更多"The nurse observes that the client’"的相关试题:
[单项选择]The nurse is caring for a client who’s hypoglycemic. This client will have a blood glucose level
A. below 70 mg/dL.
B. between 70 and 120 mg/dL.
C. between 120 and 180 mg/dL.
D. above 180 mg/dL.
[单项选择]The nurse evaluates the client’s understanding of myasthenia gravis. The nurse would judge that the client has formed a realistic concept of her condition when she says
A. "By taking medication and pacing activities, I will live longer, but ultimately the disease will cause my death. "
B. "By taking medication and pacing activities, my fatigue will be relieved, but I should expect occasional periods of muscle weakness. "
C. "By taking medication and pacing activities, my symptoms will be controlled and eventually the disease will be cured. "
D. "By taking medication and pacing activities, I should be able to control the disease and enjoy a healthy lifestyle. "
[单项选择]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
A. Stop the flow of solution temporarily.
B. Reposition the client on to her right side.
C. Remove the irrigation tube.
D. Massage the abdomen gently.
[单项选择]The nurse assesses the client’s burned right arm and notes increasing edema, absence of a radial pulse, and decreased sensation in the fingers. What should be the nurse’s priority response
A. Document findings and recheck in 1 hour.
B. Elevate extremity on one pillow.
C. Implement passive range-of-motion exercises.
D. Notify the physician immediately.
[单项选择]The nurse notices that the client’s pupils are fixed and dilated. What does this finding indicate
A. The client is permanently paralyzed.
B. The client is going to be blind as a result of an injury.
C. The client probably has meningitis.
D. The client has received a significant brain injury.
[单项选择]The nurse is evaluating a client’s lung sounds. Which of the following breath sounds indicate adequate ventilation when auscultated over the lung fields
A. Vesicular.
B. Bronchial.
C. Bronchovesicular.
D. Adventitious.
[单项选择]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]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]When bandaging the burned client’s hand, the nurse should pay more attention about which of the following
A. The bandage is free of elastic.
B. The bandage material is moistened with sterile normal saline solution.
C. The hand and finger surfaces do not touch.
D. The hand and fingers are not elevated above heart level.
[单项选择]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]The nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. What is a major complication of TPN
A. Hyperglycemia.
B. Extreme hunger.
C. Hypotension.
D. Hypoglycemi
[单项选择]The nurse is caring for a client who underwent a subtotal gastrectomy 24 hours earlier. The client has a nasogastric (NG) tube. The nurse should
A. apply suction to the NG tube every hour.
B. clamp the NG tube if the client complains of nausea.
C. irrigate the NG tube gently with normal saline solution.
D. reposition the NG tube if pulled out.
[单项选择]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]The overweight adolescent client tells the nurse that he would like to lose weight and asks the nurse’s opinion on how to accomplish his goal. Which of the following suggestions would be most appropriate
A. Exercising more often.
B. Severely limiting calorie intake.
C. Participating in an adolescent weight-reduction program.
D. Cutting clown on sweets and other snacks.
[单项选择]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
A. Leave the medications on the client’s bedside table.
B. Ask the client’s roommate to keep the medications for the client until he returns.
C. Lock the medications in the medicine preparation area until the client returns.
D. Have the client skip that dose of medication.
[单项选择]A client undergoes a total laryngectomy and tracheostomy formation. On discharge, which instruction should the nurse give to the client and family
A. "Clean the tracheostomy tube with alcohol and water. "
B. "Family members should continue to talk to the client. "
C. "Oral intake of fluids should be limited for 1 week only. "
D. "Limit the amount of protein in the diet. "
[单项选择]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]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.