更多"The nurse evaluates the client’s un"的相关试题:
[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 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 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 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]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 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 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]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 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 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 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]While caring for pregnant adolescents, the nurse should develop a plan of care that incorporates which health concern
A. Age of menarche.
B. Family and home life.
C. Healthy eating habits.
D. Level of emotional maturity.
[单项选择]At an outpatient clinic, a client asks the nurse how she can prepare for pregnancy. Which of the following responses by the nurse would be best
A. "Begin an iron supplement of 100 mg daily. "
B. "Supplement your diet with 400 meg of folio acid. "
C. "Avoid raw eggs and cats until conception. "
D. "Receive immunization against toxoplasmosis. "
[单项选择]A client asks the nurse to help her make out her will. In this situation, what should be the nurse’s best response
A. "I don’t believe in getting involved in legal matters, but maybe I can find another nurse who’ll help you. "
B. "You need to consult an attorney because I’m not trained in such matters. Is there a family lawyer I can call for you"
C. "I’m not a lawyer, but I’ll do what I can for you. "
D. "You have a long way to go before you’ll need to do that. Let’s wait on it a while, shall we"
[单项选择]The nurse instructs the client with hemorrhoids about how to decrease the discomfort. Which of the following interventions would be most likely recommended by the nurse
A. Decrease fiber in the diet.
B. Decrease physical activity.
C. Take laxatives to promote bowel movements.
D. Use warm sitz baths.
