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質問 # 492
A 3-year-old child is hospitalized with burns covering her trunk and lower extremities. Which of the following would the nurse use to assess adequacy of fluid resuscitation in the burned child?
- A. Serum potassium level
- B. Blood pressure
- C. Pulse rate
- D. Urine output
正解：D
解説：
Explanation
(A) Blood pressure can remain normotensive even in a state of hypovolemia. (B) Serum potassium is not reliable for determining adequacy of fluid resuscitation. (C) Urine output, alteration in sensorium, and capillary refill are the most reliable indicators for assessing adequacy of fluid resuscitation. (D) Pulse rate may vary for many reasons and is not a reliable indicator for assessing adequacy of fluid resuscitation.
質問 # 493
The nurse instructs a pregnant client (G2P1) to rest in a side-lying position and avoid lying flat on her back.
The nurse explains that this is to avoid "vena caval syndrome," a condition which:
- A. Results when blood flow from the extremities is blocked or slowed
- B. Is seen mainly in first pregnancies
- C. Occurs when blood pressure increases sharply with changes in position
- D. May require medication if positioning does not help
正解：A
解説：
Explanation/Reference:
Explanation:
(A) Blood pressure changes are predominantly due to pressure of the gravid uterus. (B) Pressure of the gravid uterus on the inferior vena cava decreases blood return from lower extremities. (C) Inferior vena cava syndrome is experienced in the latter months of pregnancy regardless of parity. (D) There are no medications useful in the treatment of interior vena cava syndrome; alleviating pressure by position changes is effective.
質問 # 494
An 11-year-old boy has received a partial-thickness burn to both legs. He presents to the emergency room approximately 15 minutes after the accident in excruciating pain with charred clothing to both legs. What is the first nursing action?
- A. Apply ice packs to both legs.
- B. Immerse both legs in cool water.
- C. Apply Silvadene cream (silver sulfadiazine).
- D. Begin debridement by removing all charred clothing from wound.
正解：B
解説：
(A)
Ice creates a dramatic temperature change in the tissue, which can cause further thermal injury. (B) Charred clothing should not be removed from wound first. This creates further tissue damage. Debridement is not the first nursing action. (C) Applying silver sulfadiazine cream first insulates heat in injured tissue and increases potential for infection.
(D)
Emergency care of a thermal burn is immersing both legs in cool water. Cool water permits gradual temperature change and prevents further thermal damage.
質問 # 495
A pregnant client during labor is irritable and feels the urge to vomit. The nurse should recognize this as the:
- A. Third stage of labor
- B. Transition stage of labor
- C. Second stage of labor
- D. Fourth stage of labor
正解：B
解説：
Explanation/Reference:
Explanation:
(A) The fourth stage begins after expulsion of the placenta. Client symptoms are: fatigue; chills; scant, bloody vaginal discharge; and nausea. (B) The third stage is from birth to expulsion of placenta. Client symptoms are uterine contractions, gush of blood, and perineal pain. (C) The transition stage is characterized by strong uterine contractions and cervical dilation. Clientsymptoms are irritability, restlessness, belching, muscle tremors, nausea, and vomiting. (D) The second stage is characterized by full dilation of cervix. Client symptoms are perineal bulge, pushing with contractions, great irritability, and leg cramps.
質問 # 496
A woman diagnosed with multiple sclerosis is disturbed with diplopia. The nurse will teach her to:
- A. Limit activities which require focusing (close vision)
- B. Use artificial tears
- C. Take more frequent naps
- D. Wear a patch over one eye
正解：D
解説：
Explanation
(A) Limiting activities requiring close vision will not alleviate the discomfort of double vision. (B) Frequent naps may be comforting, but they will not prevent double vision. (C) Artificial tears are necessary in the absence of a corneal reflex, but they have no effect on diplopia. (D) An eye patch over either eye will eliminate the effects of double vision during the time the eye patch is worn. An eye patch is safe for a person with an intact corneal reflex.
質問 # 497
To prevent thrombophlebitis in a client on complete bed rest, the nursing care plan should include:
- A. Massage the client's calves briskly every shift.
- B. Have the client tighten and relax leg muscles several times daily.
- C. Dangle the client's legs over the edge of the bed every shift.
- D. Keep the client's legs extended and discourage any movement.
正解：B
解説：
Explanation/Reference:
Explanation:
(A) Dangling the client's legs over the edge of the bed will contribute to stasis and pooling of blood and increases the risk of thrombus formation. (B) Massaging the client's calves could result in dislodging an embolus. (C) Decreased movement will contribute to pooling of blood and increased risk of venous thrombosis. (D) Tightening and relaxing leg muscles increases circulation and decreases the risk of venous thrombosis.
質問 # 498
A behavioral modification program is recommended by the multidisciplinary team working with a 15-year-old client with anorexia nervosa. A nursing plan of care based on this modality would include:
- A. Role playing the client's eating behaviors
- B. Encouraging her to verbalize her feelings concerning food and food intake
- C. Restriction to the unit until she has gained 2 lb
- D. Provision for a high-calorie, high-protein snack between meals
正解：C
解説：
Explanation
(A) This answer is incorrect. Role playing is based on learning but is not based on the behavioral modification model. (B) This answer is correct. The behavioral modification model is based on negative and positive reinforcers to change behavior. (C) This answer is incorrect. Verbal catharsis is not an intervention based on behavioral modification. (D) This answer is incorrect. Although an acceptable nursing intervention, it is not based on behavioral modification.
質問 # 499
A client was prescribed a major tranquilizer 2 months ago. One month ago she was placed on benztropine (Cogentin). What would indicate that benztropine therapy is effective?
- A. Muscle weakness
- B. Tremors
- C. Smooth, coordinated voluntary movement
- D. Rigidity
正解：C
解説：
(A) Benztropine is prescribed to decrease or alleviate extrapyramidal side effects of major tranquilizers. Smooth, coordinated voluntary movement indicates minimal extrapyramidal side effects. (B) Tremors are an extrapyramidal side effect. (C) Rigidity is an extrapyramidal side effect. (D) Muscle weakness is an extrapyramidal side effect.
質問 # 500
A pregnant client during labor is irritable and feels the urge to vomit. The nurse should recognize this as the:
- A. Third stage of labor
- B. Transition stage of labor
- C. Second stage of labor
- D. Fourth stage of labor
正解：B
解説：
(A) The fourth stage begins after expulsion of the placenta. Client symptoms are: fatigue; chills; scant, bloody vaginal discharge; and nausea. (B) The third stage is from birth to expulsion of placenta. Client symptoms are uterine contractions, gush of blood, and perineal pain. (C) The transition stage is characterized by strong uterine contractions and cervical dilation. Clientsymptoms are irritability, restlessness, belching, muscle tremors, nausea, and vomiting. (D) The second stage is characterized by full dilation of cervix. Client symptoms are perineal bulge, pushing with contractions, great irritability, and leg cramps.
質問 # 501
A physician's order reads: Administer KCl 10% oral solution 1.5 mL. The KCl bottle reads 20 mEq/15 mL.
What dosage should the nurse administer to the infant?
- A. 1 mEq
- B. 1.13 mEq
- C. Not enough information to calculate
- D. 2 mEq
正解：D
解説：
Explanation
(A) This answer is a miscalculation. (B) This answer is a miscalculation. (C) 1.33 mEq = 1 mL, then 1.5 mL X=1.99, or 2 mEq. (D) Information is adequate for calculation.
質問 # 502
A female client is started on warfarin (Coumadin) 5 mg po bid. To adequately evaluate the effectiveness of the warfarin therapy, the nurse must know that this medication:
- A. Stimulates the manufacturing of platelets
- B. Dissolves any clots already formed in the arteries
- C. Interferes with the synthesis of vitamin K-dependent clotting factors
- D. Prevents the conversion of prothrombin to thrombin
正解：C
解説：
(A) Thrombolytic agents (e.g., streptokinase) directly activate plasminogen, dissolving fibrin deposits, which in turn dissolves clots that have already formed. (B) Heparin prevents the formation of clots by potentiating the effects of antithrombin III and the conversion of prothrombin to thrombin. (C) Warfarin prevents the formation of clots by interfering with the hepatic synthesis of the vitamin K-dependent clotting factors. (D) Platelets initiate the coagulation of blood by adhering to each other and the site of injury to form platelet plugs.
質問 # 503
A client is experiencing mucosal cell damage secondary to chemotherapy. Because of mucosal ulcers, eating has become increasingly uncomfortable for her. Which of the following interventions would be most effective in getting her to eat?
- A. Cleaning the mouth carefully with lemon glycerin swabs and milk of magnesia before meals
- B. Local anesthetics or mouth washes applied to ulcers 30 minutes prior to meals
- C. A bland, moist, soft diet
- D. Staying with the client and providing distraction during meals
正解：C
解説：
(A) Local anesthetics do temporarily relieve the pain but leave an unpleasant taste and numb feeling that are not conductive to eating. (B) Such a diet is less irritating to the damaged mucosa and is easier for the child to tolerate. (C) This intervention is helpful if the child has only anorexia. It does not work if the type and texture of the food increase oral discomfort. (D) Lemon glycerin swabs and milk of magnesia dry the oral mucosa and should be avoided.
質問 # 504
A parent told the public health nurse that her 6-year-old son has been taking tetracycline for a chronic skin condition. The parent asked if this could cause any problems for the child. What should the nurse explain to the parent?
- A. If you give tetracycline with milk, it may be absorbed readily.
- B. Giving tetracycline to a child younger than 8 years may cause permanent staining of his teeth.
- C. Secondary infections of chronic skin disorders do not respond to antibiotics.
- D. The medication should be given to adults, not children.
正解：B
解説：
Explanation
(A) Tetracycline should be avoided during tooth development because it interferes with enamel formation and dental pigmentation. (B) Milk interferes with the absorption of tetracyclines. (C) Children older than 9 years or past the tooth development stage may be given tetracycline. (D) Secondary infections of chronic skin disorders may respond to antibiotics such as penicillin or tetracyclines.
質問 # 505
Often children are monitored with pulse oximeter. The pulse oximeter measures the:
- A. O2 content of the blood
- B. Affinity of hemoglobin for O2
- C. Oxygen saturation of arterial blood
- D. PO2
正解：C
解説：
Explanation/Reference:
Explanation:
(A) The O2 content of whole blood is determined by the partial pressure of oxygen (PO2) and the oxygen saturation. The pulse oximeter does not measure the PO2. (B) The pulse oximeter is a noninvasive method of measuring the arterial oxygen saturation. (C) The PO2 is the amount of O2 dissolved in plasma, which the pulse oximeter does not measure. (D) The affinity of hemoglobin for O2 is the relationship between oxygen saturation and PO2 and is not measured by the pulse oximeter.
質問 # 506
A client has been uncomfortable in crowds all her life. After the birth of her child, she has been housebound unless her husband can accompany her to the grocery store and for medical appointments.
His schedule will not allow for this, and he has insisted that she must be more independent. Her anxiety has increased to the point of panic. The client has been diagnosed with agoraphobia. Which statement is true about this disorder?
- A. The behavior is not considered disabling.
- B. The fears are persistent, and avoidance is used as the coping mechanism.
- C. Agoraphobia moves into remission when treated with chlorpromazine.
- D. More men suffer from agoraphobia than women.
正解：B
解説：
Explanation/Reference:
Explanation:
(A) Agoraphobia is the most pervasive and serious phobic disorder. (B) Women compose 70%-85% of agoraphobia sufferers. (C) Agoraphobia is an acute disorder that immobilizes the sufferer with extreme anxiety. (D) Chlorpromazine is not a drug used to treat phobias.
質問 # 507
A 44-year-old female client is receiving external radiation to her scapula for metastasis of breast cancer.
Teaching related to skin care for the client would include which of the following?
- A. Teach her to cover broken skin in the treated area with a medicated ointment.
- B. Encourage her to avoid direct sunlight on the area being treated.
- C. Teach her to completely clean the skin to remove all ointments and markings after each treatment.
- D. Encourage her to wear a tight-fitting vest to support her scapula.
正解：B
解説：
Explanation/Reference:
Explanation:
(A) The skin in a treatment area should be rinsed with water and patted dry. Markings should be left intact, and the skin should not be scrubbed. (B) Clients should avoid putting any creams or lotions on the treated area. This could interfere with treatment. (C) Radiation therapy clients should wear loose-fitting clothes and avoid tight, irritating fabrics. (D) The area of skin being treated is sensitive to sunlight, and the client should take care to prevent sun damage by avoiding direct sunlight and covering the area when she is in the sun.
質問 # 508
When the nurse is evaluating lab data for a client 18-24 hours after a major thermal burn, the expected physiological changes would include which of the following?
- A. Elevated serum sodium
- B. Elevated hematocrit
- C. Elevated serum calcium
- D. Elevated serum protein
正解：B
解説：
Explanation/Reference:
Explanation:
(A) Sodium enters the edema fluid in the burned area, lowering the sodium content of the vascular fluid.
Hyponatremia may continue for days to several weeks because of sodium loss to edema, sodium shifting into the cells, and later, diuresis. (B) Hypocalcemia occurs because of calcium loss to edema fluid at the burned site (third space fluid). (C) Protein loss occurs at the burn site owing to increased capillary permeability. Serum protein levels remain low until healing occurs. (D) Hematocrit level is elevated owing to hemoconcentration from hypovolemia. Anemia is present in the postburn stage owing to blood loss and hemolysis, but it cannot be assessed until the client is adequately hydrated.
質問 # 509
The nurse observes a client crying quietly. She has just experienced a spontaneous abortion at nine weeks' gestation. An appropriate response by the nurse would be:
- A. "This must be a difficult time for you. Would you like to talk about it?"
- B. "It must be God's will and probably is for the best."
- C. "I'm sure your other children will be a comfort for you."
- D. "Don't worry, you're still young. If I were you I'd just try again."
正解：A
解説：
Explanation
(A) This response is nontherapeutic because it belittles the client's response and gives a meaningless rationalization. (B) This response acknowledges the client's feelings and demonstrates the therapeutic offering of self by the nurse. (C) This response is nontherapeutic because it does not focus on the client's feelings and offers false reassurance. (D) This response is nontherapeutic because it belittles the client's feelings and offers her advice.
質問 # 510
Which type of insulin can be administered by a continuous IV drip?
- A. Lente insulin
- B. Humulin N
- C. NPH insulin
- D. Regular insulin
正解：D
解説：
(A) Humulin N cannot be administered IV. (B) NPH insulin cannot be administered IV. (C) Regular insulin is the only insulin that can be administered IV. (D) Lente insulin cannot be administered IV.
質問 # 511
A 14-year-old boy has had diabetes for 7 years. He takes 30 U of NPH insulin and 10 U of regular insulin every morning at 7 AM. He eats breakfast at 7:30 AM and lunch at noon. What time should he expect the greatest risk for hypoglycemia?
- A. 1 PM
- B. 9 AM
- C. 3 PM
- D. 11 AM
正解：D
解説：
Explanation
(A) This time is incorrect because regular insulin would peak after the teenager has eaten breakfast. (B) This time is incorrect because it is after lunch when the NPH peaks. (C) Regular insulin peaks in 2-3 hours and has a duration of 4-6 hours. NPH insulin's onset is 4-6 hours and peaks in 8-16 hours. Blood sugar would peak after meals and be lowest before meals and during the night. (D) This time is incorrect because it is before the NPH and after the regular insulin peak times.
質問 # 512
A postoperative TURP client returns from the recovery room to the general surgery unit and is in stable condition. One hour later the nurse assesses him and finds him to be confused and disoriented. She recognizes that this is most likely caused by:
- A. Hypokalemia
- B. Hyponatremia
- C. Hypovolemic shock
- D. Hypernatremia
正解：B
解説：
Explanation/Reference:
Explanation:
(A) Early signs of hypovolemic shock include hypotension, tachycardia, tachypnea, pallor, and diaphoresis.
(B) Early signs of potassium depletion include muscular weakness or paralysis, tetany, postural hypotension, weak pulse, shallow respirations, apathy, weak voice, and electrocardiographic changes. (C) Early signs of an elevated sodium level include dry oral mucous membranes, marked thirst, hypertension, tachycardia, oliguria or anuria, anxiety, and agitation. (D) This answer is correct. Important early clinical findings of a decreased sodium concentration include confusion and disorientation. Hyponatremia can occur after a TURP because absorption during surgery through the prostate veins can increase circulating blood volume and decrease sodium concentration.
質問 # 513
A 22-year-old client is 16 weeks pregnant. She and her husband are expecting their first baby. The client tells the nurse that her last normal menstrual period was February 16, with 3 days of spotting on February 17, 18, and 19. The nurse calculates her expected date of delivery to be:
- A. December 9th
- B. September 14th
- C. November 23rd
- D. December 26th
正解：C
解説：
(A) Naele's rule is as follows: add 7 days to the 1st day of the last menstrual period, subtract 3 months, and then add 1 year. (B) Naele's rule presumes that the woman has a 28-day menstrual cycle, with conception occurring on the 14th day of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naele's rule. (C) Naele's rule presumes that the woman has a 28-day menstrual cycle, with conception occurringon the 14th day of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naele's rule. (D) Naele's rule presumes that the woman has a 28-day menstrual cycle, with conception occurring on the 14thday of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naele's rule.
質問 # 514
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