insulin-dependent diabetes mellitus

A. Risk for infection related to newly diagnosed diabetes.
B. Altered nutrition, more than body requirements related to overproduction of insulin.
C. Altered health maintenance related to lack of knowledge of proper foot care.
D. Pain related to elevated blood glucose levels.
单项选择题

The nurse should plan to include which of the following interventions in the plan of care for a child admitted to the hospital with a medical diagnosis of febrile seizure

A. Keep the child supine.
B. Place the child in respiratory isolation and restrict visitors.
C. Keep the room temperature low and bedclothes to a minimum.
D. Place a padded tongue blade at the bedsid
单项选择题

A 35-year-old multigravida at 16 weeks gestation tells the nurse that she has had frequent mood swings during this pregnancy. What would be the nurse’s best suggestion to the client

A. Seek professional counseling.
B. Keep her feelings to herself.
C. Try to avoid fatigue and stress.
D. Decrease her narcissistic behaviors.
单项选择题

The client asks when he can stop taking the eye medication for his chronic open-angle glaucom().

A. Which would be the nurse’s best responseA. "You can stop using the eye drops when your vision improves. "
B. "You Need to use the eye drops only when you has symptoms. "
C. "You can discontinue the eye drops after 2 months of normal eye examinations. "
D. "You must use the eye medication for the rest of his life. "
单项选择题

As part of the respiratory assessment, the nurse observes the neonate’s nares for patency and mucus. Which of the following is the reason that the nurse employs this assessment

A. Neonates are obligate nose breathers.
B. Nasal patency is required for adequate feeding.
C. Problems with nasal patency may cause flaring.
D. A deviated septum will interfere with breathin
单项选择题

For the child experiencing excessive vomiting secondary to pyloric stenosis, the nurse should assess the child for which of the following acid-base imbalances

A. Respiratory alkalosis.
B. Respiratory acidosis.
C. Metabolic alkalosis.
D. Metabolic acidosis.
单项选择题

The nurse notices that a client’s abdominal wound has eviscerated. Which of the following would the nurse do first

A. Notify the client’s physician immediately.
B. Reinsert the protruding viscera into the abdominal cavity.
C. Place the client in reverse Trendelenburg’s position.
D. Cover the wound with sterile saline-moistened dressings.
单项选择题

Which of the following is normal neonate calorie intake

A. 90 to 100 calories per kilogram.
B. 110 to 130 calories per kilogram.
C. 30 to 40 calories per lb of body weight.
D. At least 2mL per feedin
单项选择题

Which nursing diagnosis would be the most appropriate for a client with coronary artery disease (CAD)

A. Ineffective thermoregulation.
B. Impaired gas exchange.
C. Risk for injury.
D. Decreased cardiac output.
单项选择题

A parent reports that his 2-year-old child often fails when running. The nurse interprets this as indicating which of the following as a normal aspect of a toddler’s vision

A. Near-sightedness.
B. Far-sightedness.
C. Binocular vision.
D. Strabismus.
单项选择题

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 cor
单项选择题

Before bowel surgery, the infant is to receive oral neomycin for 3 days. The appropriate pediatric dosage of neomycin sulfate is 10. 3 mg/kg q 4 hours. The infant weighs 15 pounds, 6.4 ounces. Which of the following dosages most closely approximates a safe daily dose

A. 50 mg/day.
B. 150 mg/day.
C. 280 mg/day.
D. 430 mg/day.
单项选择题

Which of the following statements represents a major principle of chronic pain management

A. A physiologic approach is most effective.
B. A psychological approach is most effective.
C. A pharmacologic approach is most effective.
D. A multidisciplinary approach is most effectiv
单项选择题

Which of the following nursing interventions is most important postoperatively for an infant who has received a ventriculoperitoneal shunt

A. Monitoring intake and output.
B. Initiating oral feedings.
C. Allowing the infant to rest undisturbed.
D. Providing age-appropriate diversionary activities.
单项选择题

A client is recovering from a gastric resection for peptic ulcer disease. Which of the following outcomes indicates that the goal of adequate nutritional intake is being achieved 3 weeks following surgery

A. Increases food intake and tolerance gradually.
B. Experiences occasional episodes of nausea and vomiting.
C. Experiences a rapid weight gain within 1 week.
D. Drinks 2000 mL/day of water.
单项选择题

The nurse would teach the client to implement which of the following nasal care measures after the nasal packing is removed

A. Irrigate the nares with normal saline solution daily.
B. Remove old blood from inside the nares with cotton-tipped applicators.
C. Avoid cleaning the nares for at least 2 days.
D. For comfort lubricate the membranes with a water-soluble lubricant.
单项选择题

A 68-year-old woman is admitted to the general surgical unit for removal of a breast mass malignancy. In the presurgical assessment of the client, which of the following choices would be most appropriate for the nurse to ask when assessing her self-concept

A. "Let’s talk about what you’d like to do that you haven’t done. "
B. "List for me your accomplishments and achievements in life. "
C. "Tell me how this breast surgery will make you feel about yourself. "
D. "What does your husband say when he compliments you"
单项选择题

Which information is most important for the nurse to include in a teaching plan for a schizophrenic client taking clozapine (Clozaril)

A. Monthly blood tests will be necessary.
B. Report a sore throat or fever to the physician immediately.
C. Blood pressure must be monitored for hypertension.
D. Stop the medication when symptoms subsid
单项选择题

A client who has been admitted to the emergency room is restless and agitated, has dry mucous membranes, and is complaining of intense thirst. The nurse suspects which of the following electrolyte imbalances

A. Hypokalemia.
B. Hypercalcemia.
C. Hypomagnesemia.
D. Hypernatremi
单项选择题

A school-aged child is admitted to the hospital with newly diagnosed, insulin-dependent diabetes mellitus. On admission his blood sugar is 180 mg/dL. His urine tests negative for ketones. He receives 10 units of regular humulin insulin subcutaneously half hour after admission. What should the nurse do next

A. Carefully regulate an intravenous solution of normal saline and insulin at 2. 5 hours after admission.
B. Encourage the child to drink at least 500 mL of a sugar-free clear liquid 1.5 hours after admission.
C. Begin intravenous administration of 5% dextrose in water 1 hour after admission.
D. Assess the child 2. 5 hours after admission for shakiness, feelings of anxiety, or decreased level of consciousness.
单项选择题

The nurse is developing a plan of care for a client with anorexia nervos().

A. Which action should the nurse include in the planA. Set up a strict eating plan for the client.
B. Encourage the client to exercise, which will reduce her anxiety.
C. Restrict visits with the family until the client begins to eat.
D. Provide privacy during meals.
单项选择题

At what gestational age would a primigravida expect to feel "quickening"

A. 12 weeks.
B. 16 to 18 weeks.
C. 20 to 22 weeks.
D. By the end of the 26th week.
单项选择题

The nurse is changing the subclavian dressing over the catheter insertion site. Which one of the following actions would be appropriate for the nurse to incorporate into the dressing change

A. Place the client in high-Fowler’s position.
B. Check for tubing kinks and leakage.
C. Cleanse the area, starting 2 inches from the insertion site and moving inward.
D. Remove old ointment from the insertion site with soap and warm water.
单项选择题

During the first 24 hours after a client is diagnosed with addisonian crisis, which of the following should the nurse perform frequently

A. Weigh the client.
B. Test urine for ketones.
C. Assess vital signs.
D. Administer oral hydrocortison
单项选择题

Which of the following is NOT a contributory factor to thermoregulation in the preterm neonate

A. Immature central nervous system (CNS).
B. Large skin surface area.
C. Lack of subcutaneous (SC) and brown fat.
D. Tendency toward capillary fragility.
单项选择题

Which of the following postoperative complications would the nurse particularly anticipate in a client undergoing a pelvic surgical procedure such as an ileal conduit

A. Bleeding.
B. Infection.
C. Thrombophlebitis.
D. Atelectasis.
单项选择题

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.
单项选择题

After 5 days of hospitalization, the client who is receiving morphine sulfate for pain control asks for more pain medication with increasing frequency and exhibits increased anxiety and restlessness. His physical condition is stable. What is the probable cause of his behavior

A. His morphine dosage is too high.
B. His coping mechanisms are exhausted.
C. He is becoming addicted to the narcotic.
D. He has developed tolerance to his narcotic dosag
单项选择题

A 20-year-old woman has just been diagnosed with Crohn’s disease. She has lost 10 lb (4.5kg) and has cramps and occasional diarrhe().

A. The nurse should include which of the following when doing a nutritional assessmentA. Let the client eat as desired during hospitalization.
B. Weigh the client daily.
C. Ask the client to list what she eats during a typical day.
D. Place the client on I＆O status and draw blood for electrolyte levels.
单项选择题

Which assessment finding would lead the nurse to suspect dehydration in a preterm neonate

A. Bulging fontanels.
B. Excessive weight gain.
C. Urine specific gravity below 1.012.
D. Urine output below 1 mL/hour.
单项选择题

A client with hepatitis A expresses concern that his friends may also acquire hepatitis. Which of the following is most commonly used for prophylactic treatment of people exposed to hepatitis A

A. Penicillin.
B. Sulfadiazine (Microsulfon).
C. Immune serum globulin.
D. Interferon.
单项选择题

A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550mL. What should the nurse do

A. Increase the frequency of the catheterizations.
B. Insert an indwelling urinary catheter.
C. Place the client on fluid restrictions.
D. Use a condom catheter instead of an invasive on
单项选择题

A neonate receives an Apgar score at 1 and 5 minutes after birth. The 5-minute Apgar score is more predictive for which of the following

A. Residual neurologic damage.
B. Residual respiratory depression.
C. Congenital heart defects.
D. Gestational age of the neonat
单项选择题

While inspecting the client’s chest, the nurse notes that the chest wall contracts on inspiration and bulges on expiration. The nurse suspects which of the following problem from this assessment

A. Hemothorax.
B. Flail chest.
C. Pneumothorax.
D. Tension pneumothorax.
单项选择题

A client in a psychiatric clinic unit tells the nurse, "I don’t think I can face going home tomorrow. " The nurse replies, "Do you want to talk more about it" The nurse is using which of the following techniques

A. Presenting reality.
B. Making observations.
C. Restating.
D. Explorin
单项选择题

The nurse instructs the client with diabetes mellitus that it is vital to recognize and treat hypoglycemia promptly based on which of the following knowledge

A. Hypoglycemia can cause brain damage.
B. Hypoglycemia necessitates increased insulin dosage.
C. The client may become dehydrated quickly.
D. The client may become confused, increasing the risk of injury.
单项选择题

A client with type 1 (insulin-dependent) diabetes mellitus who is a multigravida visits the clinic at 28 weeks’ gestation. Which of the following instruction by the nurse is appropriate for the client

A. Nonstress testing is performed weekly until 32 weeks’ gestation.
B. Weekly fetal movement counts are made by the mother.
C. Contraction stress testing is performed weekly.
D. Induction of labor is begun at 34 weeks’ gestation.
单项选择题

Which of the following would the nurse expect to find in a client diagnosed with hyperparathyroidism

A. Hypocalcemia.
B. Hypercalcemia.
C. Hyperphosphatemia.
D. Hypophosphaturi
单项选择题

A client diagnosed with hyperthyroidism has been started on propylthiouracil (PTU) as drug therapy. The nurse should closely observe the client for which of the following side effects

A. Unusual bleeding or bruising.
B. Hypertension.
C. Hypokalemia.
D. Peripheral edem
单项选择题

A client with newly diagnosed type 1 diabetes mellitus is learning about diabetic foot care. Which of the following statements by the client indicates further instruction is needed

A. "I should use lotions. "
B. "I should use antiperspirants. "
C. "I should use foot soaks. "
D. "I should use nail files. "
单项选择题

Parents of a child with cystic fibrosis demonstrate knowledge of the effects of hot weather on their child when they state that hot weather is hazardous because the child has which of the following

A. Poor ability to concentrate urine.
B. Little skin pigment to prevent sunburn.
C. Poorly functioning temperature control center.
D. Abnormally high salt loss through perspiration.
单项选择题

When assessing a client as a candidate for crutch walking, the nurse should take into account that for some elderly people, crutch walking is an impractical goal primarily because which of the following reason

A. Decreased reaction time.
B. Decreased visual acuity.
C. Decreased motor coordination.
D. Decreased level of comprehension.
单项选择题

The nurse discusses discharge plan with the parents of a child following a sickle cell crisis. Which of the following would the nurse emphasize the need to seek prompt health care

A. Headaches and nausea.
B. Fatigue and lassitude.
C. Skin rash and itching.
D. Sore throat and fever.
单项选择题

As part of the annual health screening, the nurse visits the eighth-grade physical education classes and asks each student to bend forward at the waist with the back parallel to the floor and the hands together at midline. For which of the following is the nurse assessing

A. Slipped epiphysis.
B. Developmental dysplasia of hip.
C. Idiopathic scoliosis.
D. Physical dexterity.
单项选择题

Which of the following criteria would be a reliable indicator of improvement in a patient who has a diagnosis of anorexia nervosa

A. Electrolyte balance.
B. Energy level.
C. Fluid intake.
D. Desire to eat.
单项选择题

The nurse is administering sublingual nitroglycerin (Nitrostat) to the client. Immediately afterward, the client may experience which of the following symptoms

A. Nervousness or paresthesia.
B. Throbbing headache or dizziness.
C. Drowsiness or blurred vision.
D. Tinnitus or diplopi
单项选择题

Which of the following concepts would the nurse incorporate into the plan of care for a 4-year-old child to psychologically prepare the child for cardiac catheterization

A. Anxiety decreases when a preschooler is protected from learning about unpleasant events.
B. Preschoolers are unable to understand the procedure.
C. Little psychological preparation can be given to preschoolers.
D. Preparation is a joint responsibility of the physician, parents, and nurs
单项选择题

Oxytocin (Pitocin) is administrated to a client during labor. Which of the following is the most serious adverse effect associated with oxytocin

A. Water intoxication.
B. Tetanic contractions.
C. Elevated blood pressure.
D. Early decelerations of fetal heart rat
单项选择题

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).
单项选择题

Which of the following case meets the criteria for involuntary commitment

A. A single parent who leaves her minor children unattended and stays out all night drinking.
B. A person who lives alone and isn’t able to care for himself and has schizophrenia with delusions of persecution.
C. A man who threatens to kill his wife.
D. A person with depression who says he’s tired of living but doesn’t have a suicide plan.
单项选择题

A 6-week-old female infant exhibits dry scaly skin and a protruding tongue after having trouble breast-feeding. A diagnosis of congenital hypothyroidism is made. The mother asks the nurse why the child was not diagnosed with this condition at birth. Which of the following would be the nurse’s best response

A. "We had the results of the newborn screen, but you did not bring the baby in for the 2-week checkup. "
B. "We could not reach you at home to give you the results of tests taken at birth. "
C. "Your baby had little need for thyroid hormone until she was 1 month old. "
D. "Newborns generally receive enough thyroid hormone from the mother to get by the first few weeks. "
单项选择题

A client with intrauterine growth retardation is admitted to the labor and delivery unit and started on an IV infusion of oxytocin (Pitocin). Which of the following is LEAST likely to be included in her plan of care

A. Monitoring vital signs, including assessment of fetal well-being, every 15 to 30 minutes.
B. Allowing the client to ambulate as tolerated.
C. Helping the client use breathing exercises to manage her contractions.
D. Carefully titrating the oxytocin based on her pattern of labor.
单项选择题

The nurse discusses with the 4-year-old child and parents the plan of care that will be implemented when the child returns from the throat surgery. Which of the following interventions should the nurse emphasize

A. Need for frequent coughing.
B. Use of acetylsalicylic acid for pain, as needed.
C. Ability to have ice cream right after surgery.
D. Use of sips of clear liquids when awake and alert.
单项选择题

Opiate withdrawal causes severe physical discomfort and can be life-threatening. To minimize these effects, opiate users are commonly detoxified with which drug

A. Barbiturates.
B. Amphetamines.
C. Methadone.
D. Benzodiazepines.
单项选择题

Which of the following factors would be most important in selecting the needle length to use for a subcutaneous injection of hydromorphone hydrochloride

A. The diameter of the needle.
B. The amount of adipose tissue at the administration site.
C. The amount of medication to be administered.
D. The viscosity of the solution to be injecte
单项选择题

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/minut
单项选择题

The primary reason for withholding food and fluids from a client who will receive general anesthesia is to help prevent

A. constipation during the immediate postoperative period.
B. vomiting and possible aspiration of vomitus during surgery.
C. pressure on the diaphragm with poor lung expansion during surgery.
D. gas pains and distention during the immediate postoperative perio
单项选择题

Which of the following laboratory tests is considered the most reliable indicator of renal function

A. BUN.
B. Urinalysis.
C. Serum potassium.
D. Serum creatinin
单项选择题

When caring for a client with ulcerative colitis, the nurse should include which of the following nursing interventions in the plan of care

A. Encouraging the use of stool softeners.
B. Suggesting sitz baths as needed.
C. Arrange for the client to have a private bathroom.
D. Wearing a gown to provide direct car
单项选择题

All of the following would be appropriate interventions for a client with acute epididymitis EXCEPT which of the following

A. Maintaining bed rest.
B. Elevating the testes.
C. Applying ice packs intermittently.
D. Applying hot packs to the scrotum.
单项选择题

Prevention of preterm births is vital for which of the following reasons

A. It’s costly to care for these neonates.
B. These neonates are usually mentally retarded.
C. Preterm birth causes high incidence of the neonatal deaths.
D. These neonates usually wind up with long-term health care needs.
单项选择题

The nurse is caring for a client who exhibits signs of somatization. Which of the following statements is most relevant

A. Clients with somatization are cognitively impaired.
B. Anxiety rarely coexists with somatization.
C. Somatization exists when medical evidence supports the symptoms.
D. Clients with somatization often have lengthy medical records.
单项选择题

Eight hours after catheterization, the postoperative client with abdominal hysterectomy has not voided. The client tells the nurse, "I don’t think I can urinate. " What should the nurse do

A. Call and inform the surgeon of the client’s status.
B. Administer additional pain medication.
C. Increase the client’s fluid intake.
D. Assess the client’s bladder.
单项选择题

The physician decides to artificially rupture the membranes. Following this procedure, the nurse needs to check the fetal heart tones. Why should the nurse do so

A. To determine fetal well-being.
B. To prepare for an imminent delivery.
C. To assess for prolapsed cord.
D. To assess fetal position.
单项选择题

The skin lesions evident in herpes zoster are similar to those seen in which disease

A. Impetigo.
B. Syphilis.
C. Varicella.
D. Rubell
单项选择题

The nurse is caring for a client who has a history of alcohol abuse. Why would the client act as if he didn’t have a problem

A. The client has never taken the CAGE questionnaire.
B. Denial is a defense mechanism commonly used by alcoholics.
C. Thought processes are distorted.
D. Alcohol is expensiv
单项选择题

The nurse must assess judgment to determine a client’s mental status. Which test best accomplishes this

A. Interpreting proverbs.
B. Spelling words backward.
C. Counting by serial sevens.
D. Discussing hypothetical ethical situations.
单项选择题

The client has a newly positive Mantoux skin test although she does not have active tuberculosis. Which medical therapy would be appropriate for her

A. Reevaluating the client’s condition every 6 months.
B. Performing a repeat skin test every 6 months.
C. Administering isoniazid for about 9 months.
D. Administering isoniazid until the skin test reverts to negativ
单项选择题

An 89-year-old client is suffering from dementia of the Alzheimer’s type. Which intervention would be most useful in managing his dementia

A. Provide a safe environment.
B. Provide a stimulating environment.
C. Avoid the use of touch.
D. Use restraints whenever necessary.
单项选择题

The nurse identifies a client’s responses to actual or potential health problems during which step of the nursing process

A. Assessment.
B. Analysis.
C. Planning.
D. Evaluation.
单项选择题

Which of the following would the nurse do for a 4-year-old girl who has just had a lumbar puncture

A. Administer narcotic analgesic for insertion site pain.
B. Encourage the parents to hold the child.
C. Ensure the child lies flat for at least 8 hours.
D. Place a sandbag over the puncture site for 3 hours.
单项选择题

Hormonal effects of the antipsychotic medications include which of the following

A. Retrograde ejaculation and gynecomastia.
B. Dysmenorrhea and increased vaginal bleeding.
C. Polydipsia and dysmenorrhea.
D. Akinesia and dysphasi
单项选择题

A 22-year-old client is diagnosed with dependent personality disorder. Which behavior is most likely to indicate her ineffective coping

A. Inability to make choices and decisions without advice.
B. Showing interest only in solitary activities.
C. Avoiding developing relationships.
D. Recurrent self-destructive behavior with history of depression.
单项选择题

When completing an assessment of a healthy adolescent client, which of the following would be most appropriate

A. Obtain a detailed account of the adolescent’s prenatal and early developmental history.
B. Discuss sexual preferences and behaviors with the parents present for legal reasons.
C. Discuss the client’s smoking with parents present in the room.
D. Assess the adolescent in private; gather additional information from the parents.
单项选择题

The nurse is caring for a client who exhibits magical thinking. Which of the following best describes magical thinking

A. Strong positive and negative feelings that cause conflict.
B. Returning to an earlier developmental stage.
C. Meaningless repetition of words.
D. The belief that thoughts or wishes can control other people or events.
单项选择题

Which of the following nursing measures would be most important to decrease the risk of a surgical wound infection in a client with an internal fixation and hip pinning

A. Inserting an indwelling urinary catheter to prevent possible soiling of the dressing.
B. Accurately measuring drainage from the surgical drainage tube.
C. Changing the surgical dressings using strict sterile technique.
D. Monitoring the incision for signs of redness, swelling, and warmt
单项选择题

For which type of schizophrenia should the nurse expect to provide the most physical care

A. Disorganized type.
B. Catatonic type.
C. Paranoid type.
D. Undifferentiated typ
单项选择题

The nurse teaches the client with peptic ulcer disease about how to effectively adjust his response to work-related stress. Which of the following statements by the client indicates that the education is effective

A. "My job is too stressful. I will have to find a different career. "
B. "I don’t have any control over my stressors at work. My coworkers are difficult to work with. "
C. "Well, I guess this ulcer means I won’t be able to work toward a promotion. "
D. "I will have to improve my ability to cope with stress. "
单项选择题

The nurse is teaching a client and his family about dietary practices related to Parkinson’s disease. A priority for the nurse to address is risk of

A. fluid overload and drooling.
B. aspiration and anorexia.
C. choking and diarrhea.
D. dysphagia and constipation.
单项选择题

The nurse recognizes that spinal shock is likely to persist for the first several weeks after the injury. Which of the following symptoms would be unexpected during the period of spinal shock

A. Tachycardia.
B. Rapid respirations.
C. Hypertension.
D. Dry, warm skin.
单项选择题

A 15-year-old boy is admitted to the health care facility after acting out his aggressions inappropriately at school. Predisposing factors to the expression of aggression include which of the following

A. Violence on television.
B. Passive parents.
C. An internal locus of control.
D. A single-parent family.
单项选择题

The nurse assesses the client’s urinary stoma regularly for edem().

A. Which of the following signs and symptoms might indicate excessive stomal edemaA. Elevated temperature.
B. Urine output below 30 mL/hour.
C. Urine dribbling from the stoma.
D. Complaints of discomfort around the stom
单项选择题

The nurse is teaching a client with chronic bronchitis about breathing exercises. Which of the following should the nurse include in the teaching

A. Make inhalation longer than exhalation.
B. Exhale through an open mouth.
C. Use diaphragmatic breathing.
D. Use chest breathin
单项选择题

A client is diagnosed with a herniated lumbar disk at the L-5 interspace. Which of the following symptoms would most likely be the one that first caused the client to seek health care

A. Loss of voluntary muscle control.
B. Loss of bladder control.
C. Back pain that is relieved with resting.
D. Back pain that radiates to the shoulders.
单项选择题

From an analysis of the data collected about the client who has had a gastric resection, the nurse formulates the nursing diagnosis Risk for ineffective airway clearance. Based on which of the following postoperative factors would the nurse make this diagnosis

A. Incisional pain.
B. Nausea.
C. Progressive ambulation.
D. Maintenance of a semi-Fowler’s position.
单项选择题

Which condition could a mother have and still be allowed to breast-feed her child

A. Positive for human immunodeficiency virus (HIV).
B. Active tuberculosis (TB).
C. Cardiac disease.
D. Endometritis.
单项选择题

Which of the following would be most appropriate for the nurse to include in the plan of care for a dying child to meet the child’s emotional needs during the last days of life

A. Restrict visitors to the parents to avoid overtaxing the child.
B. Answer the child’s questions about illness and death honestly.
C. Focus on the child’s physical needs to attempt to prevent sadness.
D. Encourage the child to play quietly with a roommate to provide pleasur
单项选择题

A respectable lawyer is admitted to an acute care facility with epigastric pain. Since admission, the client has called the nurse every 15 minutes with one request or another. Which of the following could explain this client’s behavior

A. Repression.
B. Somatization.
C. Regression.
D. Conversion.
单项选择题

An assisted birth using forceps or a vacuum extractor may be performed for ineffective pushing, for large neonates, to shorten the second stage of labor, or for a malpresentation. When caring for the mother following an assisted birth, the nurse should keep which of the following in mind

A. A vacuum extractor is safer than forceps because it causes less trauma to the neonate and the mother’s perineum.
B. The neonate will develop a cephalohematoma as a result of the instrumentation.
C. The use of instruments during the birth process is a fairly rare occurrence.
D. Additional nursing interventions are needed to ensure an uncomplicated postpartum.
单项选择题

A 2-year-old child is brought to the emergency room with a broken arm. Which of the following findings would lead the nurse to suspect child abuse

A. The child has bruises on the forearms.
B. The child’s clothes are dirty, torn, and obviously "hand-me-downs. "
C. The child’s father alters the story of the injury each time he tells it.
D. The child’s mother did not come to the hospital with the chil
单项选择题

Theophylline ethylenediamide is administered to a client with COPD. The nurse knows that the medication is for which of the following purpose

A. To reduce bronchial secretions.
B. To relax bronchial smooth muscle.
C. To strengthen myocardial contractions.
D. To decrease alveolar elasticity.
单项选择题

A mother of a 4-month-old infant asks the nurse when she should wean from breast-feeding and begin using a cup. Which of the following would be the best indication of the infant’s readiness to be weaned

A. Taking solid foods well.
B. Sleeping through the night.
C. Shortening the nursing time.
D. Eating on a regular schedul
单项选择题

During the first 3 months, which hormone is responsible for maintaining pregnancy

A. Human chorionic gonadotropin (HCG).
B. Progesterone.
C. Estrogen.
D. Relaxin.
单项选择题

A client is admitted for an overdose of amphetamines. When assessing this client, the nurse should expect to have which of the following findings

A. Tension and irritability.
B. Slow pulse.
C. Hypotension.
D. Constipation.
单项选择题

A woman who is 10 weeks pregnant complains about her fatigue and frequent urination. What would be the nurse’s response

A. Recognize these as normal early pregnancy signs and symptoms.
B. Question her further about these signs and symptoms.
C. Tell the client that she’ll need blood work and urinalysis.
D. Tell the client that she may be excessively worrie
单项选择题

A 58-year-old client complaining of difficulty driving at night states that the "lights bother my eyes" even though he wears corrective glasses. The nurse would suspect that the client is experiencing a deficiency in which of the following vitamins

A. Vitamin Ａ.
B. Vitamin Ｂ complex.
C. Vitamin Ｅ.
D. Vitamin Ｃ.
单项选择题

The nurse is caring for a client with bipolar disorder in a manic state. Which of the following nursing interventions should be included in the plan of care

A. Allowing the client to exhibit hyperactive, demanding, manipulative behavior without setting limits.
B. Listening attentively with a neutral attitude and avoiding power struggles.
C. Offering high-calorie meals and strongly encouraging the client to finish all food.
D. Insisting that the client remain active through the day so that he’ll sleep at night.
单项选择题

A client with testicular cancer is scheduled for a right orchiectomy. The day before surgery, the client asks the nurse whether losing a testicle will have influence on his manhood. Which of the following facts about orchiectomy should form the basis for the nurse’s response

A. Testosterone levels are decreased.
B. Sexual drive and libido are unchanged.
C. Sperm count increases in the remaining testicle.
D. Secondary sexual characteristics chang
单项选择题

The nurse is preparing the client with heart failure to go home. Which of the following should be most important to include in the discharge education

A. Monitor urine output daily.
B. Monitor daily potassium intake.
C. Maintain bed rest for at least 1 week.
D. Weigh daily.
单项选择题

The nurse assesses the client to determine the cause of autonomic dysreflexi().

A. Which of the following is the most common stimulus for an autonomic dysreflexia episodeA. Rising intracranial pressure.
B. Bowel distention.
C. Bladder distention.
D. Anxiety.
单项选择题

The nurse is caring for a client during the fourth stage of labor. Which of the following nursing interventions would be LEAST appropriate

A. Catheterization to protect the bladder from trauma.
B. Perineal assessments for swelling and bleeding.
C. Vital signs and fundal checks every 15 minutes.
D. Time with the neonate to initiate breast-feedin
单项选择题

Promethazine hydrochloride (Phenergan) 35 mg IM is ordered for a client who is experiencing nausea and vomiting after surgery. The ampule’s label reads 25 mg/mL. How many mL should the nurse prepare to administer

A. 0.7 mL.
B. 1.0 mL.
C. 1.4 mL.
D. 1.8 mL.
单项选择题

The plan of care for a client with hypertension taking propranolol hydrochloride would include which of the following

A. Instructing the client to discontinue the drug if nausea occurs and to monitor blood pressure.
B. Instructing the client to notify the physician of irregular or slowed pulse rate.
C. Monitoring blood pressure every week and adjusting the medication dose accordingly.
D. Measuring partial thromboplastin time weekly to evaluate blood clotting status.
单项选择题

The client with diverticulitis is treated as an outpatient with drug therapy. Which drug therapy will most probably be employed

A. Antidepressants.
B. Laxatives.
C. Steroids.
D. Broad-spectrum antibiotics.
单项选择题

A client diagnosed with gestational diabetes has been admitted for induction of labor at 38 weeks. The client asks the nurse, "My previous labors started on their own. How will this induction of labor be different from my last labor" Upon which theory would the nurse base her response

A. An induction causes the contractions to be more intense during the first stage of labor.
B. The risk of uterine rupture is less because the oxytocin (Pitocin) is controlled with an infusion pump.
C. The goal of induction is to produce a contractile pattern similar to that observed in spontaneous labor.
D. During an induction, fetal monitoring begins as soon as oxytocin is started, whereas in a spontaneous labor, monitoring begins when signs of distress occur.
单项选择题

A client diagnosed with a peptic ulcer undergoes an upper gastrointestinal endoscopy to help the physician visualize the ulcer’s location and severity. Immediately after the endoscopy, what would be a priority for the nurse to assess

A. Return of the gag reflex.
B. Bowel sounds.
C. Peripheral pulses.
D. Intake and output.
单项选择题

A client who survived an airplane crash has a diagnosis of posttraumatic stress disorder (PTSD). He has a history of nightmares, depression, hopelessness, and alcohol abuse. Which option offers the client the most lasting relief for his symptoms

A. The opportunity to verbalize memories of trauma to a sympathetic listener.
B. Family support.
C. Prescribed medications taken as ordered.
D. Alcoholics Anonymous (AA) meetings.
单项选择题

Which of the following drugs may be abused because of tolerance and physiologic dependence

A. Lithium (Lithobid) and divalproex (Depakote).
B. Verapamil (Calan) and chlorpromazine (Thorazine).
C. Alprazolam (Xanax) and phenobarbital (Luminal).
D. Clozapine (Clozaril) and amitriptyline (Elavil).
单项选择题

For a client in addisonian crisis, it would be very risky for a nurse to administer

A. potassium chloride.
B. normal saline solution.
C. hydrocortisone.
D. fludrocortison
单项选择题

Labor is divided into how many stages

A. Two.
B. Three.
C. Four.
D. Fiv
单项选择题

While caring for a healthy neonate female, the nurse notices red stains on the diaper after the neonate voids. Which of the following should the nurse do

A. Call the physician to report the problem.
B. Encourage the mother to feed the neonate to decrease dehydration.
C. Check the neonate’s urine for hematuria.
D. Do nothing because this is normal.
单项选择题

Which of following would lead the nurse to suspect that a client’s labor is moving quickly and that the physician should be notified

A. An increased sense of rectal pressure.
B. An increase in fetal heart rate variability.
C. A decrease in intensity of contractions.
D. Episodes of nausea and vomitin
单项选择题

After receiving large doses of an ovulatory stimulant such as menotropins (Pergonal), a client comes in for her office visit. Assessment reveals the following: 6 lb (2.7 kg) weight gain, ascites, and pedal edem().

A. These findings indicate which of the followingA. They are normal signs of an ovulatory stimulant.
B. The client is demonstrating signs of hyperstimulation syndrome.
C. The client is having a reaction to the menotropins.
D. The client is probably pregnant.
单项选择题

To help promote independence in the area of feeding for a school-aged child in skeletal traction, the nurse would help the child choose which of the following meals

A. Carrot sticks, celery with cream cheese, roast beef and gravy, peas, gelatin, and milk in a cup.
B. Chicken noodle soup with crackers, grilled cheese sandwich, cole slaw, and chocolate milk in a carton.
C. Chicken nuggets with sauce, carrot sticks, French-fried potatoes, ice cream sandwich, and milk in a carton.
D. Spaghetti and meat sauce, cherry cobbler, and apple juice in a can.
单项选择题

A client is being admitted to the labor unit. Because she’s well advanced in labor, the nurse must prioritize the admission questions. Which information is most important to obtain when birth is imminent

A. Duration of previous labor.
B. Frequency of contractions.
C. Presence of bloody show.
D. Expected due dat
单项选择题

The nurse is administering magnesium sulfate to a client with preeclampsi

a. The nurse explains to the client that this drug is given for which of the following reasonA. To prevent seizures.B. To reduce blood pressure.C. To slow the process of labor.D. To increase diuresis.
单项选择题

Which of the following pieces of equipment would do best job to help prevent external rotation of the client’s right leg postoperatively

A. Sandbags.
B. A high footboard.
C. A rubber air ring.
D. A metal bed cradl
单项选择题

A client who suffered blunt chest trauma in a car accident complains of chest pain, which is exacerbated by deep inspiration. On auscultation, the nurse detects a pericardial friction rub--a classic sign of acute pericarditis. To relieve chest pain associated with pericarditis, the nurse should encourage the client to assume which position

A. Semi-Fowler’s.
B. Leaning forward while sitting.
C. Supine.
D. Pron
单项选择题

Nursing care for a client after electroeonvulsive therapy (ECT) should include which of the following

A. Nothing by mouth for 24 hours after the treatment because of the anesthetic agent.
B. Bed rest for the first 8 hours after a treatment.
C. Assessment of short-term memory loss.
D. No special car
单项选择题

The nurse is caring for a client who undergoes a total right knee replacement. The nurse would anticipate which of the following activity orders for this client on the first postoperative day

A. Bed rest for 24 to 48 hours after surgery.
B. Ambulate with walker twice a day.
C. Up to chair with leg elevated.
D. Dangle at bedside for 20 minutes.
单项选择题

When assessing a toddler diagnosed with spastic cerebral palsy, which of the following would the nurse expect to find

A. Toe-walking.
B. Drooling.
C. Facial grimacing.
D. Wide-based gait.
单项选择题

The nurse observes that the client’s total parenteral nutrition (TPN) solution is infusing too slowly. The nurse calculates that the client has received 300 mL less than was ordered for the day. What should the nurse do next

A. Assess the infusion system, note the client’s condition, and notify the physician.
B. Discontinue the solution and administer dextrose in 5% water until the infusion problem is resolved.
C. Increase the flow rate to infuse an additional 300 mL over the next hour.
D. Maintain the flow rate at the current rate and document any discrepancy in the chart.
单项选择题

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.
单项选择题

The nurse is caring for a client who complains of chronic pain. Given this complaint, why would the nurse simultaneously evaluate both general physical and psychosocial problems

A. Depression is commonly characterized by pain disorders and somatic complaints.
B. Combining evaluations will save time and allow for quicker delivery of health care.
C. Most insurance plans won’t cover evaluation of both as separate entities.
D. The physician doesn’t have the training to evaluate for psychosocial considerations.
单项选择题

The nurse is assessing a pregnant woman in the clinic. In the course of the assessment, the nurse learns that this woman smokes one pack of cigarettes per day. Which of the following is the first step the nurse should take to help the woman stop smoking

A. Assess the client’s readiness to stop.
B. Suggest that the client reduce the daily number of cigarettes smoked by one-half.
C. Provide the client with the telephone number of a formal smoking-cessation program.
D. Help the client develop a plan to stop.
单项选择题

A 16-year-old girl comes to the school nurse complaining of cramps, backache, and nausea with her periods. The nurse most likely would interpret these symptoms as which of the following

A. Pathologic.
B. Physiologic.
C. Psychogenic.
D. Psychosomati
单项选择题

After teaching the mother about tests performed to monitor the success of the infant’s treatment for congenital hypothyroidism, the nurse would determine that the teaching was effective when the mother states that the child will need frequent blood tests and regular assessment of which of the following

A. Blood electrolyte levels.
B. Metabolic rate.
C. Muscular coordination.
D. Bone ag
单项选择题

The nurse is preparing to care for a client diagnosed with catatonic schizophreni

a. In anticipation of this client’s arrival, what should the nurse doA. Notify security.B. Prepare a magnesium sulfate drip.C. Place a specialty mattress overlay on the bed.D. Communicate the client’s nothing-by-mouth status to the dietary department.
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