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1,407 سؤال مع الإجابات الصحيحة، مرتبة للقراءة والمراجعة استعدادا لاختبار التمريض SNLE.
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1
An ICU nurse reviews the arterial blood gas results of a 47-year-old patient who has been on mechanical ventilation for a prolonged period. The results show: pH 7.16, PaCO₂ 10.66 kPa, HCO₃ 24 mmol/L, PaO₂ 6.13 kPa, and SaO₂ 81%. <br>Which acid–base imbalance is the patient most likely experiencing?
A Metabolic acidosisB Metabolic alkalosisC Respiratory acidosis الإجابة الصحيحةD Respiratory alkalosis -
2
A patient has been receiving prolonged nasogastric suction for gastric decompression. <br>Which acid–base imbalance is most likely to develop as a result of this intervention?
A Metabolic acidosisB Respiratory acidosisC Metabolic alkalosis الإجابة الصحيحةD Respiratory alkalosis -
3
An ICU nurse reviews an arterial blood gas (ABG) report showing: low pH, elevated PaCO₂, and normal HCO₃⁻ levels. <br>How should the nurse interpret these findings?
A Compensated respiratory acidosisB Uncompensated respiratory acidosis الإجابة الصحيحةC Metabolic acidosisD Metabolic alkalosis -
4
An ICU nurse reviews the arterial blood gas results of a patient showing: pH 7.37, PaCO₂ 50 mmHg, and HCO₃⁻ 30 mEq/L.<br>How should the nurse interpret these findings?
A Compensated respiratory acidosis الإجابة الصحيحةB Compensated metabolic alkalosisC Uncompensated respiratory acidosisD Uncompensated metabolic alkalosis -
5
A nurse is assessing a patient with a newly created ileostomy. <br>Which acid–base imbalance is the patient most at risk of developing?
A Respiratory acidosisB Metabolic acidosis الإجابة الصحيحةC Respiratory alkalosisD Metabolic alkalosis -
6
A patient with septic shock develops increasing confusion and hypotension. An arterial blood gas (ABG) shows: pH 7.20, PaCO₂ 38 mmHg, and HCO₃⁻ 18 mEq/L. <br>Which acid–base imbalance is most consistent with these findings?
A Respiratory alkalosisB Respiratory acidosisC Metabolic alkalosisD Metabolic acidosis الإجابة الصحيحة -
7
A 20-year-old woman with a history of panic attacks presents to the emergency department with acute anxiety and hyperventilation. An arterial blood gas (ABG) shows: pH 7.53, PaCO₂ 27 mmHg, and HCO₃⁻ 22 mEq/L. <br>Which acid–base imbalance is most likely present?
A Metabolic acidosisB Metabolic alkalosisC Respiratory acidosisD Respiratory alkalosis الإجابة الصحيحة -
8
A patient with a chest tube connected to a water-seal drainage system is being transported for a chest X-ray. How should the nurse position the drainage system during transport?
A Place it beside the patient on the stretcher, below chest level الإجابة الصحيحةB Clamp the chest tube during transportC Place it upright on the patient's abdomenD Hang it on an IV pole attached to the stretcher -
9
A 40-year-old patient has a pleural chest tube that suddenly becomes completely dislodged and falls out while in bed. <br>What is the nurse’s most appropriate initial action?
A Reinsert the chest tube and notify the surgeonB Apply an occlusive dressing to the insertion site الإجابة الصحيحةC Place the open end of the tube in 20 cm of waterD Administer O2 at 10L/min via a non-rebreather mask -
10
While attempting to get out of bed, a patient accidentally disconnects the chest tube tubing from the pleural drainage system, but the chest tube remains in the patient.<br>What should the nurse do first?
A Insert the end of the chest tube in a container of sterile solution الإجابة الصحيحةB Raise the end of the chest tube above the level of insertionC Clamp the chest tube near the Pleura-Vac drainage systemD Apply a pressure dressing to the chest tube insertion site -
11
A nurse is caring for a client with a chest tube connected to a water-seal drainage system for treatment of a pneumothorax. The client is breathing spontaneously. <br>How can the nurse ensure the system is functioning effectively?
A Observe for intermittent bubbling in the water seal chamber الإجابة الصحيحةB Flush the chest tubes with 30-60 ml of NSS every 4-6 hoursC Maintain the client in an extreme lateral positionD Strip the chest tubes in the direction of the client -
12
A client's chest tube connected to a chest tube drainage system with a water seal shows fluctuation with each breath. What does this fluctuation indicate ?
A There is an obstruction in the chest tubeB The client is developing emphysemaC The chest tube system is functioning properly الإجابة الصحيحةD There is a leak in the chest tube system -
13
While assessing the water seal chamber, the nurse notes the water moves up as the patient inhales and then moves down when the patient exhales. What could be causing this ?
A This is normal and expected الإجابة الصحيحةB The chest tube has a leakC The left chest tube is occludedD The water seal suction should be increased by 2-5 mmHg -
14
The nurse assists the physician with removal of a pleural chest tube. To minimise the risk of air entering the pleural space during tube removal, which breathing maneuver should the patient perform at the moment of withdrawal?
A Valsalva maneuver (exhale against a closed glottis) الإجابة الصحيحةB Deep slow inhalation and holdC Chest physiotherapy techniqueD Huff cough technique -
15
A nurse is caring for a patient with a pneumothorax who has a chest tube connected to a water-seal drainage system. The nurse observes the water level in the water-seal chamber rising during inspiration and falling during expiration. What is the correct interpretation of this finding?
A The drainage system is functioning correctly (tidaling) الإجابة الصحيحةB There is continuous air leak from the lungC The chest tube is obstructedD The lung has fully re-expanded -
16
A public health nurse is investigating a foodborne illness outbreak at a school cafeteria. Fifteen students developed nausea, vomiting, and abdominal cramps within 1 to 6 hours after eating lunch. All affected students consumed the same chicken salad that had been prepared earlier and left at room temperature. Which organism is the MOST likely causative agent?
A Staphylococcus aureus الإجابة الصحيحةB Salmonella typhiC Clostridium botulinumD Hepatitis A virus -
17
A 32-year-old man presents to the emergency department with a 3-month history of chronic productive cough, night sweats, fever, and unintentional weight loss. Pulmonary tuberculosis is suspected, and a chest X-ray is ordered. The patient is admitted for further evaluation. <br>Which type of transmission-based precaution should the nurse initiate immediately?
A Droplet precautionsB Contact precautionsC Airborne precautions الإجابة الصحيحةD Standard precautions only -
18
A 45-year-old man presents to the emergency department with fever, dry cough, progressive shortness of breath, and fatigue for 5 days. He has had recent close contact with a laboratory-confirmed case of COVID-19. Oxygen saturation is 88% on room air and chest imaging shows bilateral ground-glass infiltrates.<br>Which diagnosis is MOST consistent with these findings?
A COVID-19 (SARS-CoV-2) infection الإجابة الصحيحةB Influenza A (H1N1) infectionC Zika virus infectionD Acute viral hepatitis -
19
A nurse receives information about a patient with streptococcal meningitis. Which isolation precaution is necessary ?
A Droplet precautions الإجابة الصحيحةB Contact precautionsC Airborne precautionsD Neutropenic precautions -
20
A patient is diagnosed with meningococcal meningitis (Neisseria meningitidis). The nurse plans the appropriate transmission-based precautions.<br>Which isolation precaution should be implemented, and for how long?
A Droplet precautions for the first 24 hours of effective antibiotic therapy الإجابة الصحيحةB Contact precautions for the duration of hospitalisationC Airborne precautions until cultures are negativeD Standard precautions only — no additional precautions needed -
21
A 45-year-old patient admitted with pulmonary tuberculosis. The unit nurse placed the patient in an isolation room with negative air pressure and prepared all the personal protective equipment at the entrance of the room. What type of precaution measure has the nurse activated ?
A ContactB DropletC Airborne الإجابة الصحيحةD Standard -
22
A 45-year-old patient is admitted with pulmonary tuberculosis. The unit nurse placed the patient in an isolation room with negative air pressure and prepared all PPE at the entrance of the room.<br>Which of the following PPE is the most important for the nurse when caring for this patient?
A Hair coverB Sterile glovesC N95 respirator الإجابة الصحيحةD Protective goggles -
23
A patient is diagnosed with respiratory diphtheria.<br>Which transmission-based precaution should the nurse implement to reduce disease transmission?
A AirborneB ContactC Droplet الإجابة الصحيحةD Standard precautions -
24
A 58-year-old patient with a permanent colostomy reports intense peristomal itching and erythema. On assessment, the nurse notes moist, beefy-red patches with satellite lesions around the stoma. The patient recently completed a course of broad-spectrum antibiotics. <br>What is the most likely cause of these findings?
A Contact dermatitisB Candidiasis الإجابة الصحيحةC Stomal necrosisD Allergic reaction to pouch adhesive -
25
A patient presents with high fever, severe headache, projectile vomiting, and nuchal rigidity for 3 days. Bacterial meningitis is clinically suspected and there are no focal neurological signs on examination.<br>Which is the MOST appropriate first diagnostic intervention?
A Urine and stool analysisB Lumbar puncture with CSF analysis الإجابة الصحيحةC Complete blood count and blood cultureD Chest X-ray and abdominal ultrasound -
26
A patient with an indwelling urinary catheter develops fever and cloudy urine 4 days after insertion. The nurse suspects a catheter-associated urinary tract infection (CAUTI). Which nursing action is most effective to prevent further infection?
A Irrigate the catheter daily with sterile salineB Maintain a closed drainage system الإجابة الصحيحةC Clamp the drainage tubing for 2 hoursD Empty the drainage bag every 8 hours -
27
A hospitalized patient develops redness, warmth, and purulent drainage at the site of a peripheral intravenous (IV) catheter 48 hours after insertion. The nurse suspects a catheter-related bloodstream infection (CRBSI). <br>Which action should the nurse take first?
A Apply warm compresses to the insertion siteB Administer the prescribed antibioticC Document the finding and reassess in 2 hoursD Remove the IV catheter immediately الإجابة الصحيحة -
28
A patient presents with progressive enlargement of a multi-nodular goitre causing tracheal compression. Symptoms include pain radiating to the ear and jaw, difficulty swallowing, and progressive shortness of breath due to oesophageal compression.<br>What is the preferred treatment?
A Radioactive iodine treatmentB Thyroid hormone suppression therapyC Iodine supplementationD Surgical resection of the abnormal thyroid tissue الإجابة الصحيحة -
29
During a postoperative assessment after thyroidectomy, the nurse taps the patient's facial nerve (cranial nerve VII) just below the zygomatic arch.<br>A visible twitch of the ipsilateral facial muscles is observed — a positive Chvostek's sign.<br>Which electrolyte imbalance does this finding indicate?
A Hypocalcaemia (low serum calcium) الإجابة الصحيحةB Hyponatraemia (low serum sodium)C Hypokalaemia (low serum potassium)D Hypermagnesaemia (elevated serum magnesium) -
30
A patient returns from thyroidectomy recovery. Fifteen minutes later, the nurse notices the neck dressing is dry but the patient becomes restless, reports a sense of fullness in the neck, and has slight difficulty swallowing.<br>Where should the nurse assess for occult bleeding?
A StoolB VomitusC DressingD Back of neck الإجابة الصحيحة -
31
Postoperative day 1 after a thyroidectomy, a client suddenly becomes restless, develops inspiratory stridor, and reports tightness in the neck. Which nursing assessment is the PRIORITY to detect the complication most likely to cause rapid airway compression?
A Assess for perioral tingling and Chvostek sign (hypocalcemia)B Assess voice quality/hoarseness for recurrent laryngeal nerve injuryC Inspect and palpate the anterior neck/dressing for rapidly expanding swelling or bleeding (hematoma) الإجابة الصحيحةD Monitor temperature and severe tachycardia for thyroid storm -
32
A nuclear plant experienced a leakage, and all involved workers were brought to the Emergency Department for treatment. the medical team prescribed potassium iodide for the workers to block radioactive iodine to be absorbed by an organ in the body. Which of the following organs is the most sensitive to radioactive iodine ?
A BrainB LungsC KidneyD Thyroid الإجابة الصحيحة -
33
The nurse care for a 60 year old woman who history hypertension, hypothyroidism and elevated cholesterol levels. She takes tablets daily for each of the health problem. The doctor orders a routine dual- x-ray absorptiometry test that shows decrease bone density. Which medication most likely contributed the test result ?
A StatinsB Anti-hypertensiveC Synthetic thyroid hormones الإجابة الصحيحةD Cholesterol absorption inhibitors -
34
A 36-year-old man underwent a subtotal thyroidectomy. He is now suspected to have developed hypocalcemia-induced tetany post-operatively.<br>Which symptom BEST indicates tetany?
A Tingling in the fingers الإجابة الصحيحةB Pain in the hands and feetC Tension on the suture linesD Bleeding on the back of the dressing -
35
A 50-year-old woman has a markedly enlarged thyroid with compressive symptoms including progressive dysphagia and dyspnea. Laboratory results confirm hyperthyroidism (TSH low, Free T4 elevated).<br>Which management option is MOST appropriate for this patient?
A Total thyroidectomy الإجابة الصحيحةB Incision and drainage of the goitreC Radioactive iodine therapy aloneD Adrenalectomy -
36
A patient has hypocalcemia, hyperphosphatemia, muscle cramps, and a positive Trousseau sign. <br>Which diagnosis is most consistent with these findings?
A Diabetes insipidusB Conn's syndromeC Hypoparathyroidism الإجابة الصحيحةD Acromegaly -
37
An 18-year-old student presents with acute right lower quadrant abdominal pain, nausea, and guarding. Pain worsens with palpation and there is rebound tenderness. <br>What is the most likely diagnosis?
A Appendicitis الإجابة الصحيحةB Liver CirrhosisC Kidney stonesD Duodenal ulcer -
38
A male patient is being discharged following an appendectomy. Discharge teaching has been completed. What is the MOST important measurable nursing outcome for this patient after discharge?
A Report fever, redness, or drainage from the wound site الإجابة الصحيحةB Remain free of post-surgical complicationsC Use appropriate pain management techniquesD Gradually resume activities and avoid weight lifting -
39
A 17-year-old arrives to the Emergency Room with severe right lower quadrant abdominal pain rated 9/10, repeated vomiting, dry mucous membranes, BP 94/58 mmHg, HR 122/min, RR 20/min, and Temperature 39.2°C. Acute appendicitis is suspected.<br>Which of the following interventions has the HIGHEST immediate priority?
A Keep the patient NPO (nothing by mouth)B Secure IV access and begin fluid resuscitation الإجابة الصحيحةC Prepare the patient for abdominal ultrasoundD Prepare the patient for emergency surgery -
40
The nurse would increase the comfort of the patient with appendicitis by ?
A Having the patient lie proneB Flexing the patient's right knee الإجابة الصحيحةC Sitting the patient upright in a chairD Turning the patient onto their left side -
41
A patient with tuberculosis is started on isoniazid (INH) therapy. Which of the following adverse effects is a major concern that requires close liver-function monitoring during treatment?
A Peripheral neuropathy (numbness and tingling)B Hepatotoxicity الإجابة الصحيحةC Skin rashesD Bradycardia -
42
A 66-year-old woman with a history of unstable angina and hypertension presents to the emergency department with dull chest pain that she describes as similar to heartburn, radiating to her left arm. ECG shows ST-elevation. The physician suspects acute MI.<br>Which medication would be MOST appropriate as an immediate thrombolytic intervention?
A HeparinB WarfarinC Streptokinase الإجابة الصحيحةD Aspirin -
43
A 62-year-old man with a history of intracerebral haemorrhage three months ago is referred to primary care with acute stroke symptoms. Brain CT scan is normal (no new haemorrhage). Current observations: BP 185/105 mmHg, HR 82/min, RR 18/min, Temperature 36.6°C, SpO₂ 93% on 4L/min nasal cannula.<br>Which medication would be ordered FIRST?
A Alteplase (rtPA) — thrombolysisB Aspirin — antiplateletC Dopamine — vasopressorD Nicardipine — antihypertensive الإجابة الصحيحة -
44
When a patient was first diagnosed with schizophrenia, a family member asked the nurse about the possible neurochemical cause. The nurse explained that an excess of a specific neurotransmitter may be involved.<br>Which neurotransmitter is most associated with the development of schizophrenia?
A SerotoninB Dopamine الإجابة الصحيحةC GlutamateD Acetylcholine -
45
A nurse is caring for a patient who had coronary artery bypass graft surgery (CABG) 4 hours ago. The patient is restless with paresthesia. Lab results show: Sodium 145 mmol/L, Potassium 6.8 mmol/L, Calcium 2.50 mmol/L. <br>Which medication is most appropriate to reduce the serum potassium by removing potassium from the body?
A Naloxone (Narcan)B Hydralazine (Apresoline)C Potassium chloride (KCI)D Sodium polystyrene sulfonate (Kayexalate) الإجابة الصحيحة -
46
A 45-year-old woman is 6 hours post-thyroidectomy. She reports increasing difficulty breathing and a feeling of tightness in her neck. Assessment reveals inspiratory stridor, oxygen saturation of 88% on room air, and a swollen, tense neck incision site. Which intervention should the nurse anticipate FIRST?
A Administer intravenous calcium gluconateB Prepare for emergency bedside wound evacuation الإجابة الصحيحةC Apply oxygen via non-rebreather maskD Obtain a stat serum calcium level -
47
A 49-year-old woman presents to the Emergency Department with severe chest pain. ECG confirms ST-elevation myocardial infarction (STEMI). The physician orders aspirin 300 mg.<br>What is the PRIMARY mechanism of aspirin's benefit in this situation?
A Dissolves the existing coronary thrombus directlyB Inhibits platelet aggregation by blocking thromboxane A2 synthesis الإجابة الصحيحةC Inhibits the conversion of prothrombin to thrombinD Antagonises vitamin K to reduce clotting factor synthesis -
48
A 78-year-old woman who lives in a long-term care facility has been having repeated episodes of urinary tract infections. She is prescribed then amine mandelate one gram to be taken by mouth four times per day before meals and at bedtime. The nurse advises the patient that she needs to remove milk from the diet while taking the medication. What is the primary purpose of this dietary advice ?
A To prevent malabsorption of medicationB Decrease risk of gastrointestinal upsetC Reduces effectiveness of medicationD To make the urine acidic الإجابة الصحيحة -
49
An older adult client with renal failure comes to the emergency department with nausea and vomiting. The client's heart rate is 45 beats/min. The nurse is most concerned about which medication that the client takes ?
A NitroglycerinB Digoxin الإجابة الصحيحةC DoxorubicinD Furosemide -
50
A hemodynamically stable client with atrial fibrillation and RVR (HR 130/min) has severe HFrEF (EF 25%). Beta-blockers and non-dihydropyridine calcium channel blockers are contraindicated. IV digoxin failed. Which medication is most appropriate next?
A Intravenous amiodarone الإجابة الصحيحةB Intravenous diltiazemC Adenosine IV pushD Atropine IV bolus -
51
A 45-year-old client with traumatic brain injury is scheduled for a craniotomy. Which medication would the nurse expect to be prescribed to reduce or prevent increased intracranial pressure from cerebral edema postoperatively?
A Mannitol الإجابة الصحيحةB DexamethasoneC PhenytoinD Labetalol -
52
A 71-year-old woman in a long-term care facility fell while walking down stairs. Which medication would most increase her risk of serious injury if she sustains trauma from the fall?
A MetforminB LoratadineC Warfarin الإجابة الصحيحةD Diclofenac -
53
A 33-year-old woman presented to the ER with general weakness. Laboratory investigations indicated VIT D deficiency. Which of the following nutrients should be recommended as a good source of vitamin ?
A RiceB Green teaC Orange juiceD Fish liver oils الإجابة الصحيحة -
54
A 50-year-old woman is attending the outpatient clinic for an annual check-up. Which of the following should be reported if inspected during a breast examination ?
A Everted nipplesB Symmetrical visibleC Dimple in the left breast الإجابة الصحيحةD Right breast is slightly larger than the left breast -
55
While caring for a patient with a spinal cord injury, the patient develops a pounding headache, diaphoresis, bradycardia, and severe hypertension. Autonomic dysreflexia is suspected, and the head of the bed has already been elevated. What is the most appropriate immediate action?
A Notify the physicianB Assess the bladder for distension الإجابة الصحيحةC Continue to monitor for the next hourD Notify the other nurse -
56
A patient is admitted with second-degree burns involving 25% of the total body surface area. The nurse prioritizes laboratory monitoring to detect life-threatening complications early. Which laboratory result is MOST critical to monitor closely in this patient?
A White blood cell count (WBC)B Red blood cell count (RBC)C Platelet countD Kidney function tests (KFT: urea, creatinine, electrolytes) الإجابة الصحيحة -
57
A 25-year-old woman was admitted for anorexia chemotherapy, with a nursing diagnosis of imbalanced nutrition. How should the outcome of nursing care be evaluated for this patient ?
A Record daily weight الإجابة الصحيحةB Monitor vital signsC Schedule meals with family membersD Offer small portions of favorites -
58
A woman with a BMI of 35 is admitted. What's the most appropriate nursing diagnosis related to imbalance ?
A Activity intoleranceB Less than body requirementC More than body requirement الإجابة الصحيحةD Deficient knowledge on normal nutrition -
59
A 65-year-old woman with a history of multiple vaginal deliveries presents with stress urinary incontinence — leaking urine when she coughs or sneezes.<br>Which factor is MOST likely contributing to her pelvic floor weakness?
A Chronic coughing over many years الإجابة الصحيحةB Poorly controlled diabetes mellitusC Excessive high-impact sports activityD Prolonged sedentary lifestyle -
60
A 32 years old multigravida woman presents to the outpatient clinic complaining of dysmenorrhea and menorrhagia. She had been diagnosed with uterine fibroids and blood studies has been ordered for her. Which of the following results should the nurse report ?
A Hematocrit, 37%B Hemoglobin, 9 g/dl الإجابة الصحيحةC White blood cell count, 10,000 cells/mm3D Platelet count, 300,000 platelets/microliter -
61
A 30-year-old woman with previously regular 28-day menstrual cycles has had no menstrual periods for 5 months. Pregnancy test is negative, and she reports heavy exercise and a very restrictive diet. Which menstrual disorder is MOST likely?
A Normal menstrual variationB Primary amenorrhoeaC Secondary amenorrhoea الإجابة الصحيحةD Oligomenorrhoea (infrequent periods) -
62
A 34-year-old woman receiving chemotherapy develops neutropenia. Which meal is MOST appropriate to reduce foodborne infection risk while following neutropenic precautions?
A A fresh mixed salad with raw vegetablesB Sushi and raw seafoodC Hot, well-cooked chicken with steamed vegetables الإجابة الصحيحةD Unpasteurized soft cheese with crackers -
63
A client is admitted with an acute sickle cell vaso-occlusive crisis, severe pain, and moderate dehydration. Which intervention BEST addresses the TWO highest initial priorities simultaneously?
A Start IV opioid analgesia immediatelyB Initiate aggressive IV fluid hydration to prevent sicklingC Initiate IV fluid hydration AND administer IV opioid analgesia concurrently as equal first-line priorities الإجابة الصحيحةD Prepare for urgent blood transfusion -
64
A client is diagnosed as having secondary Cushing’s syndrome. The nurse knows that the client has most likely been taking which medication: ?
A EstrogenB PenicillinC LovastatinD Prednisone الإجابة الصحيحة -
65
A patient has dysfunction of the beta cells in the islets of Langerhans. Which clinical finding is MOST likely?
A AnemiaB AppendicitisC CholelithiasisD Hyperglycemia الإجابة الصحيحة -
66
A nurse has just started total parenteral nutrition (TPN) as prescribed for a patient with severe dysphagia low prealbumin levels. In one to two hours, the nurse should anticipate assessing the patient’s ?
A Blood glucose level الإجابة الصحيحةB WeightC LiverD Spo2 -
67
client with type 1 diabetes mellitus is admitted in which medication if found by the nurse in the should be clarified with the physician ?
A Humalog (lispro) sliding scale before mealsB Glargine (Lantus) 10 units subcutaneouslyC Metformin (Glucophage) 500 mg per oral الإجابة الصحيحةD Dextrose 50% ampule intravenous push for 50 mg/dL -
68
year-old woman with inflammatory bowel disease is scheduled to undergo a procedure in which a stoma will be formed in the right lower quadrant, five centimeters below the waistline. The nurse advises the patient on how to avoid potential post-operative intestinal obstruction. Which of the following types of food best recommended post-operatively ?
A Broccoli and fishB Meats and cauliflowerC Yogurt and parsley الإجابة الصحيحةD Corn and seeds -
69
A nurse is providing education to a patient who is being discharged after olecystectomy and has been placed on a low fat diet. Which of the following foods should be avoided by the patient ?
A Canned beansB Whole milk الإجابة الصحيحةC RiceD Fish -
70
The nurse is caring for a patient who has abdominal pain constipation last three days. The nurse teaches the patient about the most likely ative-producing foods. What are the foods that are mostly useful to relieve constipation ?
A Cheese, pasta, and eggsB Rice, eggs, and lean meatC Bran (Oats), figs, and prune الإجابة الصحيحةD Cabbage, bananas, and apple -
71
A nurse is caring for a patient diagnosed with abdominal x-ray reveals evidence of pancreatic sign of biliary disease. What would the nurse most likely instruct the patient ?
A Consume a high-protein dietB Gradually increase dietary fiberC Avoid ingestion of alcoholic beverages الإجابة الصحيحةD Limit activities when fatigued -
72
A 60 years old patient was admitted with hepatic coma in the intensive care unit. The physician has ordered protein restriction diet for the patient. Which of the following substances is most likely causes harmful effects when the patient increases protein intake ?
A UreaB CreatinineC Ammonia الإجابة الصحيحةD Amino acid -
73
A 40-year-old women patient with Parkinsonism Medical Ward. The patient stated that she has the past two weeks. The nurse was planning to Which type of diet is most suitable for parkin ?
A SolidB LiquidC Semi-solid الإجابة الصحيحةD Clear liquid -
74
A 68-year-old patient admitted to the Emergency Room with clinical manifestation of pulmonary embolism. Arterial Blood Gas (ABC) and chest ay were ordered. Which of the following tests is used to diagnose this condition ?
A Computed Tomography Scan (CT scan)B Magnetic Resonance Imaging (MRI)C Pulmonary angiography الإجابة الصحيحةD Pulmonary function test -
75
39- A 23-year-old woman presents to the clinic with an intense headache that rates at a level 8 on the 1-10 scale. Additionally, she feels nauseous is sensitive when exposed to bright light. Cerebrospinal fluid samples sent to the laboratory for analysis and complete blood count. Testing both kerning’s and Brzezinski’s sign are positive. The patient is admitted the hospital and one hour later she has a seizure. In the period mediately following the seizure, the nurse stays at the bedside to vide on-going care. Which of the following assessments has priority at this time ?
A Blood pressureB Respiratory drive الإجابة الصحيحةC Pupillary changesD Level of consciousness -
76
65-year-old man is undergoing pre-operative preparation for endoscope procedure in which the physician will visualize the large and distal part of the small bowel with a camera attached to the flexible tube. Which of the following positions is the most appropriate ?
A Left lateral Sim's الإجابة الصحيحةB Right lateral recumbentC TrendelenbregD Prone -
77
60-year-old man is being discharged from the post-operative Care Unit following a transurethral resection of the prostate. The nurse provides discharge information regarding the care of the bladder catheter. Which method would be most effective in bladder retraining for this patient ?
A Scheduled urination every 2-3 hours الإجابة الصحيحةB Limit fluid intake before sleeping timeC Perform pelvic floor exercises dailyD Increase fluid intake during daytime -
78
The unit nurse conducts initial assessment and observes the dressing is wet and requires change. The patient looks drowsy with warm skin (see lab results) Blood pressure 110/70 mmHg Heart rate 99 /min Respiratory rate 24 /min Temperature 38.8 C Test Result Normal Values RBC 5.5 4.7-6.1 × 1012 /L (male) 4.2-5.4 × 1012 /L (female) Hb 133 130-170 g/L (male) 120-160 g/L (female) WBC 25.5 4.5-10.5 × 109 /L What is the most likely underlying diagnosis ?
A Sepsis الإجابة الصحيحةB Gangrenous tissueC Acid base imbalanceD Hyperthermia secondary to infection -
79
A postoperative patient has on order to discontinues the foley 11:30 AM, the nurse removes the Foley intact. At 1:00 PM, the patient complains of feeling the need to urinate and voids 30 ce. The nurse should assess the patient for signs of which of the following ?
A Urinary retention الإجابة الصحيحةB Urinary tract infectionC CystitisD Hematuria -
80
At the beginning of the afternoon shifts in the receiving handover from a morning shift nurse post coronary angioplasty. The nurse waveform on the monitor, upon assessment the carotid pulse (see image). What should be the most appropriate next action ?
A Give a DC shockB Refuse to receive patientC Check ventilators settingsD Shout for help and start chest compression الإجابة الصحيحة -
81
A nurse activates the emergency call system after finding a patient unresponsive. What should the nurse do immediately next?
A Initiate ventricular pacingB Administer a prescribed bolus of lidocaineC Defibrillate the patientD Open the patient’s airway الإجابة الصحيحة -
82
The nurse is caring for a patient with a history of transient ischemic attacks (TIAs) and moderate carotid stenosis who has undergone a carotid endarterectomy. Which of the following postoperative findings would cause the nurse the most concern ?
A Blood pressure (BP): 128/86 mm HgB Neck pain: 3/10 (0 to 10 pain scale)C Mild neck edemaD Difficulty swallowing الإجابة الصحيحة -
83
A 48-year-old man was admitted with extensive anterior MI. During the night, he lost consciousness. The cardiac monitor showed ventricular fibrillation (VF). The nurse checked the carotid pulse and found no pulse. What is the best emergency management?
A Cardiac thumb twiceB Defibrillation with 50 joulesC Defibrillation with 200 joules الإجابة الصحيحةD Chest compression for five cycles -
84
A nurse is caring for a 58-year-old patient (see lab result). Test Result Normal Value Magnesium 2.8 0.7-1.2mmoI/L Which ECG change is the nurse expected to note ?
A Prolonged QRS الإجابة الصحيحةB Multiple P wavesC Prominent U wavesD Depressed ST segment -
85
During surgery requiring general anaesthesia, and a carotid pulse is not palpated. How many compressions per minute should be ?
A 50B 60C 80D 100 الإجابة الصحيحة -
86
which of the following indication for patient with MI ?
A ST depressionB ST elevation الإجابة الصحيحةC Short STD None of the above -
87
A 40-year-old man is admitted with coronary-type chest pain. His blood pressure is 123/69 mmHg and ECG shows a normal sinus rhythm. Which nursing diagnosis is MOST appropriate based on the available data?
A Acute chest pain الإجابة الصحيحةB Myocardial infarctionC Decreased cardiac outputD Ineffective tissue perfusion -
88
A man was restless and observed to have an increased physical activity after a heated argument with another person. After the assessment, the following data was gathered: agitated, diaphoretic, distorted What is the patient's level of anxiety ?
A MildB PanicC Severe الإجابة الصحيحةD Moderate -
89
A 30-year-old construction worker is stung by a bee and rapidly develops anaphylaxis with severe bronchospasm, hypotension, tachycardia, and a weak thready pulse. Which white blood cell type is primarily responsible for releasing histamine during this immediate allergic reaction?
A EosinophilsB Basophils الإجابة الصحيحةC MonocytesD Neutrophils -
90
A 28-year-old woman with an affective disorder becomes angry, panicky, apathetic, and listless. Which nursing approach is MOST appropriate?
A Be supportive and use therapeutic communicationB Improvise sign language to control forgetfulnessC Maintain a calm environment and avoid argument الإجابة الصحيحةD Anger management and speech therapy -
91
A patient with suspected acute coronary syndrome has an SpO2 of 98% on room air and no aspirin allergy or active bleeding. Using the MONA approach, which nursing action is the TOP priority?
A Administer oxygen according to the physicianB Administer aspirin according to the physician الإجابة الصحيحةC Administer morphine according to the physicianD Administer nitroglycerin according to the physician -
92
A 59-year-old woman is admitted in the Medical ward for pyomyositis in her arms and legs. The muscular strength Progressively decreased within one year. She has irregular breathing pattern and has difficulty in swallowing. Which of the following nursing diagnosis requires ?
A Risk of choking due to disturbed swallowing الإجابة الصحيحةB Weakness and fatigue due to lower muscleC Disturbed breathing due to chest muscleD Disturbed activities of daily living -
93
high school girl, who has fears of being obese thin, visited the primary healthcare centre with her The mother reports that her daughter refuses to with the family, and often pretends being a sleep Which of the following disorders best describe girl ?
A BulimiaB ObesityC Substance AbuseD Anorexia Nervosa الإجابة الصحيحة -
94
A patient returns to a clinic for a follow-up visit and is diagnosed as positive for Human Immunodeficiency Virus (HIV). The patient expresses fear related to lack of finances, fear of social avoidance, and hopelessness. Which of the following nursing action should ?
A Referral to a community-based HIV clinic الإجابة الصحيحةB Referral to a physician infectious disease specialistC Referral to the local public health departmentD Recommendation to disclose the diagnosis to family -
95
While taking the history from a new patient, the nurse densified that he had hypomanic episode which was alternating with a mirror depressiveepisode for the last two years. what is the most likely diagnosis ?
A Bipolar I disorderB Bipolar II disorderC Dysthymic disorderD Cyclothymic disorder الإجابة الصحيحة -
96
A nurse calls together an interdisciplinary team with members from medicine, social service, the clergy, and nutritional services to care for a patient with a terminal illness. Which of the following types of care would the team most likely be providing ?
A Palliative الإجابة الصحيحةB CurativeC RespiteD Preventive -
97
A 70-year-old women with a history of hypertension companies of lack of appetite due to bloating and constipation. The abdomen is distended and examination shows a positive fluid wave. palpation of the abdomen confirms guarding and tenderness over the right upper quadrant lower eg edema 3+ and pitting bilaterally are also present. She has kilograms since her last appointment three weeks before4.5 164/92 mmHg Blood pressure 90 /min Heart rate 26 /min Respiratory rate 37.1C Temperature 92% on room air Oxygen saturation What is the most likely underlying health problem ?
A Hepatic congestion الإجابة الصحيحةB Pulmonary hypertensionC Left-sided ventricle failureD Splenomegaly -
98
A 70-year-old man presents to the clinic with difficulty sleeping at night. He has not had a good night's rest for several months and feels exhausted. He needs to place three pillows behind his back in order to sleep. Examination of the lungs reveals crackles and wheels Auscultation of the heart confirms an S gallop. Which of the following is the most likely underlying health problem ?
A AsthmaB Pulmonary stenosisC Right-sided heart failureD Left-sided heart failure الإجابة الصحيحة -
99
What is the most appropriate blood product for a patient with haemorrhage due to upper GI bleeding ?
A PlasmaB Whole bloodC Packed red cells الإجابة الصحيحةD Serum albumin -
100
A 75-year-old bedridden patient has an infected pressure injury that is healing slowly. She has frequent crying spells and talks about death. Which nursing diagnosis domain is most relevant to this patient's current problem?
A Health and wellnessB Coping mechanism الإجابة الصحيحةC Self-perceptionD Belief system -
101
A patient complains of pain when standing upright hump on the upper back. In the past year slightly shorter. The doctor has suggested tests to What is the best appropriate intervention ?
A Instruct the patient in the use of prescribed magnesium supplementsB Have the patient sleep propped on two pillowsC Prepare the patient for a CT scan of both hips الإجابة الصحيحةD Instruct the patient in the use of vitamins -
102
In a post-operative patient in the Surgical Unit most indicative of a developing complication ?
A Increasing alertnessB Weak and rapid pulse الإجابة الصحيحةC Negative Homans' signD Minimal bowel sounds in four quadrants -
103
A nurse is planning to discharge a known HIV, a the Isolation Unit after the recovery from upper, Which of the following nursing problem requires ?
A Risk of infection due to altered immune function الإجابة الصحيحةB Fluid volume deficit due to frequent diarrheaC Anxiety due to disease, fear, and social isolationD Weight loss due to higher metabolism rate -
104
An elderly patient who has an aortic aneurysm Intensive Care Unit to a Medical Surgical Unit on day. While assessing the client, a nurse notes extremities and is unable to palpate the pedal pulse Which intervention should the nurse implement ?
A Wrap the lower extremities with warm blanketsB Use a Doppler ultrasound to reassess the pedal pulse الإجابة الصحيحةC Elevate the extremities above heart levelD Place a bed cradle over the bed to elevate -
105
A 60-year-old man client had a permanent complains of chest pain and dyspnea with rapid feels suffocated and appears restless 100/70 mmHg Blood pressure 96 /min Heart rate 32 /min Respiratory rate 37.2C Temperature What is the immediate nursing intervention ?
A Monitor and report findings of chest painB Chest X-ray to identify dislocationC Manage pain with medication as orderedD Administer oxygen as ordered الإجابة الصحيحة -
106
Which of the following is the appropriate nursing advice to mother complaining of epigastric burning sensation and do use of drugs ?
A Chewing gumsB Increase fluids at bedtimeC Drink orange juice on getting upD Eat small meals every 2 to 3 hours الإجابة الصحيحة -
107
A 46-year-old man is presented to Emergency Room with severe chest and unstable angina. The ECG of the patient shows ST segment pression on his 12-lead. e rhythm strip example of specific ECG changes (see image). Which of the following cases the nurse determines ST segment depression ?
A InjuryB NecrosisC Ischemia الإجابة الصحيحةD Nothing significant -
108
The nurse observes the client csf,Which of the following of csf color indication for patient with bacterial meningitis ?
A Cloudy الإجابة الصحيحةB ClearC RedD Brown -
109
A 50-year-old man presents to the Emergency Department after having suffered a fall while practicing mountain biking. He appears confused and disoriented. His friend reports that he had been thrown over the handle bars and hit his head against a rock [ Blood pressure: 108/66 mmHg, Heart rate: 102/min, Respiratory rate: 22/min, Temperature: 37.2C, Oxygen saturation: 99% room air ] Which initial intervention is the most important ?
A Intravenous infusionB Oxygen administrationC Cervical immobilization الإجابة الصحيحةD Trendelenburg position -
110
A post-operative nurse assesses the newly formed stoma and skin of a patient who is one day postoperative following a proctocolectomy with the formation of a permanent ileostomy. Which of the following clinical findings would necessities immediate care ?
A Bright red and moist stomaB Dark red and purple skin الإجابة الصحيحةC Bloody liquid in pouchD Ulcerations with a rash -
111
What do the standards of pain management dictate nurse do ?
A Avoid the use of the word """"pain""""B Screen for pain at each encounter الإجابة الصحيحةC Discourage around-the-clock dosage of analgesicsD Administer analgesics via injection whenever possible -
112
A nurse is planning post-operative teaching for a patient undergone left partial mastectomy. On the third post-operative day, the nurse teaches the patient to elevate the arm above the heart several times per day. What does this exercise reduce ?
A PainB InfectionC HematomaD Lymphedema الإجابة الصحيحة -
113
conscious victim of a motor vehicle accident arrives at the emergency department. The patient is Gasping for air, is extremely anxious, and has a deviated trachea. What diagnosis should the nurse Anticipate ?
A Pleural effusionB Tension pneumothorax الإجابة الصحيحةC PneumothoraxD Cardiac tamponade -
114
A client reports multiple mosquito bites and now has flu-like symptoms. The client asks whether seeing a health-care provider is necessary. Which statement should guide the nurse's response?
A Antiviral medications can be prescribed to destroy the virusB Clinical signs can be mild flu-like symptoms to fatal encephalitis. الإجابة الصحيحةC If the client has the West Nile virus, symptoms will progressively worsen.D If the client used insect repellent, the virus would have been destroyed when the mosquito made skin contact. -
115
A patient has been experiencing recurrence of this media antibiotic therapy and the patient was scheduled for preparative teaching, the patient asked the nurse about the purpose of the procedure. What is the best answer that the nurse should provide ?
A Stimulates motion of the ossiclesB Detects permanent hearing lossC Allows drainage of purulent fluid from the middle ear الإجابة الصحيحةD Enables medication administration directly to the affected ear -
116
A 65-year-old women visited the gynecological outpatient history reveals that she had 3 pregnancies, one abortion gestational age, had 2 normal deliveries. She smokes 20 Her complaint is that she wets herself when she cough embarrassing for her. Which of the following can be considered as risk factors pelvic floor muscles ?
A Chronic coughing الإجابة الصحيحةB Diabetes mellitusC Excessive spotD Sedentary lifestyle -
117
A 55 year-old man takes cyclosporine mg by mouth twice per day. He had a heart transplant two months ago. He complains of stomach cramping, diarrhea and muscle twitches. Which electrolyte is most likely elevated ?
A MagnesiumB SodiumC CalciumD Potassium الإجابة الصحيحة -
118
MR ahmed admitted to ICU with congestive heart disease his vital signs BP 110/60 HR 120 . stroke volume 80 the nurse expected cardiac output to be ?
A 1700B 2400C 9600 الإجابة الصحيحةD 180 -
119
A surgical nurse is assigned to care for a woman who had undergone vaginal hysterectomy. The nurse performed assessment. Which of the following potential problem that the nurse should observe ?
A Bladder dysfunction الإجابة الصحيحةB PainC FeverD Anxiety -
120
A 45 year-old man who is hospitalized feels tge constant need to keep things in order, particularly whilst eating m the nurse observe him arranging the food on his plate into symmetrical and equal bite sized pieces, he constantly worries that the food served could be outdate and potentially causes illness Which nursing diagnosis is most important ?
A Anxiety الإجابة الصحيحةB Self-esteem disturbanceC Ineffective verbal communicationD Impaired social interaction -
121
A patient with septic shock develops elevated blood glucose levels ranging from 180–225 mg/dL. The patient has no history of diabetes. The spouse asks why insulin is being given. Which nursing response is MOST appropriate?
A Critically ill patients often develop diabetes temporarily, so insulin is given to keep glucose levels below 140 mg/dL.B The patient probably had diabetes before but it was not diagnosed. Insulin is given to keep glucose levels between 70–110 mg/dL.C High blood glucose can occur as a stress response during severe illness. Insulin is used to maintain glucose levels around 140–180 mg/dL. الإجابة الصحيحةD High glucose levels are common in critically ill patients and affect the ability to fight infection, so insulin is given to maintain normal levels of 70–110 mg/dL. -
122
33-year old man presents to the emergency department with high grade fever, tachycardia, and tachypnea. What is an appropriate nursing intervention for the patient’s fever ?
A Provide dry clothing الإجابة الصحيحةB Keep limbs close to the bodyC Cover the patient’s scalp with a capD Measure the patient’s fluid intake and output -
123
A 62 year-old male patient, admitted in the surgical Ward is scheduled for the surgical removal of polyps from his descending colon under general anaesthesia. he is experiencing fatigue, abdominal pain and blood streaked stools for a couple of months. he is worried whether the bleeding in his stools is going to stop after surgery. What is most appropriate response by the nurse for the patient concern ?
A Surgery often relieves the symptomsB Let us have a detail discussion with your physician الإجابة الصحيحةC Your condition may or may not resolve, it dependsD In fact, surgery is the only treatment for the problem -
124
A 70year-old male patient is brought to the emergency department on awheelchair he complain of drowsiness, fatigue,lack od appetite for the last 3days. with history taking, the patient stated that he did not eliminate since 5 days and he is not ambulating a lot because he has arthritis in both knee. why constipation is one of the common problem for immobilized Patients ?
A Decreased peristalsis الإجابة الصحيحةB Increased colon motilityC An increased defecation reflexD Decreased tightening of the anal sphincter -
125
A patient has undergone pericardiocentesis as part of the management of cardiac tamponade Which of the following would be most indicative of cardiac tamponade recurring ?
A Facial flushingB Declining heart soundsC Muffled heart sounds الإجابة الصحيحةD Increasing blood pressure -
126
A patient diagnosed with obsessive-compulsive disorder (OCD) continually carries a toothbrush, and will brush and floss up to fifty times each day. The healthcare provider understands that the patient's behavior is an attempt to accomplish which of the following ?
A Experience pleasureB Relieve anxiety الإجابة الصحيحةC Avoid social interactionD Promote oral health -
127
Patient with cataract was admitted in the ward for cataract surgery. On admission, the patient perceived that surroundings are mer as if her glasses need cleaning .What is the most important nursing problem at the early stage ?
A Eye painB DiplopiaC Blurred vision الإجابة الصحيحةD Light scattering -
128
patient is being weaned off from the mechanical ventilator is about to hook the endotracheal tube to oxygen at FiO2 of 40 Which of the following oxygen administration device is the best the nurse in this situation ?
A Ambu bagB Venturi maskC Tracheostomy collarD T-piece/ Briggs الإجابة الصحيحة -
129
A 22-year-old patient is admitted in the male diagnosis of tonsillar abscess. He has high fever along with dysphagia, difficulty in talking and patient is planned for needle aspiration of the intravenous antibiotic including penciling.What is nursing problem need attention first ?
A An imbalance nutrition due to inadequateB Acute pain related to throat inflammationC Impaired swallowing related to dysphagia الإجابة الصحيحةD Hyperthermia related to acute infection -
130
A newly appointed nurse is caring for an obese patient after an open laparotomy. Which postoperative complication is the patient at highest risk for because of obesity?
A HungerB Gas painC HemorrhageD Impaired wound healing الإجابة الصحيحة -
131
A nurse has taught a patient with iron deficiency anemia about eating als that are high in iron. Which of the following meal is low in iron ?
A Dried beans and brown riceB Eggs and whole wheat toastC Steak and a salad made with fresh spinachD Cheese pizza and pasta with tomato sauce الإجابة الصحيحة -
132
A 45-year-old woman patient was diagnosed with bronchial asthma and was admitted in the Medical Ward. The nurse taught the patient to metered dose nebulizer. Which of the following action indicates that she understands the instruction ?
A Inhale slowly and deeply puff الإجابة الصحيحةB Does not shake the pre-packaged nebulizerC Administer the puffs rapidly between breathD Remove the aero chamber immediately after administering the puff -
133
A37 years-old man present man present to emergency department with chest pain. An ECG shows significant elevation in the ST segm II, III and aVF,indicating MI related to occlusion in the artery what is the location of MI ?
A Posterior MIB Anterior MIC Inferior MI الإجابة الصحيحةD Lateral MI -
134
70 years-old woman is admitted to the cardiac care unit wit atrial fibrillation and is receiving intravenous diltiazem and heparin What is the most likely nursing diagnosis ?
A High risk for infectionB High risk for impaired gas exchangeC High risk for decreased cardiac output الإجابة الصحيحةD High risk for disturbed sensory perception -
135
A patient hospitalized with chest pain is diagnosed with angina Which of the following discharge instruction takes priority ?
A Recognize signs and symptoms that require immediate report الإجابة الصحيحةB Maintain low cholesterol, low sodium, and low potassiumC Carry heavy objects away from the chest areaD Maintain physical exercise daily -
136
The nurse is assigned to care for a patient with Paget’s dis complaining of bone pain. Which of the following conditions is this patient high risk for ?
A HypomagnesemiaB HypernatremiaC Hypercalcemia الإجابة الصحيحةD Hyperkalemia -
137
A 44 year-old woman presented to the Emergency Department with eye pain and redness. She was diagnosed with uveitis related to a viral infection. The doctor prescribe dexamethasone eye drops.Where is the correct place to instill eye drops ?
A Above the eyelidB Directly into the corneaC Into the conjunctiva sac الإجابة الصحيحةD Outside the conjunctiva sac -
138
A 22-year-old man presents to the Emergency Department complaints of breathing difficulties. He appears restless and reports that he has had a cough with thick green sputum for days. The nurse performs auscultation over the lung fields. Blood pressure 130/80 Heart rate 100 Respiratory rate 24 Temperature 39 Which clinical finding is most likely heard over the right lower ?
A Decreased vocal resonanceB Decreased fremitusC TympaniD Bronchial الإجابة الصحيحة -
139
A hospitalized 72-years-old man who uses a walker is received medication and must use the bathroom several times each night To promote the safety of the patient, which of the following appropriate nursing action ?
A Keep the side rails upB Leave the bathroom light onC Provide a bedside commode الإجابة الصحيحةD Withhold the patient’s diuretic medication -
140
A man patient admitted to the Medical Unit was diagnosed with deep venous thrombosis complaining of pain on both legs. Which of the following nursing diagnosis most likely describes problem ?
A Risk for injuryB Fluid volume excessC Electrolyte imbalanceD Impaired tissue perfusion الإجابة الصحيحة -
141
A client is 24 hours after exploratory laparotomy for blunt abdominal trauma and now develops hypotension, tachycardia, oliguria, and severe nausea. Which nursing diagnosis is the priority?
A NauseaB Risk for infectionC Deficient fluid volume الإجابة الصحيحةD Impaired urinary elimination -
142
patient with a spinal cord injury states, """"I have no constitution; I can’t do anything for myself."""" Which of the following best describes this patient condition ?
A Powerlessness الإجابة الصحيحةB DelusionsC SuicidalD Resignation -
143
A 43 year-old man in the post-surgical area complains of abdominal pain radiating to the naval which is increasing with examination his abdomen is guarded with marked tender lower quadrant. What is the immediate goal of care to do ?
A Teach abdominal splinting during coughingB Administer pain medication as orderedC Assess pain and report immediately الإجابة الصحيحةD Position on the left lateral side -
144
27 years old female brought to the Emergency Room accompanied by her husband. He described that she had marked Weight loss with episodes of emesis in the past three months. She is diagnosed as having anorexia. She reported feeling Febrile, but had not measured her temperature. Her White Blood Count was 11,000/mm3. Which of the following most Likely describe her diagnostic criteria for her anorexia ?
A Restricting food intakeB Fear of gaining weight الإجابة الصحيحةC Problems with body imageD Binge eating disorder -
145
A nurse is caring for a patient two hours after a pacemaker placement. The patient suddenly starts complaining of chest pain. The nurse observes dyspnea, cyanosis and absent breath sounds on the right side. The nurse should anticipate what complications ?
A HemothoraxB Perforation of the heartC Pneumothorax الإجابة الصحيحةD Hemorrhage -
146
Which of the following could adversely affect the function of a pacemaker ?
A HairdryerB Electric razorC Airport metal detectors الإجابة الصحيحةD Electric mixer -
147
A 58-year-old man is being discharged after permanent pacemaker insertion. Which nursing outcome is most important to ensure safe self-management at home?
A Understand functioning and operating of pacemakerB Monitor pulse rate and identify need for reporting الإجابة الصحيحةC Able to identify the signs of detached pacemakerD Modify lifestyle and wear a pacemaker alert sign -
148
A client in diabetic coma is receiving IV sodium bicarbonate for acidosis. The nurse finds the client lethargic, confused, and breathing rapidly. What is the priority nursing action?
A Stop the infusion and notify the physician because the client is in alkalosis.B Decrease the rate of the infusion and continue to assess the client for symptoms of alkalosis.C Continue the infusion, because the client is still in acidosis, and notify the physician. الإجابة الصحيحةD Increase the rate of the infusion and continue to assess the client for symptoms of acidosis. -
149
A nurse who works in the surgical unit at one of the hospitals was asked by the home health care nurse to make a home visit to a patient with colostomy, who had been discharged the previous day in order to give him a follow-up care and education which of the following nurses should do the assigned task ?
A Critical care nurseB Psychiatric nurseC Surgical nurseD Community nurse الإجابة الصحيحة -
150
A 46-year-old patient is admitted in the female Medical Ward for seven back pain, which is graded 6 on the scale of 10. Her vital signs are take with the slight elevation in her blood pressive. The patient has refused eat lunch which is a low sodium diet. The attending nurse has documented that patient is uncooperative and has refused to eat the lunch. What nursing intervention needs attention first ?
A Arrange for an alternative dietB Teach importance of the low salt dietC Take appropriate measures to relieve pain الإجابة الصحيحةD Inform the physician for elevated blood pressure -
151
A 30-year-old man was brought to the hospital by ambulance sitter felling from a height of 10 meters. He was mechanically ventilated on after a Glasgow Coma Score showed a level of six. The nurse is observe for any changes in perceptual, sensory or cognitive Which of the following is an expected patient's response at this time ?
A Slowly obeys commandsB Exhibits no motor responseC Reacts towards painful stimuli الإجابة الصحيحةD Uses incomprehensible words -
152
A 46-year-old woman with systemic lupus erythematosus has joint pain, dull aching pain in the lumbar region, and a butterfly rash. Which nursing intervention should be performed first?
A Skin care and cortisone ointment as orderedB Pain relieving measures and physiotherapyC Assess back pain and monitor urine output الإجابة الصحيحةD Analgesics as ordered in a warm environment -
153
A patient with SLE (systemic lupus erythematosus) report decreased urinary output during the past 2-4 days and chest pain that is aggravated by breathing and coughing. The patient vital signs remain within the baseline normal range s1 and s2 are present with audible friction rub. Which of the following statement would be appropriate for the nurse to make ?
A It sounds like SLE is being well controlledB I need to get some nitroglycerine for your chest painC There may be some inflammation surrounding your heart الإجابة الصحيحةD Your symptoms may be due to a urinary tract infection -
154
A 45-year-old of man was admitted to the Surgical Ward after removed of pancreatic cyst. The registered nurse checked the post-operative orders Ondansetron PRN was prescribed for the patient. Which of the following complaints from the patient will require the registered nurse to serve the Ondansetron after 12 hours of post-operative period ?
A Wound painB Nausea and vomiting الإجابة الصحيحةC Congestion of flameD Difficulty in passing urine -
155
A nurse is caring for a woman diagnosed with major depressive disorder. The client states, "I have never had a male nurse before." Which response by the nurse is MOST therapeutic?
A Do you feel threatened by having a male nurse?B Many nurses working here are male.C How do you feel about having a male nurse caring for you? الإجابة الصحيحةD Would you prefer that I ask for a female nurse instead? -
156
A 72-year-old patient presents to the medical clinic drooling with a blank, masklike facial expression and a high-pitched, monotone, weak wike When walking, the patient does not swing the arms normally, but holds hem stiffly rigid. What is the most likely diagnosis ?
A Parkinson's disease الإجابة الصحيحةB Substance abuseC Traumatic brain injuryD Transient ischemic attack -
157
A 69-year-old obese woman with a pelvic fracture has been immobile for four days. The patient is now anxious, dyspneic, and complaining of substernal pain. The patient's capillary refill is greater than seconds. Heart rate 122 /min Respiratory rate 26 /min Temperature 38.2 C Which of the following does the nurse suspect for this patient ?
A Panic attackB Pulmonary embolism الإجابة الصحيحةC Aspiration pneumoniaD Pneumothorax -
158
The nurse is planning for a discharge teaching plan for a family of a 30-year-old man with AIDS in relation to sanitation practices. Which of the following statements should the nurse include in her instructions ?
A Wash used dishes in hot soapy water الإجابة الصحيحةB Boil the dishes the patient used for 30 minutes and then wash with soapC Have the patient use disposable eating tools so it can be discarded afterD Soak the kitchen tools in hot water for 24 hours before washing with soap -
159
The nurse is planning care for an older client with respiratory acidosis. Which intervention should be included in the plan of care?
A Administer prescribed intravenous fluids carefullyB Administer intravenous sodium bicarbonateC Maintain adequate hydration الإجابة الصحيحةD Reduce environmental stimuli -
160
Patient has nausea, vomiting, and muscle weakness comes to ER, after assessment the doctor considers that sign and symptom due to: ?
A Hypokalaemia الإجابة الصحيحةB HypernatremiaC HyperkalaemiaD Hypoglycaemia -
161
A client has atrial fibrillation. Which complication should the nurse monitor for most closely?
A Cardiac arrestsB Cerebrovascular accident الإجابة الصحيحةC Heart blockD Ventricular fibrillation -
162
An adolescent is being treated for recurrent chlamydial infection. Which teaching is most important to prevent reinfection and detect serious coinfections?
A Use two forms of contraception while taking the medicationB Ensure sexual partners are evaluated and treated and undergo screening for HIV and other STIs الإجابة الصحيحةC Avoid high-fat foods and caffeine during therapyD Report joint pain immediately -
163
According to information provider in the accompanying graphic, a transverse colostomy would be expected to produce which of the following (see image) ?
A Fluid fecesB Mushy feces الإجابة الصحيحةC Semi-fluid fecesD Solid feces -
164
A client's arterial blood gas shows a PaO2 of 72 mmHg. For which associated problem should the nurse assess this client?
A CommunicationB PerfusionC Fluid and electrolyte imbalanceD Cognition الإجابة الصحيحة -
165
According to the Ramsay Sedation Scale, a patient who is in deep sleep and not responsive to light stimulation would score:
A 2B 3C 4D 6 الإجابة الصحيحة -
166
During a home visit, the nurse evaluates care provided to a client with type 1 diabetes mellitus and a history of metabolic acidosis. Which outcome indicates that the care of this client has been successful?
A The client is injecting insulin into thigh muscleB The client is taking laxatives three times a week to ensure adequate bowel movementsC The client is eating three balanced meals per day with two snacks الإجابة الصحيحةD The client is taking aspirin 325 mg every 6 hours to treat arthritis pain -
167
Using the Parkland formula (4 mL × kg × %TBSA), how much IV fluid is required in the first 24 hours for a 48-kg patient with 9% TBSA burns?
A 1,572 mlB 1,220 mlC 1,728 ml الإجابة الصحيحةD 2,000 ml -
168
A 75-year-old man is scheduled for phacoemulsification (cataract) surgery under local anesthesia. During the procedure, what is the patient MOST expected to do to support safety and surgical precision?
A Lie supine and remain still throughout the procedure الإجابة الصحيحةB Sit upright and follow verbal commandsC Cough gently if necessaryD Turn head side to side to assist the surgeon -
169
A 47 years old newly been diagnosed as having gastroesophageal reflux disease (GERD) comes to the clinic for follow up appointment. The nurse prepares health education on the cause and care of GERD. Which of the following stomach area is associated with the diagnosis ?
A 1 الإجابة الصحيحةB 2C 3D 4 -
170
A nurse is giving health education regarding the management of premenstrual syndrome symptoms to a group of first-year nursing students. Which of the following information regarding diet will the nurse include in the presentation ?
A Take three healthy meals a day to prevent hypoglycemia and increase feeling of well-beingB Include simple sugars in the diet to prevent low blood glucose levels which cause mood swingsC Drink 2000ml of fluid (water, coffee, tea) per day to flush the kidneys and improve fluid retentionD Decrease intake of caffeine such as coffee and chocolate to minimize irritability, insomnia, and anxiety الإجابة الصحيحة -
171
A diabetic mellitus patient had left low-knee amputation. Which sign shows poor glucose control in wound healing ?
A Swelling of the stumpB Bleeding of the stumpC Mild redness of the wound siteD Separation of the wound edges الإجابة الصحيحة -
172
A client has just returned from surgery after an above-knee amputation of the right leg. The nurse wants to reduce postoperative edema and provide comfort during the first 24 hours after surgery. Which position is most appropriate?
A ProneB Reverse Trendelenburg'sC Supine, with the amputated limb flat on the bedD Supine, with the amputated limb supported with pillows الإجابة الصحيحة -
173
A home health nurse visits a patient newly diagnosed with diabetes mellitus. Which teaching topic should take priority initially?
A Glucose monitoringB Dietary requirements الإجابة الصحيحةC Exercise regimenD Medication -
174
A 30-year-old married man presents to the clinic with complaints of feeling sad for the past three months. He is unable to maintain a regular sleep routine; he lost his appetite and has difficulty concentrating. He is prescribed medication that prevents the reuptake of specific neurotransmitters that could contribute to his mental health problem. Which side effects would be most important for the nurse to advise the patient on ?
A PolyuriaB PhotophobiaC Fluid retentionD Sexual dysfunction الإجابة الصحيحة -
175
A 35-year-old post-appendectomy patient has abdominal distention and absent bowel sounds. Which nursing intervention is most appropriate?
A Encourage ambulationB Provide a liquid diet as toleratedC Ensure patency of nasogastric tube الإجابة الصحيحةD Check surgical site for signs of infection -
176
Which one of the following signs and symptoms is associated with increased intracranial pressure ?
A Restlessness and confusion الإجابة الصحيحةB Bradycardia and hypertensionC Tachycardia and hypotensionD Respiratory depression and headache -
177
A cardiac monitor for a patient in a Coronary Care unit shows an abnormal ECG rhythm with a heart rate of 159 beats, QRS complex (0.18 seconds), and an absent P wave. What could be the type of possible dysrhythmia ?
A Sinus tachycardiaB Ventricular tachycardia الإجابة الصحيحةC Ventricular fibrillationD Supraventricular tachycardia -
178
A 50-year-old man is in the ICU 24 hours after a head injury and has a Glasgow Coma Scale score of 10. What is the priority nursing action?
A Inform the registered nurse in chargeB Raise both side rails to ensure safetyC Prepare the patient for emergency surgeryD Perform neurological assessment every 15 minutes الإجابة الصحيحة -
179
A teenage client with bipolar disorder has incoherent speech and reports seeing and hearing things that others do not. Which essential finding must the nurse monitor and report?
A Visual and auditory hallucinations الإجابة الصحيحةB Frequency and duration of mood swingsC Level of agitation and speech difficultyD Medication schedule and expected side effects -
180
A 62-year-old diabetes type II patient rates preoperative pain at 9. How can phantom pain post-amputation be best controlled ?
A Post-operative elevation of limbB Apply pressure bandage to stumpC Control pain pre-operatively الإجابة الصحيحةD Apply ice to site -
181
A patient is being discharged after an aortic valve replacement and receives teaching about long-term care and medication safety. Which patient statement indicates that the teaching was effective?
A I am glad I can continue taking Ginkgo biloba supplements.B I will increase my intake of green leafy vegetables.C I will apply vitamin E to my chest incision after showering.D I will use an electric razor instead of a blade when shaving. الإجابة الصحيحة -
182
Which disorder should the nurse suspect in a patient with acute shortness of breath, pink frothy sputum, and low blood pressure?
A PneumothoraxB Unstable anginaC Pulmonary edema الإجابة الصحيحةD Pulmonary embolus -
183
What type of pain describes tingling, coldness, and cramping in the right foot of a post-amputation patient ?
A VisceralB SomaticC IschemicD Neuropathic الإجابة الصحيحة -
184
What sign suggests a nose is still bleeding after a trauma-related nose injury ?
A Complaint of nasal bone painB Difficulty in breathingC Swallowing frequently الإجابة الصحيحةD Increased swelling -
185
After starting antidepressant therapy, when do therapeutic effects typically begin to appear?
A 3-4 daysB 10-14 daysC 14-18 days الإجابة الصحيحةD A month -
186
Which physician order should the nurse question for a patient with sudden onset right lower quadrant abdominal pain?
A Apply heating pads to abdomen الإجابة الصحيحةB Obtain abdomen X-rayC Start IV dextrose 5%D Nothing by mouth -
187
A nurse identifies the diagnosis "Risk for ineffective peripheral tissue perfusion" in a patient during the first 24 hours after amputation. Which intervention is most appropriate?
A Ensure adequate pain reliefB Elevate residual limb on a pillow الإجابة الصحيحةC Administer oxygen by facemaskD Apply ice to the stump -
188
What is the most important nursing action to prevent muscle contracture in a patient with immobility from a cerebrovascular accident ?
A Provide diet rich in proteinB Turning the patientC Provide range of motion exercises الإجابة الصحيحةD Apply moisturizing cream -
189
Which weaning parameter indicates adequate muscle strength for a patient on a ventilator ?
A Normal electrolytesB Positive fluid balanceC Negative inspiratory force الإجابة الصحيحةD Increased minute ventilation -
190
A client is receiving mechanical ventilation when the alarm sounds and displays an alert showing low tidal volumes. All connections and the ET tube are checked and secured but the alarm persists while O2 saturation continues to drop. Which of the following is the most appropriate initial action ?
A Increase oxygen delivery to 100%B Manually ventilate through the endotracheal tube الإجابة الصحيحةC Call the respiratory therapist to assess the patientD Elevate the head of the bed and apply a non-rebreather mask -
191
A 16-year-old girl with anorexia nervosa appears very weak and requires support to walk. What is the primary nursing diagnosis?
A Risk for injury related to low potassiumB Body image disturbance related to obesityC Imbalance nutrition related to compulsive overeatingD Imbalance nutrition related to restricting caloric intake الإجابة الصحيحة -
192
A patient with a closed head injury has an intracranial pressure of 16 mmHg. What's the most appropriate nursing intervention ?
A Provide an intravenous fluid bolusB Position the patient in semi-fowler's الإجابة الصحيحةC Prepare for hypothermia inductionD Hyperventilate with positive pressure -
193
A nurse is assigned to care for a patient with a thrombotic stroke. What is the likely cause ?
A Blockage of large vessels as a result of atherosclerosis الإجابة الصحيحةB Emboli produced from valvular heart diseaseC Decreased cerebral blood flow due to circulatory failureD A temporary disruption in oxygenation of the brain -
194
Which intervention is appropriate for the diagnosis of a patient at risk for injury with a pacemaker ?
A Offer back rubs to promote relaxationB Instruct patient in dorsiflexion exercise of anklesC Have patient avoid exposure to MRI الإجابة الصحيحةD Observe incision site for redness, purulent drainage, warmth, soreness -
195
A 43 year old man is 30 hours post-operative following placement of a partial thickness skin auto graft for a burn injury on the lower anterior leg. During routine assessment, the nurse notices the wound is bleeding continuously. Which of the following is the nursing action ?
A Use a pen to outline and monitor areaB Perform a wound swab for laboratory analysisC Incise and drain fluids from the wound bedD Apply firm and direct pressure for 10 minutes الإجابة الصحيحة -
196
A 28 year old man is recovering from a moderate concussion following a motor vehicle accident two week ago, when he suddenly develops an increased thirst, craving cold water, the patient urinated very large amounts of dilute, water like urine with a specific gravity of 1.001 to 1.005. Which of the following is the patient most likely developing ?
A Diabetes mellitusB Diabetes insipidus الإجابة الصحيحةC HypothyroidismD Thyroid storm -
197
A25 years old patient telephone the nurse in the day surgery unit and complains of intense pain in the frontal lobe. Two days previously, she had undergone an elective surgical procedure that had required a spinal anesthetic block. Which of the following remedies is the most alleviate the patient symptoms ?
A 1000ml fluid intake per dayB Decrease exposure to lightC Lie down in a flat position الإجابة الصحيحةD Acetaminophen 200 mg by mouth -
198
A 32-year-old man with advanced acquired immune deficiency syndrome (AIDS) is admitted to the isolation unit with a very low CD4 count. He is married and has one child. His wife is depressed because of his diagnosis. Based on priority nursing care, which nursing problem requires immediate planning?
A Risk for infection related to severe immunosuppression الإجابة الصحيحةB Nutrition deficit due to body cell mass wastageC Risk of ineffective psychosocial and family supportD Knowledge deficit about prognosis and treatment -
199
A 55 year patient stats states that he has difficulty in sleeping in the hospital because of the noise. The nurse kept trying reassuring the patient but still cannot sleep. To assist an adult patient to sleep better the nurse recommends which of the following ?
A Eating a large meal one hour before bedtimeB Consuming a small glass of warm milk at bedtime الإجابة الصحيحةC Performing mild exercise 30 minutes before bedD Administer a sedative, as ordered by the physician -
200
A postoperative client who received spinal anesthesia 5 hours ago reports incisional pain. The incision is dry and intact, and the client is pale and restless with BP 175/90 mm Hg, HR 112/min, RR 27/min, and temperature 37.6°C. Which nursing intervention is most appropriate first?
A Obtain a 12-lead ECGB Administer the prescribed pain medication الإجابة الصحيحةC Notify the treating physician immediatelyD Start IV infusion and place the patient supine -
201
A patient with hypertension, diabetes, and obesity appears apathetic and uninterested in learning about recommended nutritional guidelines. What is the most appropriate nursing action?
A Collaborate with the patient to set goals الإجابة الصحيحةB Add a nursing diagnosis of non-complianceC Refer to psychiatric screening for depressionD Discuss nutritional interventions with the spouse -
202
A 60-year-old man admitted with coronary artery disease. Which factors are modifiable risks for coronary artery disease ?
A Age and genderB Gender and diabetesC Family history and smokingD Smoking and high cholesterol الإجابة الصحيحة -
203
Discharge instructions for pneumonia. What statement would indicate the need for more teaching ?
A Gradually increase my activitiesB Have another chest X-ray in 4-6 weeksC Not needing influenza or pneumonia vaccine الإجابة الصحيحةD May experience fatigue and weakness for a prolonged time -
204
A man admitted for a stoma with a dark red purple stoma leaking scant blood. Which observation needs immediate attention ?
A Color الإجابة الصحيحةB EdemaC Absence of stoolD Presence of blood -
205
A 45-year-old man is admitted with a second-degree burn involving 10% of his left arm after hot water spillage. During assessment, the nurse observes the wound for clinical signs of the inflammatory phase of wound healing. Which finding is MOST characteristic?
A Vasoconstriction of blood vesselsB Antibody reaction towards antigenC Redness due to vessel dilation الإجابة الصحيحةD Migration of macrophages to ingest microorganism -
206
A 66-year-old client has dyspnea that worsens with activity and at night, palpitations, and weakness. ECG shows atrial fibrillation with right ventricular hypertrophy and right axis deviation. Which underlying disorder is the most likely origin of this condition?
A HypertensionB Rheumatic fever الإجابة الصحيحةC AtherosclerosisD Genetic predisposition -
207
A 35 years old patient was admitted to the medical ward through emergency department accompanied by her. her chief complains include severe epigastric pain, abdominal tenderness and distension for the last 24 hours. she was anorexia and had passed sex watery diarrhea since few hours. She was feeling lethargic due to frequent elimination action is required ?
A Provide fluids to drinkB Arrange a soft dietC Check vital signs الإجابة الصحيحةD Inform physician -
208
A client is 1 year post liver transplant and presents with fever of 39.2°C, dyspnea, tachycardia, leukopenia, and jaundice. Which post-transplant complication is most likely?
A BleedingB EmbolismC Superinfection الإجابة الصحيحةD Organ rejection -
209
A 23-year-old client with fever of unknown origin is quiet, withdrawn, has poor hygiene, and refuses hospital food. Her mother yells at her in front of others and forces her to eat. According to Maslow hierarchy of needs, which need is most directly threatened?
A Self-esteem الإجابة الصحيحةB Self-actualizationC Safety and securityD Food, water, and shelter -
210
A 42 year old man with thalassemia received a packed cell transfusion. The nurse assess the stability of his condition after transfusion by monitoring the vital signs and general condition every two hour. When should the nurse immediately report the patient condition ?
A Severe headache and raised blood pressureB Raised body temperature and flushed skin الإجابة الصحيحةC Joint pain, body ache, listlessnessD Restlessness and bradycardia -
211
A client with severe varicose veins reports dependent leg edema and dark skin discoloration consistent with chronic venous stasis. Which teaching is most appropriate?
A Teach self-blood monitoringB Assess for right-sided heart failureC Encourage joining an exercise classD Teach how to apply thigh-high compression stockings الإجابة الصحيحة -
212
When caring for a client with acute respiratory distress syndrome, the nurse elevates the head of the bed to 30 degrees. What is the primary reason for this intervention?
A Reduce abdominal pressure on the diaphragm الإجابة الصحيحةB Promote bronchodilation and effective airway clearanceC Decrease pressure on the medullary center which stimulates breathingD Promote retraction of intercostal accessory muscles of respiration -
213
A 60-year-old man is 3 days post hip arthroplasty, has abdominal distention, hypoactive bowel sounds, no bowel movement since surgery, and is taking opioid analgesics. Which nursing intervention is most appropriate to address altered bowel elimination?
A Request an increased opioid dosageB Perform passive range of motion exercisesC Encourage increased fluid intake الإجابة الصحيحةD Provide soft foods based on bland diet -
214
A 40year old client underwent and exploratory laparotomy with anesthesia. An assessment of abdominal 36 hours postoperative showed abdominal distension and an absent of bowel sound. Which complication is most likely ?
A Paralytic ileus الإجابة الصحيحةB HemorrhageC Ruptured colonD Intussusception -
215
A 55 year old underwent total hip replacement. Two hours post. post-operative an orthopedic unit nurse notes the patient was lethargic and dizzy [ Hb: 9.8 (normal: 13-17) ] What nursing intervention is the most appropriate ?
A Start IV fluids الإجابة الصحيحةB Administer paracetamol 1 gm IVC Request one unit of packed RBCD Encourage ambulation for enhanced recovery -
216
A nurse is caring for a client with syndrome of inappropriate antidiuretic hormone (SIDH). Which of the following should be a priority intervention for the client ?
A Monitoring hourly intake and outputB Pressure ulcer prevention strategiesC Encourage eating foods rich in potassiumD Restrict fluid intake to less than 1000 ml/day الإجابة الصحيحة -
217
A 75 year old man is pale and lethargic. he weights 105kg and is bedridden with urine and stool incontinence. Which of the following is the appropriate nursing diagnosis ?
A Risk for fallsB Risk for infectionC Risk for fluid imbalanceD Risk for impaired skin integrity الإجابة الصحيحة -
218
A patient, who had abdominal surgery six days ago, has been ambulating in the halls without much difficulty. however, on seventh postoperative day, the patient complains of increased pain at incisional site and is walking bent over. What is the most likely cause ?
A Intestinal inflammationB Pulmonary edemaC Wound infection الإجابة الصحيحةD Deep vein thrombosis -
219
A nurse is completing the preoperative assessment of the patient who is scheduled for vein ligation and stripping. The nurse should explain that which of the following is included in the patient postoperative plan of care ?
A Apply cold packs الإجابة الصحيحةB Wearing elasticized stockingsC Ambulating with axillary crutchesD Participating in physical therapy -
220
A patient was admitted to the emergency room with abdominal pain. On assessment, a positive psoas sign was noted, and the patient was rushed to the operating room for a stat appendectomy. Postoperatively, when should a nasogastric tube be removed?
A Patient feels hungryB Upon patient requestC Flatus reported by patient الإجابة الصحيحةD Patient consciousness is regained -
221
Which of the following interventions is appropriate for the diagnosis of risk for injury of patient that has a pacemaker ?
A Offer back rubs to promote relaxationB Instruct patient in dorsiflexion exercises of anklesC Have patient avoid exposure to magnetic resonance imaging الإجابة الصحيحةD Observe incision site for redness, purulent drainage, warmth, soreness -
222
A patient is brought to the emergency department suffering from inhalation up on assessment, a nurse observe that the patient aggressive and confused Which of the following is the most likely explanation ?
A PainB ManiaC AnxietyD Hypoxia الإجابة الصحيحة -
223
A 56 year old present to the emergency department experiencing left sides eye discomfort for the past 3 hours, left eye was blurred while vision in the right eye remained examination showed increased intra-ocular pressure in the left eye pupil of the left also reacted slowly to light. which is the most likely health problem ?
A Detached retinaB Macular holeC Glaucoma الإجابة الصحيحةD Cataract -
224
A patient was on regular dose haloperidol. The nurse noticed that he start developing side effects in the form stopped posture with shuffling gait and pill-rolling movement of his hands. Which of the following is most likely the side effect ?
A AkathisiaB Acute dystoniaC Tardive dyskinesiaD Pseudo-parkinsonism الإجابة الصحيحة -
225
A patient with pleural effusion requires immediate thoracentesis. Which intercostal space is the most appropriate site to prepare for needle insertion?
A Between 5th and 6thB Between 6th and 7thC Between 7th and 8th الإجابة الصحيحةD Between 8th and 9th -
226
A 60 year old with gout visited the Medical Clinic and advice to increase fluid intake. Which of following is the benefit of increase fluid ?
A Decrease inflammationB Increase calcium absorptionC Promote the excretion of uric acid الإجابة الصحيحةD Provide a cushion for weakened bones -
227
Which nursing intervention is most appropriate to help prevent postoperative pneumonia in a 37-year-old woman after appendectomy?
A Restrict fluid intakeB Teach how to use spirometer الإجابة الصحيحةC Encourage ambulation as toleratedD Avoid coughing and deep breathing -
228
A patient reports waking several times at night to urinate. Which term best describes this complaint?
A DysuriaB PolyuriaC Nocturia الإجابة الصحيحةD Hematuria -
229
A 29-year-old woman is receiving an intravenous infusion of 5% dextrose in 0.45% sodium chloride. the intravenous line had been started one day prior and now the patient complains of tenderness at the site. On examination, the site is pink colored, swollen and tender to the touch. Which side effect of intravenous infusion problem is most likely ?
A InfiltrationB Phlebitis الإجابة الصحيحةC Catheter sepsisD Air embolism -
230
A 25-year-old woman present to the Emergency Room with acute gastritis and signs of moderate dehydration. Which is the most appropriate nursing diagnosis ?
A InfectionB Fluid volume deficit الإجابة الصحيحةC Activity intoleranceD Fluid volume excess -
231
Patient receiving potassium sparing diuretics should be monitoring. Which of the following ?
A HypokalemiaB Hyperkalemia الإجابة الصحيحةC HypocalcemiaD Hypercalcemia -
232
A nurse was assigned to facilitate a group therapy for a group of patients with cluster a personality disorders ( odd eccentric group) which of the following should the first nursing intervention ?
A Avoid self-mutilationB Provide adequate nutritionC Build a therapeutic relationship الإجابة الصحيحةD Give health education about medication -
233
A nurse reviews a client's laboratory results and notes magnesium = 1.7 mmol/L (normal 0.7–1.2). Which finding should the nurse monitor for?
A Positive Trousseau signB Depressed respirations الإجابة الصحيحةC Elevated blood pressureD Increased deep tendon reflexes -
234
Which test reflects the average blood glucose level over the previous 2 to 3 months in a patient with diabetes?
A Fasting blood sugarB Random blood sugarC Glucose tolerance testD Glycosylated hemoglobin الإجابة الصحيحة -
235
Cardiogenic shock and inadequate tissue perfusion result from ?
A Increase resistance of arterialB Decrease effectiveness of the heart as pump الإجابة الصحيحةC Increased shunting of critical blood flow to heartD Decrease capacity of the venous beds -
236
Following sinus surgery, which finding most strongly suggests that the client may have aspirated blood or secretions?
A Pulmonary decompensation الإجابة الصحيحةB HemorrhageC AspirationD Infection -
237
A 53 years old man is diagnosed as HIV positive. He had a history of and off diarrhea and progressive weakness for past few months. He sigmoidoscopy. Which of the following measure should the healthcare providers evaluate ?
A Reverse isolation and optimum nutrition الإجابة الصحيحةB Confidentiality and social support systemC Health maintenance and follow-up regimenD Family screening and prevention of infection -
238
A 55-year-old man is hospitalized with myocardial infarction and is receiving anticoagulant therapy. Which finding would be of greatest concern?
A Trouble sleepingB NauseaC Elevated creatinineD Purpura الإجابة الصحيحة -
239
A 52-year-old woman is scheduled for an abdominoperineal resection for rectal cancer. She will receive prophylactic antibiotics and a mechanical bowel preparation the day before surgery. Which additional preoperative preparation is most appropriate?
A Wear pressure stockingsB Perform leg strengthening exercisesC Maintain high-protein low-residue diet الإجابة الصحيحةD Take daily ferrous iron tablets -
240
A patient who was immobilized in skeletal traction for six weeks had a urinary catheter discontinued and is now experiencing urinary incontinence. Which intervention is most appropriate to manage this problem?
A Scheduled toiletingB Bladder retraining الإجابة الصحيحةC Promoted voidingD Behavioral training -
241
A patient presents to the clinic with 3+ edema of the lower extremities, diagnosed neck veins, tachycardia, bounding pulse, weight gain of 4 kilograms with 7 days, shortness of breath, and wheezing. Fluid intake over the past 24 hours has been 3700ml output is estimated at 2400ml. which of the following is the most likely nursing diagnosis ?
A Fluid volume excess الإجابة الصحيحةB Urinary tract infectionC HypothyroidismD Ketoacidosis -
242
A patient is being prepared for discharge following hip replacement surgery. The nurse is providing him with discharge education. Which of the following information should be taught to him as an effective pain management principle ?
A Avoid giving pain medication prior to physical therapyB Give a double dose if pain is intolerableC Give pain medication before pain becomes severe الإجابة الصحيحةD Delay giving pain medication as long as possible -
243
A 57 year old man is admitted to the cardiac unit with palpations, headache, and chest tightness, on auscultation S3 gallop and a diagnostic murmur can be heard, a doctor orders 2.5mg of verapamil slow IV push. However, the ventricular rate does not slow down BP 95/62 HR 170 RR 25 TEMP. 36.9 what next action should the nurse expect ?
A Vagal maneuverB Sedation and intubationC Another dose of verapamilD Synchronized cardioversion الإجابة الصحيحة -
244
A home health nurse is teaching a 65-year-old patient recovering from a cerebrovascular accident (CVA) how to use a wheelchair safely. Which patient statement indicates that the teaching was effective?
A I should lock the wheelchair brakes whenever I stop or transfer.B I will push the wheelchair in front of me when walking.C I will remove the footrests whenever possible.D When entering an elevator, I will back into it so the large wheels go in first. الإجابة الصحيحة -
245
A 42-year-old patient is admitted in the Female Medical Ward for sickle cell anemia. She is irritable and shouting on her helper and the nursing staff. The nurse has politely discussed her concerns and finally asked why she has been shouting on others. The patient stated that because her husband did not visit her even once during her hospitalization. Which of the following nursing interventions must have priority ?
A Reassure to solve her problem الإجابة الصحيحةB Discuss the situation with her husbandC Help patient come up with a solutionD Use probing to gather more information -
246
A 52 years old man was working in tall grass when a snake bit him. An ambulance arrived at the scene 20 minutes later. They found the man lying on the ground with cold and clammy skin. He was having difficulty breathing and the right ankle was swollen. He complained of double vision, feeling weak and itching skin. He reported that this was his second snakebite. The paramedics prepare to administer intramuscular epinephrine and place a tourniquet. Blood pressure 86/48 mmHg Pulse rate 130/min Respiratory rate 28/min Which of the following nursing diagnosis has highest priority ?
A Disturbed sensory perception related to effects of pruritusB Ineffective breathing pattern related to bronchospasm الإجابة الصحيحةC Decrease cardiac output related to systemic vasoconstrictionD Risk for injury related to drug treatment and adverse effects -
247
A 30-year-old woman suffered an automobile accident and was brought to the hospital by emergency services. She has no known medical history but exhibits signs of neurological damage. An assessment shows a Glasgow Coma Score of 6. What would be expected ?
A Decerebrate posturing الإجابة الصحيحةB Withdrawal to pain stimuliC Confused verbal responseD Spontaneous eye opening -
248
A 58-year-old woman presents with tiredness and weakness. Which thyroid laboratory results are most consistent with hypothyroidism?
A Increase T4 and decrease TSHB Increase T4 and TSH unchangedC Decrease T4 and increase TSH الإجابة الصحيحةD Unchanged T4 and decrease TSH -
249
A nurse is caring for an elderly bedridden patient dependent on staff for most activities of daily living. Which of the activities would require precautions according to the patient's care plan that includes standard precautions ?
A Brushing teeth الإجابة الصحيحةB FeedingC Hair washingD Nail care -
250
Following a lumbar puncture, a patient has several complaints. Which of the following complaints indicate that patient is experiencing a complaints ?
A I have a headache that gets worse when I sit up الإجابة الصحيحةB I am having pain in my lower back when I move my legsC My throat hurts when I swallowD I feel sick to my stomach and I'm going throw up -
251
A nurse is caring for a patient admitted with a urinary tract infection and exhibiting symptoms of feeling cold, shivering, elevated blood pressure, and increased heart rate. What is the best nursing action ?
A Provide a hot drinkB Cover the patient with a light blanket الإجابة الصحيحةC Start the air conditioning systemD Turn off lights and close curtains -
252
A 45-year-old woman presents with a severe throbbing headache at the crown of the head since last night. Which nursing action should be taken first to begin appropriate assessment?
A Document information that is gatheredB Arrange for investigations as orderedC Prepare for physical examination الإجابة الصحيحةD Promote rest and relaxation -
253
Which of the following nursing interventions assists in the prevention of pressure ulcers following abdominal surgeries ?
A Frequent surgery site every two hoursB Frequent moisturizing of skinC Use side rails as restraintsD Encourage ambulation الإجابة الصحيحة -
254
A nurse is preparing a patient for discharge following below-the-knee amputation with a rigid dressing over the residual limb. Which resting position is most beneficial?
A Sitting with legs crossedB Abduction of residual limbC Knee flexion when sitting in a chairD Knee extension when in bed الإجابة الصحيحة -
255
A client has just returned to a nursing unit after an above-knee amputation of the right leg. In which position should the nurse place the client ?
A ProneB Reverse Trendelenburg'sC Supine, with the amputated limb flat on the bedD Supine, with the amputated limb supported with pillows الإجابة الصحيحة -
256
A patient was admitted to the burns unit 12 hours ago with deep partial-thickness burns. What would be expected to be seen ?
A Increased body temperatureB Increased hematocrit levels الإجابة الصحيحةC Increased blood pressureD Increased urine output -
257
Most common cause for acute renal failure ?
A PyelonephritisB Tubular destructionC Urinary tract obstructionD Dehydration الإجابة الصحيحة -
258
A client with spinal cord injury develops severe throbbing headache, diaphoresis, flushing, and vital sign changes. What should the nurse do first?
A Adjust room temperatureB Check Foley catheter for kinks or obstruction الإجابة الصحيحةC Notify the physician immediatelyD Administer acetaminophen -
259
After pericardiocentesis, a polyethylene catheter is left in the pericardial sac. How should the nurse explain the purpose of this catheter to the patient?
A Monitor consistency of drainageB Prevent movement of the pericardial sacC Prevent recurrence of cardiac tamponade الإجابة الصحيحةD Prevent increase in venous and blood pressure -
260
A 53-year-old patient with newly diagnosed hyperglycemia does not understand why insulin is needed. Which learning need does this indicate?
A Insulin alternativesB Complications of diabetesC Disease process of diabetes الإجابة الصحيحةD Lifestyle and dietary changes -
261
Which patient is contraindicated for an enema ?
A GlaucomaB HypertensiveC Renal failure الإجابة الصحيحةD Liver disease -
262
A woman presents with abdominal pain, distension, quiet bowel sounds, resonance on percussion, and tenderness without guarding. What health problem is most likely ?
A DiverticulitisB Obstruction الإجابة الصحيحةC AppendicitisD Crohn's disease -
263
A woman with a loop ileostomy is instructed on discharge. What symptom should the nurse instruct the client to report immediately ?
A Temperature of 37.6°CB Passage of liquid stool in the stomaC Occasional presence of undigested foodD Absence of drainage from the ileostomy for 6 or more hours الإجابة الصحيحة -
264
A 21-year-old woman admitted for panic anxiety attacks asks about improving her behavior with her mother. What should be the main emphasis for health education ?
A Social interactionB Family's counselingC Role and relationshipD Coping-stress tolerance الإجابة الصحيحة -
265
A nurse is discharging a patient after hospitalization due to myocarditis. What statement should be included in discharge teaching ?
A There is usually some residual heart enlargement الإجابة الصحيحةB May resume previous activities as before hospitalizationC Avoid immunizations against infectious diseasesD Rapidly beating heart is a common side effect of the illness and is not dangerous -
266
A woman presents with leg cramps, muscle twitching, irregular menstrual cycles, dry skin, and abnormal lab results. What lifelong diet would be most beneficial for this patient ?
A Increased magnesium and vitamin CB Increased calcium and vitamin D الإجابة الصحيحةC Increased dairy and ironD High protein and high calorie -
267
A patient comes to the Emergency Department after falling out The nurse notices that the patient's left leg is externally rotate shorter than the right leg. The patient cannot move the left complains of severe pain. What is the most likely cause of these symptoms ?
A Dislocated patellaB Fractured left hip الإجابة الصحيحةC Fractured left tibiaD Dislocated left fibula -
268
A patient diagnosed with hypothyroidism. How long will the patient need to take thyroid hormone replacement therapy before reassessment by the physician ?
A About two monthsB One yearC His entire life الإجابة الصحيحةD Until his laboratory result normal -
269
The nurse is caring for a client with a head injury. The client appears disoriented and is unable to recall recent events. What additional clinical findings are likely ?
A Dryness of the faceB Increase in heart rateC Constriction of pupils الإجابة الصحيحةD Decrease in blood pressure -
270
A patient allergic to cats arrives at the ER with symptoms after visiting someone with cats. Besides confirming airway patency, what is most appropriate to prepare the patient for ?
A Intravenous line insertionB Intravenous glucocorticoidC Subcutaneous epinephrine الإجابة الصحيحةD Application of ice to the throat -
271
A patient admitted for observation after a road traffic accident has a decrease in consciousness. What is the most likely cause ?
A HypovolemiaB HypothermiaC Pulmonary embolismD Increased intracranial pressure الإجابة الصحيحة -
272
A patient presents with hearing loss in the left ear, and the Weber test indicates lateralization to the right ear. What type of hearing loss is suspected ?
A Left-sided conductiveB Right-sided conductiveC Left-sided sensorineural الإجابة الصحيحةD Right-sided sensorineural -
273
A patient with liver cirrhosis has elevated ammonia levels. What plan is most likely based on the ammonia level ?
A Encourage high protein intakeB Restrict high vitamin C foodsC Restrict high protein intake الإجابة الصحيحةD Encourage high vitamin C foods -
274
A patient with a depressed skull fracture has headaches and seizures. Which nursing problem needs more attention initially ?
A Disturbed coping and anger spellsB Risk of injury due to seizures الإجابة الصحيحةC Disturbed communication and irritabilityD Pain management and comfort measures -
275
A nurse obtain a urine dipstick analysis sample from a 35 year-old woman who reports having burning sensation with urination and a sense of urgency and frequency. She had been diagnosed with the condition six months previously and was prescribed a course of antibiotics. Urinalysis Result Normal Range Colour Dark yellow Straw coloured Odour Abnormal Almost nothing Appearance Turbid Clear Leukocyte esterase Positive Negative Nitrities Positive Negative Which type of pharmacological is most likely ?
A Anti-viralB Anti-fungalC Anti-bacterial الإجابة الصحيحةD Anti-parasitic -
276
A female patient diagnosed with cancer she intended to spend a part of her money for the poor people in case of her cure. this action by the patient is considered ?
A DenialB AcceptanceC Bargaining الإجابة الصحيحةD Anger -
277
patient presented with high fever, headache, vomiting and neck stiffness for the past 3 days, which of the following is the first diagnostic intervention for this patient: ?
A Urine and stool analysisB Lumber puncture with CSF aspiration ……………. Rationale meningitis الإجابة الصحيحةC Complete blood countD Chest and abdomen x-ray -
278
Best method to decrease confusion and irritability for an asthmatic patient ?
A Give oxygen الإجابة الصحيحةB Give antibioticC Give sedativeD Give vasodilator -
279
Not a risk factor for acute myocardial infarction ?
A Hemophilia الإجابة الصحيحةB SmokingC HyperlipidemiaD Coronary artery disease -
280
As identified by DR Elizabeth Kubler which stage of dying is characterized by the transition from 'No, not me' to 'Yes me, but...' ?
A AcceptanceB AngerC Bargaining الإجابة الصحيحةD Depression -
281
Coping phase: "If I can just live long enough to attend my daughter's graduation, I'll be ready to die." ?
A Bargaining الإجابة الصحيحةB AngerC DenialD Depression -
282
A client is suspected of having acute deep vein thrombosis (DVT). Which intervention is least appropriate before anticoagulation therapy has been started?
A Apply warm moist compressesB Administer prescribed analgesicsC Use anti-embolism stockings per orderD Encourage gentle mobility as directed الإجابة الصحيحة -
283
A 50-year-old woman post-myocardial infarction with specific vital signs. Likely complication ?
A Arrhythmias الإجابة الصحيحةB EndocarditisC Cardiac failureD Cardiogenic shock -
284
Position post-appendectomy ?
A High fowlersB Semi fowler الإجابة الصحيحةC SittingD Dorsal recumbent -
285
When the client imitates or repeats what the nurse is says this is an example of ?
A Clang associationB Echolalia الإجابة الصحيحةC NeologismsD Word salad -
286
When the psychiatric patient repeats his words boat, boat, boat. What is the best term describes the patient action ?
A EcholaliaB Palilalia الإجابة الصحيحةC NeologismD Ward Salad -
287
A nurse is interviewing a client with schizophrenia when the client begins to say, """"Kite, night, right, height, fright."""" The nurse documents this as: ?
A Verbigeration.B Stilted language.C Clang association. الإجابة الصحيحةD Neologisms. -
288
A nurse was trying to establish a therapeutic with patient the schizophrenia, During the conversation she noticed that he says; I go shop, hop, bop, top Which of the following symptom reflects the patient's speech pattern ?
A NeologismB Flight of ideaC Clang association الإجابة الصحيحةD Pressure of speech -
289
During the working phase of the helping relationship, the patient was crying while disclosing his problems to the nurse. Then in the middle of their conversion, the patient becomes silent. Which of the following should the nurse do ?
A Ask questionB Introduce another topicC Stay with client and be silent الإجابة الصحيحةD Terminate session immediately -
290
What is t give to asthma patient ?
A Beta agonist and corticosteroids الإجابة الصحيحةB Alpha agonist and corticosteroidsC Beta antagonist and corticosteroidsD Alpha antagonist and corticosteroids -
291
Patient has cystic fibrosis and the nurse wants to perform postural drainage when is the best time for posture drainage ?
A Before mealsB After mealsC After half an hour of meals الإجابة الصحيحةD Before sleep -
292
60 YEARS AGE PATIENT WEIGHTED 73 KILOGRAMS .DURING THE CURRENT CLINIC VISIT THE NURSE noted that the patient has an unintended weight loss. This weight loss over 6 months would be considered clinically significant as soon as reaches the point of being more than a ?
A 5% lossB 8% lossC 10% loss الإجابة الصحيحةD 20% loss -
293
A 45-year-old man has crushing chest pain, and ECG shows ST-segment elevation in leads V3 and V4. What is the most likely location of the myocardial infarction?
A InferiorB Anterior الإجابة الصحيحةC PosteriorD Lateral -
294
A 16-year-old girl developed an infection over the surface of the heart after having her nose pierced to place jewelry On admission, she had developed pyrexia of 38C, a heart murmur and petechiae over the whole body. She was admitted to the hospital and treated with intravenous antibiotics. The nurse explains to the patient that she is at high-risk for re-infection and provides discharge teaching on preventive measures. Which of the following would most likely require prophylactic treatment ?
A A pelvic examinationB Dental care الإجابة الصحيحةC BronchoscopyD Urinary catheterization -
295
14.An 84 year-old bedridden patient with Alzheimer's disease lives in a long-term care facility. A nurse enters the patient's room at 7:30 and finds the patient lying towards the foot of the bed on wet sh draw sheet beneath t. Another nurse is called to the room to assist. They place a patient and prepare to first move him upwards in the bed which of thefollowing is the best explanation for using the sheet ?
A Provide material for graspingB Keep the patient dryC Prevent skin rubbing الإجابة الصحيحةD Minimize patient confusion -
296
Position during liver biopsy ?
A ProneB Supine right hand below head الإجابة الصحيحةC Right side lyingD Lateral -
297
After thyroidectomy which of the following juice should be offered ?
A Apple juice الإجابة الصحيحةB Tomato juiceC Orange juiceD Strawberry -
298
Treatment of dissociative disorder ?
A ECTB Psychotherapy الإجابة الصحيحةC Behavioral therapyD Antidepressant therapy -
299
A patient has undergone a subtotal thyroidectomy. Postoperatively, the blood pressure is 150/100 mmHg, heart rate is 120 bpm, and temperature is 40°C. What is the most likely cause?
A Hyper metabolism due to increase in T3&T4 الإجابة الصحيحةB Hypo metabolism due to decrease T3&T4C Hypo metabolism due to increase in T3&T4D Hyper metabolism due to decrease in T3&T4 -
300
A 65 year-old woman is admitted to the Surgical Unit for a mitral valve replacement. Her medical history includes severe mitral stenosis and mitral valve regurgitation. The nurse interviews the patient for hospital admission. Which of the following childhood disease was most likely ?
A Streptococcal pharyngitis الإجابة الصحيحةB Bacterial meningitisC PoliomyelitisD Malaria -
301
The nurse is teaching a client with insomnia to improve sleeping habits. which statement by the client require further teaching ?
A I will avoid naps later in the dayB I will keep the room temperature coolC I will read in a book before trying to sleep الإجابة الصحيحةD I will avoid caffeine after dinner -
302
The dialysis solution is warmed before use in peritoneal dialysis primarily to: ?
A Encourage the removal of serum urea الإجابة الصحيحةB Force potassium back into the cellsC Add extra warmth to the bodyD Promote abdominal muscle relaxation -
303
perform peritoneal dialysis at home. The nurs instructs the client to warm the dialyzing solution to 37 degrees celsius so that it will ?
A Relax the abdominal musclesB Dilate the peritoneal blood vessels الإجابة الصحيحةC Maintain a constant body temperatureD Remove toxins from the body's cells -
304
Nurse is watching the cardiac monitor, and a client’s rhythm suddenly changes. There are no P waves; instead there are wavy lines. The QRS complexes measure 0.08 second, but they are irregular, with a rate of 120 beats a minute. The nurse interprets this rhythm as: ?
A Sinus tachycardiaB Atrial fibrillation الإجابة الصحيحةC Ventricular tachycardiaD Ventricular fibrillation -
305
A nurse is caring for a client in the medical–surgical unit who is recovering after a femoral angioplasty. During assessment, the nurse notes that the affected leg has become pale and cool to the touch. The nurse immediately pages the health care provider. The provider calls back angrily and says, "Why does this unit always call at 2 AM with ridiculous questions?" Which response by the nurse is MOST appropriate?
A How would you feel if this were your own father not receiving the care he needed?B I am concerned that the client may develop severe limb ischemia if this condition is not evaluated immediately. الإجابة الصحيحةC Your behavior is unprofessional and I will report this to my supervisor.D I am sorry to bother you, but hospital policy requires that I report postoperative complications. -
306
A 77 year old man was diagnosed with a right renal tumor size 3.5 cm. he underwent a radical right nephrectomy. Which of following pot operative cares is of high priority ?
A Take body temperatureB Measure hourly urine output الإجابة الصحيحةC Provide sips of clear liquidD Turn client from side to side -
307
A 46 year-old patient is in the male Urology Ward after the surgical removal of the stone from his left kidney through percutaneous nephrolithotomy under general anesthesia He has nausea and dull aching pain in left lumbar region His nephrostomy bag is attached through a tube in his left kidney for a few days (see image). What of the following problems is is needed to focus on ?
A Risk of impaired skin integrity due to infection الإجابة الصحيحةB Disturbed life cycle related to nephrostomy bagC Knowledge deficiency for self-care managementD Impaired social interaction due to altered lifestyle -
308
46year-old patient is in the male Urology Ward after the surgical removal of the stone from his left kidney through percutaneous nephrolithotomy under general anesthesia. He has nurse and dull acting pain in left lumbar region. His nephrostomy bag is attached through a tube in his left kidney for a few days ( see image) What findings should alert the nurse to report to the physician immediately ?
A Abdominal discomfortB Patient very exhaustedC Presence of blood and stone gravels in urineD Urine output less than 30 ml/hour الإجابة الصحيحة -
309
A 56- year old man with history of COPD is complaining of chest, shortness of breath, lethargy, fever and productive cough. Upon examination, crackles could be heard in the lower lobes BP 11./70 HR 111 RR 18 TEM 37.4 Oxygen Sat 90% ?
A ProneB SupineC High Fowler الإجابة الصحيحةD Trendelenburg -
310
During assessment of an adolescent's back, the nurse notes a lateral deviation of the spine with one shoulder blade higher than the other. These findings indicate which condition?
A Spinal fusionB KyphosisC LordosisD Scoliosis الإجابة الصحيحة -
311
A nurse is assessing a patient who just arrived in the department after a motor vehicle collision. The patient has a strong of alcohol on the breath, is restless, and has a bluish discoloration abdomen by the umbilicus. BP 100/62 HR 120 RR 24 TEM 37.2 while other members of the team are evolution the patient, the nurse obtain ?
A Pair of elastic support stockingsB Supplies for peritoneal lavage الإجابة الصحيحةC Chest tube insertion trayD Vial of hydralazine -
312
A 44 year old obese patient was subject for a surgery called bariatric gastric bypass to specific. The nurse and the physician are giving information about the procedure to the patient. Which of the following statement is the best describing the patient understanding ?
A Same effect with liposuctionB An opening will placed in my medicationC The surgery will reduce the size of my stomach الإجابة الصحيحةD Easiest way to lose weight no need to exercise after surgery -
313
A 55-year-old patient has lower abdominal distention and the nurse suspects urinary retention. Which finding best supports this concern?
A HyperthermiaB Urine output of 35 ml/hourC Imbalanced electrolyte levelsD Voiding small amounts of urine at a time الإجابة الصحيحة -
314
A 30 years old man is brought to the ER room. He is diagnosed as having adrenal crisis. Which is the primary sign of acute adrenal insufficient ?
A HypotensionB Hyperpigmentation الإجابة الصحيحةC Unexplained hypercalcemiaD Hypernatremia -
315
Post right-side mastectomy where to take blood pressure ?
A Right brachialB Left brachial. الإجابة الصحيحةC Right radialD Left radial. -
316
patient is admitted to the ER after sustaining abdominal injuries and broken femur from motor vehicle accident. He is pale, diaphoretic, and is not talking coherently. Vital signs upon admission are temperature 98.0 (36.3 C), Pulse: 130 beats/minute, RR: 34 B/min, Bl. pressure 50/40mmHg.The healthcare provider suspects which type of shock ?
A DistributiveB NeurogenicC CardiogenicD Hypovolemic الإجابة الصحيحة -
317
Which of the following clients with burns will most likely require an endotracheal or tracheostomy tube ? A client who has:
A Electrical burns of the hands and arms causing arrhythmias.B Thermal burns to the head, face, and airway resulting in hypoxia. الإجابة الصحيحةC Chemical burns on the chest and abdomen.D Secondhand smoke inhalation. -
318
There is someone his father is dead. Then he turned his sadness and anger by learning martial arts. What is the defense mechanism that he used ?
A DisplacementB Sublimation الإجابة الصحيحةC ProjectionD Denial -
319
30-year-old female patient went to the clinic for consultation after her work due to Pain no both legs during prolongs standing and sitting Doppler ultrasound was cone and confirmed the initial diagnosis of varicose veins. The patient asked what is the possible surgical procedure in relation to her case ?
A AmputationB SclerotherapyC Thermal ablationD Ligation and stripping الإجابة الصحيحة -
320
Women come to ER with her husband and the husband demonstrate she not talk or voluntary eat since the son died in accident, what the women need according to Maslow ?
A loving and belongingB psychological needs الإجابة الصحيحةC spiritual supportD family support -
321
A client with renal failure has metabolic acidosis. Which finding indicates that interventions to correct the metabolic acidosis have been effective?
A Decreased respiratory depth الإجابة الصحيحةB PalpitationsC Increased deep tendon reflexesD Respiratory rate of 38 -
322
Patient has difficulty in walking and lethargic, there decrease in capillary refill and urine incontinence, has risk for ?
A aspirationB infectionC skin breakdown الإجابة الصحيحةD body disturbance -
323
A nurse notices that a client has received 1000 mL of 0.9% normal saline in 2 hours. Which observation most likely prompted the nurse to assess the client for manifestations of metabolic acidosis?
A Client sleeping with the head of the bed flatB Half of the client's lunch tray uneatenC One formed stool in the bedside commodeD 1000 mL of intravenous 0.9% normal saline infused in 2 hours الإجابة الصحيحة -
324
49-year-old patient was admitted in the Medical Ward to rule out his pale appearance, loss of appetite, abdominal pain in the right upper quadrant, dark urine and grey colored stools for the last few days. He was diagnosed with Hepatitis and was discharge from the hospital when his condition gets stable. He was given the advice to take his medication regularly. What should be the nurse’s prime focus in the discharge teachings for the patient ?
A Family supportB Dietary counsellingC Activity and exerciseD Understanding of the disease الإجابة الصحيحة -
325
A client develops hepatitis after eating contaminated food. Which statement is most consistent with this type of hepatitis?
A The disease is transmitted through the bloodB The disease is transmitted through sexual contactC Incubation period 3-5weeks الإجابة الصحيحةD Incubation period 4-5 month -
326
An old patient admitted to ICU with signs and symptoms of Dyspnoea, cough, expectoration, weakness, and edema. Which of the following conditions are correct related these symptoms ?
A Pericarditis الإجابة الصحيحةB HypertensionC ObliterativeD Restrictive -
327
The nurse prepares a cardiac patient for insertion of a pulmonary artery (Swan-Ganz) catheter. The catheter is inserted primarily to obtain information about which of the following?
A Stroke volumeB Venous pressureC Cardiac outputD left ventricular functioning الإجابة الصحيحة -
328
patient is attending primary health clinic for regular checkup. He complains of constipation. After assessment, the nurse instructed him to consume bulk-forming foods. Which of the following is the best bulkforming foods ?
A Fruit juiceB Raw meatC Whole grains الإجابة الصحيحةD Milk products -
329
female patient complains of abdominal discomfort. Watery stool has been leaking from her rectum. This could be sign of which of the following ?
A fecal impaction الإجابة الصحيحةB constipationC bowel incontinenceD diarrhea -
330
The nurse is assessing patient after craniotomy. The patient's blood pressure is 180/65 ICP is 25. What is the patient's cerebral perfusion pressure ?
A 72mmHgB 81mmHgC 78mmHg الإجابة الصحيحةD 83mmHg -
331
man is to be discharged from the General appendectomy. The precautionary measures, plans are discussed with him. What is the most important desired outcome after discharge ?
A Remain free of post-surgical complications الإجابة الصحيحةB Report fever, redness or drainage from the wound siteC Use pain management techniques aproposD Resume gradual activities and avoid weight -
332
A client with metabolic acidosis has been admitted to the unit from the Emergency Department. The client is experiencing confusion and weakness. Which of the following does the nurse implement as a priority of care for this client?
A Place the client in a high-Fowler's positionB Protect the client from injury الإجابة الصحيحةC Administer sodium bicarbonateD Give the client skin care -
333
The nurse is assisting patient to ambulate in hall. The patient has history of coronary artery disease (CAD) and had coronary artery bypass graft surgery (CABG) days ago. The patient reports chest pain rated on scale of (no pain) to 10 (severe pain). The nurse should first ?
A Determine how long it has been since the patient's last dose of aspirinB Obtain chair for the patient to sit down الإجابة الصحيحةC Assess the patient's radial pulseD Ask the patient to take several slow, deep breaths -
334
The nurse is caring woman that has cancer, and she is under Chemotherapy. She is complaining anorexia and the patient has low weight. What should the nurse instruct her ?
A Eat small meals every day الإجابة الصحيحةB Eat large meals every dayC Eat if you are hungryD Eat your favourite food -
335
A client with deep vein thrombosis has been switched from heparin to warfarin. Which measure should the nurse teach the client to continue?
A Daily complete blood count (CBC)B Laboratory tests for partial thromboplastin time (PTT)C Strict bed restD Wearing elasticized support stockings الإجابة الصحيحة -
336
patient is transferred to the Intensive Care following craniotomy. The Patient is difficult to arouse, and the pupils are pinpoint and non-reactive. Blood pressure 118/70 mmHg, Heart rate 58/min, Respiratory rate 11/min, Temperature 37.2°C. Which medication should the nurse prepare administer ?
A AdrenalineB ThiamineC Naloxone الإجابة الصحيحةD Dextrose 50% -
337
Patient with schizophrenia. He complains with anxiety episodes which needs is highest priority in Maslow hierarchy ?
A Physiological needsB Self esteemC Safety الإجابة الصحيحةD actualization -
338
An 82-year-old woman with Alzheimer’s disease had moved into long-term care facility two weeks previously. Since then, the staff has found her wondering in the hallways in middle of the night. When approached, she is confused and frustrated, often forgetting where she is. Which intervention would most likely decrease the patient's confusion ?
A Administer sleeping sedativeB Provide full-time nursing careC Place nightlight in the room الإجابة الصحيحةD Provide large meal before bed -
339
A client has chronic heart failure and COPD and presents with cough and severe dyspnea. Which diagnostic test is most useful to determine whether the dyspnea is due to heart failure exacerbation?
A B-type natriuretic peptide (BNP) الإجابة الصحيحةB arterial blood gas (ABG)C cardiac enzymes (CK-MB)D chest x-ray -
340
patient returned to the Surgical Unit from the thyroidectomy. The nurse observed that the arousable. Blood pressure 90/60 mmHg Heart rate 108 /min What immediate action should the nurse take ?
A Recheck pulse and blood pressureB Administer intravenous fluids as orderedC Place client in modified Trendelenburg'sD Assess the back of neck surgical dressing for bleeding الإجابة الصحيحة -
341
Pt when entered ER he said, my heart will get out of my chest fell that will die he diagnosed with panic attack what is the medical problem that will be developed if panic not controlled ?
A Respiratory acidosisB Respiratory alkalosis الإجابة الصحيحةC Metabolic acidosisD Metabolic alkalosis -
342
A client with schizophrenia appears unkempt and actively hallucinating during admission. Which assessment is the nurse's priority?
A Perception of realityB Ability to follow directionsC Physical needs الإجابة الصحيحةD Mental status -
343
client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. Which of the following would the nurse anticipate when auscultating the client's breath sounds ?
A StridorB Crackles الإجابة الصحيحةC Scattered rhonchiD Diminished breath sounds -
344
Which of these following indicates signs of severe COPD ?
A High p02 and high pC02B Low p02 and low pC02C Low p02 and high pC02 الإجابة الصحيحةD High p02 and low pC02 -
345
During health teaching for an elderly patient, the nurse notices that the patient asks for repeated instructions many times. Which cause should the nurse most expect?
A Patient does not careB Patient confusedC Sensory defect الإجابة الصحيحةD Mental problem -
346
Which of the following can lead to infertility in adult males ?
A Orchitis الإجابة الصحيحةB German measlesC RubellaD Chicken pox -
347
Which of the following the most common cause of dissociative disorder ?
A Family historyB Drug abuseC Traumatic Event الإجابة الصحيحةD Behavioral changes -
348
when caring for patient with an ostomy the nurse knows that extra skin protection for the personal skin is MOST important for those patients with (an) ?
A Ileostomy الإجابة الصحيحةB Ascending colostomyC Transverse colostomyD Sigmoid colostomy -
349
patient with long-standing diabetes mellitus (type I) is scheduled for surgical amputation of gangrenous toes on the right foot. Which surgical intervention would this be classified as ?
A Palliative الإجابة الصحيحةB CurativeC ReconstructiveD Diagnostic -
350
the nurse is teaching group of nursing students how provide care to clients with anger management and aggression problem. Which statement made by the nurse is most indicative of effective teaching ?
A Avoid taking the client's anger personally الإجابة الصحيحةB Defend yourself from the client's angerC Take responsibility for the client's angerD Respond firmly to the client to relieve your own stress -
351
An underweight 18-year-old girl who induces vomiting states that vomiting helps clear stomach bacteria. Which aspect of health pattern is most altered?
A Self-conceptB Health perception الإجابة الصحيحةC Value-belief systemD Nutrition management -
352
year-old woman patient was brought to the Outpatient for the removal of stitches on her left cheek which was treated nine days back after being involved in road traffic accident. She covers her face completely and requests to be seen by female doctor. The site of the wound was red, swollen and some pussy points were visible. She states that she did not wash her face since her accident and kept her face covered all the time as she did not want anyone to see it. What is the most appropriate nursing diagnosis ?
A HopelessnessB Social isolation الإجابة الصحيحةC AnxietyD Powerlessness -
353
A client has just returned after a right-sided renal biopsy. The nurse should intervene if the nursing assistant is observed doing which action?
A Obtaining the client's vital signsB Positioning the client on the left side الإجابة الصحيحةC Positioning the client on the right sideD Providing the client with reading materials -
354
Patient with TB going on Isoniazid medication. To prevent peripheral Neuropathy What should be included in care plan advice ?
A Instruct low protein dietB Avoid sun exposure too muchC Provide vitamin B6 intake الإجابة الصحيحةD Increase fluid intake -
355
A patient has deficient fluid volume after a massive burn injury. Which assessment finding is of greatest concern?
A The blood pressure is 90/40 mm Hg الإجابة الصحيحةB Urine output is 30 ml over the last hourC Oral fluid intake is 100 ml for the last 8 hoursD There is prolonged skin tenting over the sternum -
356
21-You are assisting MD with the removal of chest tube. What activity may the MD have the patient perform while the chest tube is being remove ?
A Valsalva maneuver الإجابة الصحيحةB Leopold ManeuverC Chest PhysiotherapyD Huff Cough Technique -
357
A patient with a recent history of acute appendicitis now has worsening abdominal pain, abdominal distention, diarrhea, and changes in bowel habits. Which diagnosis is most likely?
A colitisB peritonitis الإجابة الصحيحةC gastritisD none -
358
Schizophrenic patient with auditory hallucination. What should the nurse do ?
A Accept the patientB Put patient in isolated roomC Let him share in activity الإجابة الصحيحةD Say Don't hallucinate -
359
An older-adult patient has developed acute confusion. The patient has been on tranquilizers for the past week. The patient’s vital signs are normal. What should the nurse do ?
A Take into account age-related changes in body systems that affect pharmacokinetic activity الإجابة الصحيحةB Increase the dose of tranquilizer if the cause of the confusion is an infectionC Note when the confusion occurs and medicate before that timeD Restrict phone calls to prevent further confusion -
360
A person stopped smoking successfully and has sustained the change long enough to move beyond the maintenance phase. Which stage of change is represented by this description?
A He stop applying change process in action stageB He stop applying change process in preparation stageC He stop applying change process before maintenance stage completeD He stop applying change process after Maintenance complete الإجابة الصحيحة -
361
47-year patient received spinal ane sthesia five hours ago in the operation theatre and was transferred to the surgical unit. Few hours later the patient complains of incisional pain. The surgical site is dry and intact but the patient looks pale irritated. BP 175/90 HR 112 RR 27 TEM 37.6 What is the most appropriate nursing intervention ?
A Take 12 lead ECGB Administer pain medicationC Notify treating physician الإجابة الصحيحةD Strat IV infusion and place patient in supine -
362
A client had a right modified radical mastectomy this morning. Which exercise should the nurse encourage the client to perform this evening?
A Hair combing exercises with the right armB Wall climbing exercises with the right armC Movement of the fingers and wrists of the right arm الإجابة الصحيحةD Exercises of the left arm only -
363
The nurse is caring for client who has had chest tube inserted and connected to water seal drainage. The nurse determines the drainage system is functioning correctly when which of the following is observed ?
A Continuous bubbling in the water seal chamberB Fluctuation in the water seal chamber الإجابة الصحيحةC Suction tubing attached to wall unitD Vesicular breath sounds throughout the lung fields -
364
A 72-year-old man with insomnia is receiving teaching about sleep hygiene. Which statement made by the client indicates a need for further teaching?
A “I will avoid daytime naps.”B “I will read a book before going to sleep.”C “I will keep my bedroom cool at night.”D “I will drink coffee right before going to bed.” الإجابة الصحيحة -
365
A client has been vomiting for several days. The nurse recognizes that the client is at risk for metabolic alkalosis because gastric secretions have which characteristic?
A Gastric secretions are green in color.B Gastric secretions are alkaline.C Gastric secretions are acidic. الإجابة الصحيحةD Gastric secretions have a foul smell. -
366
The nurse is monitoring client in the Medical- Surgical Unit who is recovering overnight following femoral angioplasty and observes that his leg has become pale and cool to the touch. After paging the health care provider for an emergency evaluation, the nurse receives an angry telephone call asking why this department always calls at AM with ridiculous questions. Which of the following is the most appropriate response ?
A how would you feel if it was your father not getting the medical care, he needed.B I am worried that this man may lose his leg unless something is done immediately. الإجابة الصحيحةC your behavior at this time is extremely unprofessional, and will be making formal report to my supervisor.D I am sorry, but it is hospital policy to report any post-operative complications to the health care provider on call. May ask what's has been bothering you about this department's pages -
367
Client who underwent surgical procedure the preceding day normal assessment with an oral body temperature of 37.5 0800 hours. If the condition remains stable the client is to be in the afternoon. which of the following is the highest priority intervention ?
A Observation الإجابة الصحيحةB Inform the surgeonC Administer dose of aspirinD Ensure proper use of the incentive spirometer -
368
For patient with colostomy, which of the following-intervention is appropriate for preventing the risk of the impaired skin related to exposure excretions ?
A Empty pouch when it is completely fullB Remove the skin barrier inspect the skin monthlyC Recaps Skin barrier opening to size of stoma with each changeD Cut an opening in the skin barrier then the circumference of the stoma الإجابة الصحيحة -
369
What position should the nurse place the head of the bed for heart failure patient with jugular vein distention ?
A High fowler'sB Raised 10 degreesC Raised 30 degrees Semi fowler الإجابة الصحيحةD Supine position -
370
A psychiatric patient is speaking loudly, laughing excessively, wearing brightly colored clothes with inappropriate makeup, and has a past history of depression. Which diagnosis is most likely?
A Major depressionB Bipolar disorder I الإجابة الصحيحةC Bipolar disorder llD Cyclothymic disorder -
371
45-year-old woman presents with generalized rash that is not itchy. She reports that she has had the problem for the past 15 years. Examination reveals well-outlined, reddish plaque over the right gluteal fold. The plaque has scales over it and is cracked in some areas Which of the following interventions is the most appropriate ?
A Apply topical cream to the affected areaB Expose area to sunlight for twenty minutes' dailyC Maintain immunosuppressant therapy regimen الإجابة الصحيحةD Increase dietary intake of vitamin A -
372
Patient with leukemia which blood component most affected ?
A RBCsB WBC الإجابة الصحيحةC PlasmaD Platelet -
373
A client is brought to the Emergency Department after passing out in a local department store. The client has been fasting and has ketones in the urine. Which acid-base imbalance would the nurse expect to assess in this client ?
A Metabolic acidosis الإجابة الصحيحةB Respiratory alkalosisC Metabolic alkalosisD Respiratory acidosis -
374
Which laboratory test should be obtained from a patient with major burns before starting antibiotic therapy to help identify the infecting organism?
A complete blood accountB wound culture الإجابة الصحيحةC type and cross matchD sensitivity studies -
375
A 62-kg adult has partial-thickness (second-degree) burns to the posterior left arm (4.5% TBSA) and the posterior surfaces of both legs (18% TBSA), for a total of 22.5% TBSA. Using the Parkland formula, <br>how much IV fluid is required in the first 24 hours after the burn?
A 5580 mL الإجابة الصحيحةB 6580 mLC 6680 mLD 7680 mL -
376
Which of the following is the most affected drug for The psychiatric patient and cause more problem ?
A Atypical antipsychoticB Typical antipsychotic because it has side effects more than atypical الإجابة الصحيحةC Serotonin inhibitorD Dopamine inhibitor -
377
Which of the following laboratory values may be affected in severe liver dysfunction because the liver is responsible for converting ammonia into urea?
A CreatinineB BUN الإجابة الصحيحةC UreaD Urine gravity -
378
What is the Position after thyroidectomy ?
A Lateral flexedB Semi fowler with slight neck flexed الإجابة الصحيحةC Prone head extendedD High Fowler with neck extended -
379
What is the Position during thyroidectomy ?
A Supine with hyper flexion of neckB Supine with hyperextended neck الإجابة الصحيحةC Semi fowlerD Lateral with slightly flexion neck -
380
patient has history of severe, uncontrolled epistaxis. The patient's blood. pressure and platelet count are normal. To minimize the occurrence of bleeding episodes the nurse should teach the patient to ?
A Sleep with the head elevated on at least two to three pillowsB Apply firm pressure to the nostrils four times dayC Apply water- soluble lubricant to the nasal septum twice daily الإجابة الصحيحةD Minimize the intake of caffeine and increase fluids intake -
381
71-year-old woman who resides in long-term nursing home fell while walking downstairs. The attending nurse arrives to find the patient sitting motionless on the stairs. She is alert and oriented but wishes to rest. While she rests, the nurse reviews the chart and notes that her medication regimen includes metformin, loratadine, warfarin and diclofenac. Which medication is most likely to increase the patient's risk of injury ?
A MetforminB Loratadine الإجابة الصحيحةC WarfarinD Diclofenac -
382
45-year-old woman presents to the Emergency Room and reported that she has lost her husband due to lung cancer three months aga. She believes that she has colon cancer, despite of negative results in repetitive and extensive diagnostic tests which were negative. What is the most likely diagnosis ?
A Pain disorderB Hypochondriasis الإجابة الصحيحةC DepersonalizationD Body dysmorphic disorder -
383
Patient with ABG PH 7.33 HCO3 30, PCO2 50 ?
A Compensate respiratoryB Compensate metabolicC Uncompensated respiratory الإجابة الصحيحةD Uncompensated metabolic -
384
A 25-year-old patient presents 3 hours after ingesting 225 mg of methylphenidate and has a heart rate of 190 beats per minute. What is the nursing priority?
A Gastric lavageB Put pt. on cardiac monitor الإجابة الصحيحةC Give activated charcoalD Check blood pressure -
385
The patient has skull fracture. The patient is complaining racoon eye, pain,and posterior neck fracture what is the type of skull fracture ?
A Basilar الإجابة الصحيحةB DepressedC CompoundD Linear -
386
A nurse is caring for a patient receiving total parenteral nutrition (TPN). The patient suddenly reports shortness of breath and anxiety. On assessment, the nurse hears crackles in both lower lung lobes, and the patient’s oxygen saturation is 90% on room air. What should the nurse do immediately?
A Turn off the TPN الإجابة الصحيحةB Notify the physicianC Asses the patient’s capillary blood glucose levelD Attempt to suction the patient’s airway -
387
25yearold woman presents to the Emergency Room with problem. Her main complaint is that she woke up that morning see anything. All medical examination was normal. However, reported that two days ago her husband had asked for divorce. What is the most likely disorder ?
A PainB ConversionC Somatization الإجابة الصحيحةD Body Dimorphic -
388
The nurse is assisting doctor with the removal of central venous catheter. To prevent complications, the patient should be instructed to ?
A Turn his head to the left side and hyperextend the neck while looking upB Take slow, deep breaths as the catheter is advancedC Perform the Valsalva maneuver as the catheter is pulled الإجابة الصحيحةD Turn his head to the right while grasping the siderails -
389
female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive the highest priority at this time ?
A Impaired gas exchange related to increased blood flowB Fluid volume excess related to peripheral vascular diseaseC Risk for injury related to edemaD Altered peripheral tissue perfusion related to venous congestion الإجابة الصحيحة -
390
female client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client ?
A Acute pain R/T surgeryB Deficient fluid volume R/T blood and fluid loss from surgeryC Impaired physical mobility R/T surgeryD Risk for aspiration R/T anesthesia الإجابة الصحيحة -
391
Which of the following nursing diagnoses has the highest priority when caring for an older adult client with Alzheimer's disease ?
A Impaired physical mobilityB Impaired memoryC Self-care deficitD Risk for injury الإجابة الصحيحة -
392
A patient with a stroke has left-sided paralysis and has developed a pressure ulcer on the left hip. Which nursing diagnosis is most appropriate?
A Impaired physical mobility related to left-sided paralysisB Risk for impaired tissue integrity related to left-sided weaknessC Impaired skin integrity related to altered circulation and pressure الإجابة الصحيحةD Ineffective tissue perfusion related to inability to move independently -
393
You are preparing the nursing care plan for middle-aged patient admitted to the intensive care unit for an acute myocardial infarction (heart attack). His symptoms include tachycardia, palpitations, anxiety, jugular vein distention, and fatigue. Which of the following nursing diagnoses is most appropriate ?
A Decreased Cardiac Output الإجابة الصحيحةB Impaired Tissue PerfusionC Impaired Cardiac ContractilityD Impaired Activity Tolerance -
394
A 23-year-old man believes people are spying on him, avoids family contact, has never had an intimate relationship or job, and shows marked social withdrawal. Based on Erikson theory, which stage is most likely unresolved?
A Autonomy versus shame and doubtB Initiative versus guiltC Trust versus mistrustD Identity versus confusion الإجابة الصحيحة -
395
A 39-year-old woman is being prepared for an endoscopic craniotomy. Which essential information about the procedure should the nurse explain?
A Small skull bone is removed to biopsy brain tissueB Needle is guided to remove abnormal brain tissueC Specialized tools are used to remove bones sectionD Lighted tube camera is used to look inside the skull الإجابة الصحيحة -
396
Patient recieves (Psychotrophic medication ). The Patient develop agranulocytosis. This side effects to which medication cause ?
A Typical antipsychoticB Atypical antipsychotic الإجابة الصحيحةC Sertonin reuptake inhibitorD Noradrenaline reuptake inhibitor -
397
A nurse monitors a client with head injury for decerebrate posturing. Which finding is characteristic of this posture?
A Flexion of the extremities after stimulusB Extension of the extremities after stimulus الإجابة الصحيحةC Upper extremity flexion with lower extremity flexionD Upper extremity flexion with lower extremity extension -
398
A 62 year-old male patient , admitted in the surgical Ward is scheduled for the surgical removal of polyps from his descending colon under general anaesthesia . he is experiencing fatigue , abdominal pain and blood streaked stools for a couple of months . he is worried whether the bleeding in his stools is going to stop after surgery . What is most appropriate response by the nurse for the patient concern ?
A Surgery often relieves the symptomsB Let us have detail discussion with your physician الإجابة الصحيحةC Your condition may or may not resolve, it dependsD In fact surgery is the only treatment for the problem -
399
A 40-year-old smoker has cold pale-blue toes, small skin ulcerations, normal blood glucose, and no history of diabetes. Which intervention would be most effective?
A Antibiotic administrationB Reduced fat intakeC Smoking cessation الإجابة الصحيحةD Regular exercise -
400
schizophrenia patient started shouting loudly in the ward to anyone who speaks to him. what should the nurse do ?
A administer tranquilizer IMB call the securityC isolate the patientD speak quietly to the patient and be cautious الإجابة الصحيحة -
401
patient with Alzheimer's disease has been hospitalized after sustaining fall and fractured hip. The patient attempts to get out of bed and has fallen twice since admission. What is the most likely nursing action ?
A Continue the care plan as writtenB Revise the goals and interventions الإجابة الصحيحةC Add restraints to the interventionsD Add new nursing diagnosis of noncompliance -
402
Patient with (HF) he is on Digoxin, when the nurse checks vital signs, she noticed pulse was 110. what is the nurse intervention ?
A hold digoxin medicationB inform doctorC recheck pulseD give medication الإجابة الصحيحة -
403
The nurse is caring for an adult patient who is admitted with. Chest pain that started four hours ago. Which test will be most specific in identifying acute heart damage ?
A CKPB Troponin level الإجابة الصحيحةC CK-MBD Cholesterol level -
404
The nurse is caring for patient who is admitted with chest pain and diagnosed with MI. Which test is assisting in diagnosis ?
A CK-MRB CK-MHC CK-MB الإجابة الصحيحةD CK-HM -
405
A client on the first postoperative day after open thyroidectomy becomes drowsy, restless, and mildly dyspneic. What is the initial nursing priority?
A Monitor vital signs of thyroid stormB Assess for bilateral vocal fold mobilityC Monitor for swelling on the neck الإجابة الصحيحةD Monitor for vocal cord paralysis -
406
Collection of air in pleural space ?
A pneumothorax الإجابة الصحيحةB hemothoraxC AtelectasisD Pleural effusion -
407
Which cardiac monitor finding is consistent with first-degree atrioventricular block?
A QRS complexes are dropped randomlyB No association between the waves and QRS complexesC Significant shortening of the PR intervalD Slowed conduction through the AV node الإجابة الصحيحة -
408
patient with sever varicose veins of the left leg presents to the clinic. The patient states that three days ago the right leg became very swollen and the skin on the right half area was very darkly colored. The capillary refill in the fingers is three seconds and on the right toes is four seconds ?
A Teach the patient self-blood monitoringB Assess the patient to sided heart failureC Encourage the patient to joint an exercise classD Teach the patient how to apply thigh high anti embolic stocking الإجابة الصحيحة -
409
Patient with bipolar disorder schizophrenia. What should the nurse ask the patient to assess orientation for him ?
A Family historyB The last events in countryC Date, Time, Person name الإجابة الصحيحةD Months from back to first -
410
19-year-old boy has been hospitalized with fracture in upper and lower extremities after accident then provided with casts for upper and lower limbs. Which of these Nursing diagnoses should the nurse consider in the Nursing plan of care According to his age ?
A Impaired social interactionB Alteration in body image الإجابة الصحيحةC Risk for infectionD Anxiety -
411
Patient came to ER after motor accident. The patient diagnosed hemiparesis /hemiplegia. Which part of spinal cord injury is affected ?
A Cervical الإجابة الصحيحةB LumbarC ThoracicD Sacral -
412
Schizophrenic patients says i feel like my arms and limbs are deatcahed from my body and don’t feel like am alive and it made me avoid socializing” the nurse interpreted this as ?
A Depersonalization الإجابة الصحيحةB Loss of associationC Dissociative identity disorderD Dissociative amnesia -
413
48yearold patient in the male Surgical Ward had his gall bladder removed through laparoscopic cholecystectomy 24 hours ago. While evaluating his general condition, the patient appears lethargic and complains of severe nauseated feeling along with disco mfort in the abdomen. What nursing problem needs to be prioritized ?
A Disturbed metabolism due to higher energy demandB Weak and lethargic due to low food and fluid intakeC Nausea and vomiting due to slower gut movement الإجابة الصحيحةD Impaired comfort related to postsurgical effects -
414
Patient with Manic bipolar disorder. He is hyperactive, too much moving, talk alot and he has loss of appetite, very thin The patient also don't sleep. What is the most appropriate nursing diagnosis ?
A High risk for suicideB High risk for injury الإجابة الصحيحةC Nutritional disturbanceD Alter sleep pattern -
415
Psychiatric patient was crying. When the nurse asked him, He said want to stay alone. don’t want anyone with me leave me cry. What is the best action for the nurse ?
A Maintain privacy and leave him aloneB You appear sad. am here to help you الإجابة الصحيحةC Stay with him and be silentD Say Okay and let him cry -
416
Rehabilitation nurse reviews post stroke patient immunization history which immunization is priority for 72-year-old patient ?
A hepatitis B vaccineB hepatitis C vaccineC rotavirus vaccineD pneumococcal vaccine الإجابة الصحيحة -
417
Self limited crisis Duration for solving ?
A 2 weeksB 4 weeks الإجابة الصحيحةC 6 weeksD 8 weeks -
418
Psychiatric patient doesn’t like her nose and mouth shape. She has false belief of disturbed body image and counselled many doctors' for doing operation. Doctor's not accepted her due to no need everything is normal. What is type of disorder ?
A PainB ConversionC Body dysmorphic disease الإجابة الصحيحةD Hypochondriasis -
419
patient with congestive heart failure and severe peripheral edema has nursing diagnosis of fluid volume excess What are the two MOST important interventions for the nurse to initiate ?
A Diuretic therapy and intake and outputB Nutritional education and low-sodium dietC Daily weights and intake and output الإجابة الصحيحةD Low-sodium diet and elevate legs when in bed -
420
Psychiatric patient repeats unknown words for nurse but the patient can understand it. What is the best term describing situation ?
A Word saladB Neologism الإجابة الصحيحةC CircumstantialityD Thought problem -
421
The patient came to receive his Lab results from the nurse. The patient has diagnosed with cancer. The patient said to nurse am not believe that is my diagnosis, that is not mine. What is the stage considering ?
A Denial الإجابة الصحيحةB AngerC DepressionD Bargaining -
422
What is the best nutrition teaching instruction for patient with Parkinson disease ?
A ChokingB Drooling الإجابة الصحيحةC AspirationsD Dysphasia -
423
Patient with SLE. What is the patient statement indicating that need furthered education ?
A Exposure to sun will harm my skinB Hypertension must be anticipatedC Hypertension is not common with SLE الإجابة الصحيحةD The symptom will exacerbate more in winter and spring -
424
32-year-old woman being hospitalized since six days for obesity treatment she reported to the nurse """"I feel burning in my left calf for the last two days """"after nursing assessment the nurse found that left thigh edema, local tenderness, thigh circumference is more by cm than right thigh and it is warmer to touch, no trauma or wounds. What is the most possible cause for that ?
A ObesityB Local cellulitisC HypertensionD Deep vein thrombosis الإجابة الصحيحة -
425
An elderly client is experiencing an alteration in his equilibrium and coordinated muscle movements. The nurse realizes that these functions are controlled by which area of the nervous system ?
A Brain stemB CerebrumC DiencephalonD Cerebellum الإجابة الصحيحة -
426
patient is having difficulty with cognitive abilities after stroke. What part of the brain was MOST likely affected ?
A MidbrainB Cerebrum الإجابة الصحيحةC Medulla oblongataD Cerebellum -
427
Patient came to ER with acute chest pain, restlessness. The patient has cardiac surgery before. He has some injuries on his body Bl. 110/70 mmhg, HR 14 b/m, RR 22. What is the most appropriate nursing intervention ?
A Obtain 12 lead ECG الإجابة الصحيحةB Assess for bed soresC Administer Pain medicationD Start I. fluids -
428
Patient after inguinal hernia What is best indicator for dischrage ?
A Patient eat very wellB Patient free of painC Patient move without assistance الإجابة الصحيحةD Patient urine output500 ml -
429
patient diagnosed with delirium sees the intravenous (IV) tubing and believes it to be snake. How should the healthcare provider document this behavior ?
A HallucinationB Illusion الإجابة الصحيحةC ConfusionD Delusion -
430
Patient has been diagnosed with urinary tract infection. What is the most likely cause of this infection ?
A Staphylococcus aureusB Neisseria gonorrheaC Escherichia coli enterococci الإجابة الصحيحةD Streptococcal beta-hemolytic and B -
431
A client with increased intracranial pressure is prescribed a medication to prevent straining during defecation, which can further raise intracranial pressure. Which medication serves this purpose?
A WarfarinB MorphineC PotassiumD Dulcolax الإجابة الصحيحة -
432
45-year-old woman is receiving chemotherapy for breast cancer. Two weeks after the initial treatment she telephoned the nurse at the cancer center and reports she has hair loss, nausea, tiredness, body temperature is 38.1 C, and air hunger. Which finding most likely indicates she needs to report the clinic ?
A PyrexiaB NauseaC Hair lossD Air hunger الإجابة الصحيحة -
433
Patient came to ER after motor accident. The patient has sever bleeding with urine output 30 ml /hr and normal vital signs Normal Bl. P, normal HR, Normal respiration). The doctor ask the nurse to assess good tissue perfusion. Which of the following signs detect that ?
A heart rateB Respiration rateC Urine output الإجابة الصحيحةD Blood pressure -
434
patient is scheduled for an abdominal aneurysm repair This is what type of surgical intervention ?
A DiagnosticB TransplantC Curative الإجابة الصحيحةD Palliative -
435
26.A Patient has dissection aortic aneurysm. The patient’s surgery would be categorized as ?
A ElectiveB UrgentC Emergency الإجابة الصحيحةD Diagnosed -
436
38-year- old patient is about to have lumber disk surgery. during preoperative care, the nurse instructs the patient including the family. members how to do log rolling to change patient position. One of the family members ask why they must do such action in turning the patient. postoperative. Which of the following is the nurse best response ?
A Facility good circulationB Avoid spinal movement الإجابة الصحيحةC Prevent post-operative bed soreD Makes changing of patient position easier -
437
A woman becomes socially withdrawn and stops eating voluntarily after the death of her son. Which type of long term care is most important?
A Physiological needsB psychological Care الإجابة الصحيحةC spiritual supportD family support -
438
client diagnosed with somatization disorder visits multiple physicians because of var- ious, vague symptoms involving many body systems. Which nursing diagnosis takes priority ?
A Risk for injury / treatment from multiple physician الإجابة الصحيحةB Anxiety / unexplained multiple somatic symptomsC Ineffective coping / psychosocial distressD Fear / multiple physiological complaints -
439
Which of the following diagnostic studies is essential to differentiate between renal failure and lower renal obstruction that cause urinary retention ?
A Cholesterol levelB Abdominal X-rayC Complete blood testsD Blood urea nitrogen and serum Creatinine الإجابة الصحيحة -
440
A client has been admitted with chronic obstructive pulmonary disease. Diagnostic tests have been ordered. Which of the tests will provide the most accurate indicator of the client's acid-base balance ?
A Arterial blood gases (ABGs) الإجابة الصحيحةB Pulse oximetryC Sputum studiesD Bronchoscopy -
441
A patient presents to the emergency department with fever, nausea, vomiting, abdominal pain, bloody diarrhea, and rebound tenderness. Which diagnosis is most consistent with these findings?
A Lower right painB AppendicitisC GastroenteritisD Devirticulitis الإجابة الصحيحة -
442
A patient is admitted with a confirmed severe bacterial infection and has the following assessment findings: temperature 40°C (104°F), blood pressure 100/70 mmHg, heart rate 89/min, and hemoglobin 11.7 g/dL. Which intervention should the nurse anticipate as the priority initial treatment?
A Administer corticosteroids for inflammationB Administer antibiotics for infection الإجابة الصحيحةC Start intravenous fluids for blood pressure supportD Prepare for blood transfusion for the hemoglobin level -
443
a Patient takes full course of treatment Levofloxacin for pneumonia what confirmed that treatment was effective ?
A decrease haemoglobin levelB decrease wbc count الإجابة الصحيحةC low platelets countD high hematocrite -
444
Which assessment finding reflects increased intracranial pressure (ICP) ?
A TachycardiaB Unequal pupil size الإجابة الصحيحةC Decreasing body tempD Decreasing systolic BP -
445
572 26 years old married woman is admitted in the plastic surgery for the correction of burn strictures and skin rafting on her neck andface under general anesthesia. While discussing the treatment with her, the plastic surgeon explained that she will have series of surgeries but she needs to be on family planning until the treatment is completed. the patient aske the nurse whether she will be normal again. What initial assessment is required ?
A Detailed history and physical examinationB Patient’s acceptance for the treatment planC Need for psychological support to reduce anxiety الإجابة الصحيحةD Family’s involvement and consent for her treatment -
446
A 70 year old woman has dyspnea on exertion, orthopnea, basal crackles, and a history of myocardial infarction. Which heart chamber most likely failed first?
A Right atrialB Right ventricleC Left ventricle الإجابة الصحيحةD Left atrial -
447
42 year-old patient went to the clinic for an eye consult Patient complained of blurred vision ocular pain and head active During assessment tonometry was done see results. Test Result Normal Values Intraocular pressure 34 10-20mmHg Which surgical procedure is the most appropriate ?
A LaminectomyB Laser trabeculoplasty الإجابة الصحيحةC Incision and drainageD Extra capsular cataract extraction -
448
A patient has ABG results showing low pH, high PaCO2, and normal HCO3-. Which option is most consistent with acute respiratory acidosis?
A Vomiting and difficult breathing SOBB Headache and vomiting الإجابة الصحيحةC Shallow, rapid breath and vomitingD Kaussmal respiration -
449
What is the goal for giving Corticosteroids in Asthma ?
A BronchodilatorB Decrease airway swelling الإجابة الصحيحةC Chest clear and Remove secretionsD Vasodilation -
450
The nurse is providing Session about disease process, coping, dietary management) for patient. Which is the initial important long term goal ?
A Increase understanding of disease processB Have healthy life style الإجابة الصحيحةC Increase copingD Dietary management -
451
nurse is caring for patient who had cerebrovascular accident 30 minutes ago with residual right-side hemiparesis. The nurse places trochanter roll next ending from the patient's iliac crest to the mid. What is the most likely complication ?
A Adduction of the legB External rotation of the hipC Muscle spasms in the thigh الإجابة الصحيحةD Flexion contractures of the knee -
452
A 57 year old woman has pain in the toes and foot with swollen knees. Which musculoskeletal disorder is most likely?
A Osteoarthritis.B Rheumatic arthritisC OsteomyelitisD Gout الإجابة الصحيحة -
453
A patient with nephrotic syndrome is being monitored for complications. Which complication is most commonly associated with this condition among the following options?
A UTIB Peritonitis الإجابة الصحيحةC Bladder infectionD Hypertension encephalopathy -
454
A client is suspected of having systemic lupus erythematosus. Which finding is one of the early characteristic signs?
A Weight gainB Fever, malaise الإجابة الصحيحةC Elevated red blood cell countD Rash on exetremties and the face -
455
The patient is postoperative and sedated. Which of the following signs require immidiate intervention ?
A Urine bag is fullB Hemovac bag is full with serosanguineous drainageC Intermediate nasogastric suction is not connected الإجابة الصحيحةD Nasal cannula 4L without humidification -
456
Which position is most recommended for a client with severe ascites?
A Side lying.B Sim’s.C Dorsal.D Fowler’s الإجابة الصحيحة -
457
nurse is caring for patient receiving skeletal traction. Due to the patients severe limits on mobility, the nurse has identified risk for atelectasis or pneumonia. What intervention should the nurse provide in order to prevent these complications ?
A Perform chest physiotherapy once per shift and as neededB Teach the patient to perform deep breathing and coughing exercises الإجابة الصحيحةC Administer prophylactic antibiotics as orderedD Administer nebulized bronchodilators and corticosteroids as ordered -
458
Patient came to ER after motor accident. The patient has sever bleeding. Postoperative head surgery the vital signs are Bl. 90/60, HR 126 b/m respiration 24 b/m). The doctor ask the nurse to assess good tissue perfusion. Which of What is Indication of Improve tissue perfusion ?
A decrease HR to 100B increase pulmonary wedge pressureC Increase Systolic BP to 86D 100 ml dark urine الإجابة الصحيحة -
459
The nurse received the patient after hip surgery. The nurse is unable to locate an older client's left popliteal pulse. Which action will the nurse take next ?
A Check for the femoral pulseB Check for the pedal pulse الإجابة الصحيحةC Use doppler ultrasound for locationD Measure the blood pressure on the left thigh -
460
patient with server diverticulitis had surgery for placement of colostomy. The patient is upset, crying, and will not look at the colostomy. Which of the following would be the highest priority nursing diagnosis at this time ?
A Knowledge deficit, colostomy careB Distorted body image الإجابة الصحيحةC Self-care deficit, toiletingD Alteration in comfort -
461
24 years old patient brought to emergency room after an accident and the nurse noticed leaking of clear fluid from the nose. nurse anticipated the injury is ?
A Basilar الإجابة الصحيحةB Frontal lobeC Temporary lobeD Neuropathic -
462
A patient is diagnosed with retinal detachment after reporting dark spots and visual changes. Which history question is most relevant to a possible cause?
A Do you have history of cataract الإجابة الصحيحةB Do you have hypertensionC Do you have facial surgeryD Are you smoker -
463
A 71-year-old woman residing in a long-term care facility falls while walking down the stairs. She is found sitting on the stairs, alert and oriented, and reports only mild discomfort. Her medication list includes metformin, loratadine, warfarin, and diclofenac. Which potential complication is the nurse most concerned about?
A Bleeding الإجابة الصحيحةB Bone fractureC Brain concussionD Hypoglycemia -
464
65 year-old woman presents to her care provider with complaints of bright red -15 blood in the stool, loss of appetite, feeling of fullness and fatigue. She has lost five kilograms in the past three weeks without dieting. faecal occult blood test is positive and the patient scheduled for an additional screening test. Which of the following screening tests is the most appropriate ?
A barium enemaB colonoscopy الإجابة الصحيحةC endoscopyD computed tomography scan -
465
Community health nurse visited alzheimer's disease patient. The patient complained from bruises and many injuries. The caregiver denied any fallness caused for patient. What is the nurse response ?
A Restrain the patientB Blame to patient that he is the reasonC The cause is cognitive impairementD Arrange room and provide lightnight in room الإجابة الصحيحة -
466
Patient admitted to hospital with COPD. The patient will dischrage. What is the dischrage instructions should the nurse give ?
A Avoid and remove every thing that irritate him at home الإجابة الصحيحةB Report any signs of cyanosisC Provide dietary managementD Avoid exercise -
467
Community health nurse visited patient in home with alzheimer's disease. The patient complained from bruises and several injuries on his body. The community nurse noticed patient fall and The caregiver denied any fallness occurred for the patient. What should the nurse do ?
A Provide restrain to the patientB Blame the patient that he is the reasonC Arrange the room and provide nightlight الإجابة الصحيحةD The cause of fall is cognitive impairement -
468
A nurse is teaching a client with metabolic acidosis about the safe use of sodium bicarbonate. Which client statement indicates that further teaching is needed?
A I should contact my doctor if I develop stomach discomfort along with chest pain.B I should choose antacid products that do not contain sodium.C I should continue taking this antacid for at least two months. الإجابة الصحيحةD I should call my doctor if I develop shortness of breath or excessive sweating. -
469
Which of the following patient care plan is the most appropriate for 37 years old post appendectomy woman who is at risk of pneumonia ?
A Restrict fluid intakeB Teach how to use spirometerC Encourage ambulation as tolerated الإجابة الصحيحةD Avoid coughing and deep breathing -
470
25-year-old man presents with compound fracture in the left leg and profuse bleeding What immediate action should be taken to control the bleeding ?
A Elevate the patient's legB Apply pressure on the femoral arteryC Use tourniquet above the fracture siteD Apply direct pressure on the fracture site الإجابة الصحيحة -
471
49-year-old women presented to the Emergency Department complaint of severe chest pain. The ECG showed that the patient myocardial infarction. The doctor ordered the nurse to give the 800 mg of aspirin. What is the primary indication of aspirin in this case ?
A Breaks down the thrombusB Decreases the formation of platelet plugs الإجابة الصحيحةC Inhibits the conversion of prothrombine to thrombinD Interferes with vitamin to maintain clotting factors -
472
nurse the medical surgical unital is review plan of care elderly client with chronic obstruction pulmonary disease COPD) limited mobility the nursenotes that the physical therapist change in the plan of care to progress ambulation from 50 to 100 times day. Which action in necessary to ensure that the client need are ?
A Inform physical therapist of client respiratory status before progressing to ambulation الإجابة الصحيحةB Instruct physical therapist not to proceed with ambulation nurse presenceC Inform physician about physical decision to ambulationD Cancel referral to physical therapist -
473
What is the Nursing diagnosis of chest radiography tuberculosis ?
A Ineffective breathing pattern related to tuberculosisB Infection related diseaseC Difficult breathing related to secretionD Ineffective breathing pattern related to secretion الإجابة الصحيحة -
474
A patient converts anxiety into physical symptoms. Which defense mechanism is this?
A Social isolationB ProjetionC RegresionD Conversion الإجابة الصحيحة -
475
A patient has persistent sore throat, mouth lesions that do not heal, dysphagia, and weight loss. Which diagnosis is most likely?
A GastritisB TonsillitisC Laryngeal cancer الإجابة الصحيحةD Emphysema -
476
Patient admitted to hospital with hip fracture. The patient was submitted to surgery with external fixation. The patient complained from pain from 10 level and numbness in limbs. What is the most appropriate nursing intervention for patient ?
A Give patient placebo drug analgesicB Teach patient to take deep breathing exercise الإجابة الصحيحةC Give patient local anesethiaD Allow his family stay beside him -
477
How many week fever sustain in rheumatic fever ?
A 1 week الإجابة الصحيحةB 4 daysC 5 daysD 3 days -
478
Which of the following diets would be most appropriate for the client with Crohn's disease ?
A High-calorie, low-proteinB High-protein, low-residue الإجابة الصحيحةC Low-fat, high-fiberD Low-sodium, high-carbohydrate -
479
The community health nurse During home visit, client with AIDS tells the nurse hat he has been exposed to measles from his brother 's son since 10 days Which action by the nurse is most appropriate ?
A Administer an antibioticB Contact the physician for an order for immune globulin الإجابة الصحيحةC Administer an antiviralD Tell the client that he should remain in isolation for two weeks -
480
An older woman has fatigue, exertional chest pain, pallor, gait imbalance, and numbness in the hands and feet. Which test is most appropriate in this item?
A Schilling الإجابة الصحيحةB Folic acid levelsC Lymph node biopsyD Bone marrow aspiration -
481
A 70-year-old man presents to the clinic with difficulty sleeping at night. He has not had good night's rest for several months and feels exhausted. He needs to place three pillows behind his back in order to sleep. Examination of the lungs reveals crackles and wheel Auscultation of the heart confirms an gallop. Which of the following is the most likely underlying health problem ?
A ApneaB Rest dyspneaC Orthopnea الإجابة الصحيحةD Dyspnea at night -
482
The nurse is teaching patient who was just diagnosed with narcolepsy. The nurse should teach the patient that which of the following typically increases the level of fatigue ?
A Eating large meal الإجابة الصحيحةB Participating in an exercise programC Taking brief napsD Working in cool environment -
483
A patient is diagnosed with agoraphobia. Which of the following would the healthcare identify as characteristic of this disorder ?
A Refuses to use public restroomB Fear from crowded area الإجابة الصحيحةC Avoids interacting with strangersD Fear from dealing with animals -
484
36-year-old son is the primary caregiver to his 76-year-old has many chronic diseases and need full time assistance discussed with the community nurse the idea of referring his of the elderly day care centers. The nurse explains the case to such services which of the following elderly groups this patient belongs to this service ?
A With busy caregivers who need assistance الإجابة الصحيحةB are bored staying at home and need socializationC Who have been diagnosed with AlzheimerD Who want to engage in handcraft activities and art -
485
A 19 year old patient with fractures and casts on the arm and leg is hospitalized after a traffic accident. Considering the patient's age, which short term goal is most appropriate?
A Personal counseling for safe driving practiceB Importance of body image for the patient الإجابة الصحيحةC Respect patient privacy needsD Encourage activity and exercise -
486
A patient with Alzheimer disease requires restraints. Which action is the first safety measure to prevent injury?
A Tie the extremities to the side railsB Tie the extremities to fixed part of the bed الإجابة الصحيحةC Put pads on bony prominenceD Allow restrain to tightly to Avoid the patient move freely -
487
A 57 year-old patient with diabetes mellitus. The nurse is instructing patient how to care for his foot. Which of the following is appropriate instruction ?
A Use antibiotic ointment when injuredB Wearing open slipperC Keep foot dry properly after bathing الإجابة الصحيحةD Apply closed socks -
488
A patient has pins and needles in one foot and optic neuritis with shimmering vision. The patient is most likely to be tested for which disorder?
A GlaucomaB Multiple sclerosis الإجابة الصحيحةC Lesion of brain stemD Psychosis -
489
A woman with likely recent diazepam overdose presents with decreased reflexes, hypoventilation, hypotension, and constricted pupils. Which intervention should the nurse expect among the following options?
A NaloxoneB Active charcoal الإجابة الصحيحةC Tap water enemaD Magnesium sulfate to reduce the risk seizure -
490
A woman admitted for corrective plastic surgery after burn contractures asks whether she will ever be normal again. Which nursing problem is most evident?
A Lack of understanding of surgical procedureB Chronic low self-confidence due to disfigurement الإجابة الصحيحةC Possible discontinuation from long term treatmentD Lack of family's support and carin -
491
A patient reports recent unemployment, no income, and sleep disturbance related to financial worry. Which combination of stressors is present?
A Environmental and socioculturalB Psychological and environmental الإجابة الصحيحةC Physiological and psychologicalD Environmental and cognitive -
492
A client tells the nurse that the television newscaster is sending secret messages to her. The nurse suspects the client is experiencing which symptom?
A Delusion.B Flight of ideasC Ideas of reference الإجابة الصحيحةD Hallucination. -
493
For a patient with ineffective airway clearance related to increased mucus production, why should the nurse encourage fluids?
A Maintain nutritionB Prevent boredomC Stimulate coughingD Thin secretion الإجابة الصحيحة -
494
Immediately after craniotomy, which type of drainage on the dressing should be reported to the surgeon?
A Blood tingedB Straw colored الإجابة الصحيحةC ClottedD Foul-smelling -
495
40 year-old female is diagnosed to have stress Incontinence one of nursing diagnosis stated by the nurse is """"Stress incontinence related to decrease pelvic muscle tone"""" What is the most appropriate nursing intervention ?
A Apply adult diapersB Catheterize the patientC Teach Kegel exercises الإجابة الصحيحةD Initiate bladder emptying program -
496
A patient has been diagnosed with acidemia. Which interpretation is expected in this item?
A Compensate respiratoryB Compensate metabolicC Uncompensated respiratoryD Uncompensated metabolic الإجابة الصحيحة -
497
56-year-old man with history of COPD was rushed to the Emergency Department with chest pain, shortness of breath, fever and cough. Upon assessment, crackles can be heard over the low lobes. The patient looks pale and lethargic (see image) Blood pressure 110/70 mmHg Heart rate 130 /min Respiratory rate /min Temperature 38.1C Oxygen saturation 85 What is the most likely condition ?
A Bronchial asthmaB Respiratory failure الإجابة الصحيحةC Pulmonary embolismD Myocardial infarction -
498
What is the Location of rheumatic arthritis ?
A Wrist الإجابة الصحيحةB ElbowC KneeD Shoulder -
499
36-year-old man who is cardiac patient presents Beck's triad manifestations. Which of the following is the most likely occurs in Beck's triad ?
A Flushing, pruritus and urticarialB Tachypnea, tachycardia and hypoxiaC Hypotension, muffled heart sounds and jugular venous distension الإجابة الصحيحةD Swelling of lips and tongue, Shortness of breath and edema of larynx and epiglottis -
500
nurse is conducting health screening for osteoporosis. Which of the following clients is at greatest risk of developing this disorder ?
A A 25-year-old woman who jogsB A 36-year-old man who has asthmaC A 70-year-old man who consumes excess alcoholD A sedentary 65-year-old woman who smokes cigarettes الإجابة الصحيحة -
501
What is the time nurse should follow Glasgow's coma scale ?
A Every quarter of an hourB Every hourC Every two hours الإجابة الصحيحةD Every shift -
502
A patient develops right-sided hemiparesis after a stroke. Damage to which area of the brain is the most likely cause?
A Left frontal lobe الإجابة الصحيحةB Right parietal lobeC Brain stemD Cerebellum -
503
Which food should a cancer patient with treatment-related nausea most likely avoid?
A Fatty food الإجابة الصحيحةB High soduim foodC Fiber foodD Bran products containing food -
504
Patient after liver biopsy position on right sided .Why should the nurse keep patient on operation site ?
A Enhance blood circulationB Prevent bleeding الإجابة الصحيحةC Increase comfortableD Prevent trapped fluid -
505
Patient with pneumonia. The doctor wants to ventilate the patient. What is the expected stage of pneumonia ?
A ModerateB Sever الإجابة الصحيحةC NormalD Mild -
506
Patient with Bp: 145/95. What stage of hypertension ?
A Stage 1B Stage 2 الإجابة الصحيحةC ElevatedD Crisis -
507
What are the characteristics of renal colic pain ?
A DullB ThroppingC CrampingD Sharp Stabbing الإجابة الصحيحة -
508
An elderly patient with paralytic ileus has an NG tube inserted. What is the main purpose of the tube?
A Decompression الإجابة الصحيحةB Enternal feedingC Fluids specimenD Suction -
509
A patient is diagnosed as HIV positive. Which statement indicates a need for further teaching?
A This doesn’t mean have aidsB Antiviral will decrease the chance of developing AidsC When the HIV positive that mean develop immunity against this disease الإجابة الصحيحةD My test is positive that mean have ability to transmited the disease for others -
510
What is the priority nursing intervention for a client with an open fracture before definitive treatment?
A Mobilize as much as possibleB Left uncoveredC Splinting leg الإجابة الصحيحةD Rise leg 90 degree -
511
A 22-year-old patient is anxious and hyperventilating after a fight. ABG shows pH 7.41, PaCO2 10.6, and HCO3 20. Which nursing action is most appropriate for this expected finding?
A Admit patient to cardiac unitB Give patient paper Bag to push on it الإجابة الصحيحةC Inform the policeD Sedation and intubation -
512
A 70-kg older patient with heart disease and hypoxia is being started on mechanical ventilation. Which tidal volume is the best initial setting?
A 400 mlB 620 mlC 540 ml الإجابة الصحيحةD 700 ml -
513
Doctor order medication for psychiatric patient, the drug is not for therapeutic cause but to decrease the concern of the patient. The nurse should expect which effect ?
A Placebo effect الإجابة الصحيحةB Tolerance levelC Pain controlD Addictive level -
514
Patient with burn. The burn include epidermis and dermis layers of skin and reach to tissue. Which of the following stage of burn ?
A FirstB SecondC Third الإجابة الصحيحةD Fourth -
515
A patient with chronic renal failure is scheduled for hemodialysis at 10 a.m. Which medication is commonly withheld until after the dialysis session?
A Calcium channel blocker الإجابة الصحيحةB Intermittent InsulinC Proton pump inhibitorsD Laxatives for constipation -
516
A nurse is caring for a client after mastoidectomy. Which nursing intervention is appropriate?
A Maintain supine positionB Position the client on the affected side to promote drainage الإجابة الصحيحةC Change the ear dressing dailyD Monitor for signs of facial nerve injury -
517
Mother is depressed and tell the nurse that her son is dead in swimming pool and she is responsible about that. What should the nurse do ?
A You are rightB SympathyC Repeat mother words to clarifyD Empathy الإجابة الصحيحة -
518
The nurse is caring for a patient who has abdominal pain last three days. The nurse teaches the patient about the most likely active-producing foods. What are the foods that are mostly useful to produce laxative ?
A Cheese, pasta and eggsB Rice, eggs, and lean meatC Bran(Oats), figs, and chocolate الإجابة الصحيحةD Cabbage, bananas, and soda -
519
What is complication of rheumatic fever ?
A Aortic Valve Stenosis الإجابة الصحيحةB CyanosisC ConvulsionD Heart damage -
520
What is the most common indication of ECT ?
A Generalized Anxiety DisorderB Manic episodesC SchizophreniaD Given Major depression الإجابة الصحيحة -
521
30- Doctor after inserting a subclavian catheter for the patient, blood flow is observed from the catheter, and the patient is experiencing respiratory restlessness. What is the expected problem with the patient ?
A Right side failureB PneumoniaC Pulmonary embolismD Pneumothorax الإجابة الصحيحة -
522
Patient came to ER after accident the vital signs all stable and conscious but expected has increased the pressure (ICP). Which of the following first indicate ICP ?
A Change in consciousness (loss of consciousness) الإجابة الصحيحةB Unreactive pupilC BradycardiaD Depress respiratory -
523
Patient for cardiac catheterization by cardiologist. What is the purpose of this procedure ?
A Check cardiac pressure الإجابة الصحيحةB Check the O2 in heartC Pulmonary embolismD Pneumothorax -
524
The nurse is caring for a client newly diagnosed with hyperthyroidism. Which nursing intervention is priority to decrease the client’s anxiety ?
A Keeping the client warmB Encouraging the client to increase activityC Providing a calm, restful environment الإجابة الصحيحةD Placing the client in semi-fowler’s position -
525
The nurse is analyzing the client's arterial blood gas report, which reveals a pH of 6.58. The client has just suffered a cardiac arrest. Which of the following consequences does the nurse consider for this client?
A Decreased cardiac output الإجابة الصحيحةB Increase magnesium levelsC Decreased free calcium in the ECTD Increased myocardial contractility -
526
What is the most common site of myocardial infarction ?
A left atriumB Left ventricle الإجابة الصحيحةC Right atriumD Right ventricle -
527
The patient has kidney stones. What foods should the patient eat to prevent kidney stone ?
A Cranberry and prunes الإجابة الصحيحةB ColaC Salt foodD Liver -
528
A client has a history of urolithiasis related to hyperuricemiTo prevent the formation of future stones, the nurse instructs the client to avoid certain foods, including ?
A Liver الإجابة الصحيحةB CarrotsC Skim milkD White rice -
529
Which of the following diet instructions should be given to the client with recurring urinary tract infections ?
A Increase intake of meats.B Avoid citrus fruits.C Perform peri care with hydrogen peroxide.D Drink a glass of cranberry juice every day الإجابة الصحيحة -
530
The patient has a UTI. What advice is given regarding drinking to prevent UTI ?
A Cranberry الإجابة الصحيحةB YogurtC Orange juiceD Vegetable juice -
531
Why is the patient educated to drink cranberry juice after having a stone removed ?
A Help Inhibit infection الإجابة الصحيحةB Increase urine outputC Inhibit urinary retentionD Decrease stone formation -
532
In the early post-traumatic period after a hip or femoral fracture, which finding should be closely monitored as a sign of an early complication?
A Fever الإجابة الصحيحةB HypertensionC Acute painD Hematuria -
533
A nurse is caring for an immobile and ventilated patient in the intensive care unit. The patient is at high risk for pressure ulcers. Which intervention should the nurse prioritize to prevent pressure ulcers in this patient ?
A Keep the patient's skin dryB Keep the head of the bed at 40°C Massage the reddened prominent bonesD Keep the head of the bed at 30° while in a side-lying position الإجابة الصحيحة -
534
The Elderly patient, 80 years old, underwent a nurse assessment of activities to measure their ability to perform self-care tasks such as bathing and eating. What type of assessment is the nurse conducting ?
A PsychosocialB EconomicC Functional الإجابة الصحيحةD Psychological -
535
What is the preferred postoperative position after surgery for vulvar carcinoma?
A RecumbentB Semi Recumbent الإجابة الصحيحةC ProneD Lithotomy -
536
A patient with pneumonia completed a course of levofloxacin. Which laboratory value best helps determine treatment effectiveness?
A WBC الإجابة الصحيحةB KC PlateletD Hematocrit (HCT) -
537
A patient with Cushing's syndrome has been using corticosteroids for a long time. What are the effects of using corticosteroids for long time ?
A Hypertension الإجابة الصحيحةB HypercalcemiaC HypermagnesemiaD Hypotension -
538
The patient who came to the emergency room presents with a two-day history of vomiting and abdominal pain that is referred to the right shoulder after eating fried. Where should the patient be feeling the pain ?
A Upper right abdomen الإجابة الصحيحةB Upper left abdomenC Lower right abdomenD Lower left abdomen -
539
A 32-year-old woman has sudden right upper quadrant pain radiating to the right shoulder, fever, nausea, vomiting, leukocytosis, and a positive Murphy's sign. What is the most likely diagnosis?
A Acute pancreatitisB Acute appendicitisC Acute cholecystitis الإجابة الصحيحةD Right basal pneumonia -
540
What is signs indication of left side heart failure ?
A Breathing Sound (Crackles, Wheezes) الإجابة الصحيحةB SwellingC EdemaD Jugular vein distension -
541
A patient with diabetes has a morning glucose of 50. The patient is sweaty, cold, and clammy. Which of the following nursing interventions is the MOST important ?
A Recheck the glucose levelB Give the patient 1?2 cup (4 oz) of fruit juice الإجابة الصحيحةC Call the doctorD Keep the patient nothing by mouth. -
542
A postoperative patient has a chest tube in place. After about 3 hours, what type of drainage is most expected in the collection chamber?
A BloodB Serous drainageC Serious Song drainage الإجابة الصحيحةD Mucous secretion -
543
What prevents the recurrence of Rheumatic fever ?
A Antibiotic الإجابة الصحيحةB AntibacterialC Anti-viralD Corticosteroids -
544
Which assessment indicates therapeutic effect of mannitol (Osmitrol) ?
A Decreased intracranial pressure الإجابة الصحيحةB Decreased potassiumC Increased urine osmolalityD Decreased serum osmolality -
545
A patient presents with a blood pressure reading of 189/90. What would patient at high risk for ?
A Stroke الإجابة الصحيحةB HypertensionC DVTD DM -
546
The old patient is suffering from hearing problems. What is the best way to measure their degree of hearing ?
A Asking the family about their hearing level.B Standing behind them and speaking loudly.C Writing on a piece of paper and asking them to read it.D Use verbal communication first and evaluate الإجابة الصحيحة -
547
The health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instructions should the nurse provide ?
A Sunscreen should be applied every 8 hoursB Use sunscreen when participating in outdoor activities الإجابة الصحيحةC Avoid exposure to the sun in the late afternoonD Avoid exposure to the morning sun -
548
A patient with an aortic aneurysm requires urgent surgery. Which investigation is most important to perform immediately?
A PTB PPTC Cross match and type blood group الإجابة الصحيحةD Ultrasound -
549
While changing the tracheostomy ties, the client coughs and the tracheostomy tube becomes dislodged. What is the nurse's initial action?
A Call a respiratory therapist to reinsert the tracheotomy.B Cover the tracheostomy site with a sterile dressing.C Call the physician to reinsert the tracheotomy.D Grasp the retention sutures to spread the opening الإجابة الصحيحة -
550
A patient with renal calculi is undergoing a percutaneous nephrostomy and asks the nurse to explain the procedure. What should the nurse's answer be ?
A Administering a chemical agent to dissolve the stone.B Using laser wavesC Incision in renal pelvic to remove stoneD Using an incision in the skin with a scope and forceps to remove stones الإجابة الصحيحة -
551
A Patient with second degree AV block medication (atropine,adenosine, diltiazem ) After confirmation safety in patient arrest what second action ?
A Check responsiveness الإجابة الصحيحةB Shout for helpC Start chest compressionsD Activate EMR -
552
Which diagnostic test is used to detect a Trendelenburg sign?
A DVTB Varicose veinC Valvular disorder الإجابة الصحيحةD Thrombophlebitis -
553
What are the foods that patients with gout should avoid, and what is the food that is considered high in protein ?
A EggsB NutsC Red meat الإجابة الصحيحةD Legumes -
554
A patient will go to rectal surgery, doctor ask the nurse to bath him for the surgery which kind of bath the nurse will do ?
A Bed bathB Sitz bath الإجابة الصحيحةC Partial bathD With Cleansed -
555
Which of the following is not alif threating cause of chest pain ?
A Pulmonary embolismB M l (myocardial infarction)C Acute coronary syndromeD Esophageal rupture الإجابة الصحيحة -
556
What is the recommended diet for gout disease ?
A High fiberB Potassium modifiedC Low calciumD Low-purine diet الإجابة الصحيحة -
557
Patient 75 years old had a history of peptic ulcer ..has pain in joint. What is the expected drug should be give by the nurse ?
A AspirinB IbuprofenC NaproxenD Acetaminophen (Paracetamol) الإجابة الصحيحة -
558
A registered nurse reviews a plan of care developed by a nursing student for a client with depression and notes a nursing diagnosis of impaired nutrition: less than body requirements. The registered nurse asks the student to revise the plan if which incorrect intervention is documented (NCLEX) ?
A Offer small, high-calorie, high protein snacks frequently throughout the day and eveningB Offer high protein, high-calorie fluids frequently throughout the day and eveningC remain with the client during mealsD complete the food menu for the client during the depressed period الإجابة الصحيحة -
559
A patient came to the ER presenting with agitation. Which drug should the nurse use for patient ?
A LorazepamB ClozapineC Haloperidol الإجابة الصحيحةD Zolpidem -
560
The patient is an amputee and is taking medication. They came to the clinic after two weeks complaining of recurring pain. What is the appropriate action by the nurse ?
A Refer the patient to a psychiatristB Explain about phantom pain and how to cope with it الإجابة الصحيحةC Prescribe an analgesic drugD Provide reassurance to reduce anxiety -
561
Which of the following position should the client with appendicitis assume to relieve pain ?
A Prone positionB Sitting positionC Supine positionD Lying with legs drawn up الإجابة الصحيحة -
562
The nurse is preparing the patient for hospital discharge following an above-the-knee amputation with a rigid dressing over the residual limb. Fourteen days after surgery, the patient is successfully fitted with a prosthetic limb and begins physical therapy. Which resting position is most beneficial?
A Sitting with legs crossedB Abduction of residual limbC Hip flexion when sitting in chairD Hip extension when in bed الإجابة الصحيحة -
563
Adult patient complains of diarrhea, vomiting, abdomen cramp and pain within the past 2 weeks. The patient reported that the pain increases when he eats and relieves when he passes stool. Which of the following may bethe cause ?
A AppendicitisB Crohnâs disease الإجابة الصحيحةC Ectopic pregnantD Cholecystitis -
564
Renal failure patient came for dialysis, the nurse suspect that the patient develop Steal Syndrome. What is the Steal Syndrome characteristic ?
A Pain and warmthB Pain and coldness الإجابة الصحيحةC Redness and warmthD Redness and coldness -
565
A patient with septic shock has stress hyperglycemia. What is the best explanation to the spouse about why insulin is needed?
A It is common for critically clients to develop type diabetes. We give insulin to keep glucose level under control (less than140 mg/dL)B Patient had diabetes before, you just didn't know it. we give insulin to keep glucose level in the normal range (70-110 mg/dL)C Increase in glucose is a normal response to stress by the body. We give insulin to keep the level 1t 140-180-mg/dL الإجابة الصحيحةD Increase is common in critically ill clients and effects their ability to fight off infection. We give insulin to keep the glucose level in the normal range (70-110 mg/dL) -
566
What is the most common symptom of COPD?
A Air hungerB Dyspnea الإجابة الصحيحةC Cough with sweat nightD Persistent cough -
567
year-old man is in the Emergency Department with S Ose bleeding as a result of falling down while climbing up the wall. On assessment, his nose appears slightly deviated and 2 swollen. Heis breathing from his mouth What sign helps evaluate that his nose is still bleeding ?
A Complain of sharp pain in the nasal boneB Experiencee more difficulty in breathingC patientt is swallowing frequently الإجابة الصحيحةD Increased swelling of the nose -
568
A 46-year-old male patient is admitted to the urology ward after undergoing percutaneous nephrolithotomy (PCNL) for removal of a left kidney stone under general anesthesia. A nephrostomy tube is in place and connected to a drainage bag. The patient reports dull pain in the left lumbar region. Which finding requires the nurse to notify the physician immediately?
A Abdominal discomfort and conniptionB Severe pain and discomfort at surgical siteC Presence of blood and stone gravels in urineD Urine output less than the identified amount الإجابة الصحيحة -
569
After major trauma and blood loss, which finding best indicates improving tissue perfusion?
A decrease HR to 100 الإجابة الصحيحةB increase pulmonary wedge pressureC Increase Systolic BP to 86D 100 ml dark urine -
570
A patient with hypothyroid symptoms is not taking levothyroxine as prescribed. Which laboratory pattern is most likely?
A Increase T4 and decrease TSHB Increase T4 and TSH unchangedC Decrease T4 and TSH increase الإجابة الصحيحةD Unchanged T4 and TSH decrease -
571
A nurse enters the room of a 72-year-old client and finds the client unconscious and unresponsive. The cardiac monitor displays a chaotic rhythm with no identifiable P waves, QRS complexes, or T waves. No pulse is palpable. What is the nurse's priority action?
A Begin defibrillation immediately الإجابة الصحيحةB Administer intravenous amiodaroneC Prepare for synchronized cardioversionD Insert a temporary pacemaker -
572
A 45 year old client who diagnosed with brain was schedule for craniotomy. It is important to preventing the developing of cerebral edema after surgery. What medication would the nurse expect to prescribed the client ?
A Steroids الإجابة الصحيحةB DiureticsC Ant convulsionsD Antihypertensive -
573
After teaching a 54 year old patient with angina on how to take nitroglycerin sublingual PRN. Which of the following statements reflect the patient understanding ?
A I have to take this medication once i need it only الإجابة الصحيحةB It is ok to take one tablet daily to prevent the heart attackC I can take two tablets together at once if the attack isD This medication will regulate my heart beats and I will be -
574
When ventricular fibrillation occurs in a CCU, the first person reaching the client should : ?
A Administer oxygenB Defibrillate the client الإجابة الصحيحةC Initiate CPRD Administer sodium bicarbonate intravenously -
575
A patient visiting the 10 days after a sinus surgery for a follow up complains of having a bad taste in the mouth. The nurse smells of foul odor while examining the patient mouth. What does the suspect the patient may have ?
A Pulmonary decompensationB HemorrhageC AspirationD Infection الإجابة الصحيحة -
576
The nurse is reviewing orders for a client with metabolic acidosis. Which order should the nurse question?
A Begin intravenous infusion of 0.9% normal salineB Draw serum potassium levels every 2 hoursC Draw arterial blood gas samples every 2 hoursD Administer 1 ampule of sodium bicarbonate now الإجابة الصحيحة -
577
A 34 years old woman was diagnosed with breast cancer and underwent surgery. She is currently receiving monthly chemotherapy she telephone the clinic and notifies the nurse that she developed a sore throat. Which of the following foods would be the most appropriate to recommended ?
A Fresh fruits and vegetables الإجابة الصحيحةB SeafoodC Dried fruits nutsD pasteurized cheese -
578
Which hemoglobin type is primarily responsible for the abnormal red blood cell shape seen in sickle cell disease?
A Hemoglobin AB Hemoglobin FC Hemoglobin S الإجابة الصحيحةD Hemoglobin C -
579
What is the priority nursing problem for a patient with schizophrenia?
A Self esteemB Medication complianceC Family supportD Impaired thought process الإجابة الصحيحة -
580
The nurse is caring for a client diagnosed with a herniated lumbar intervertebral disk who is experiencing low back pain. Which position would the nurse place the client in to minimize the pain?
A Supine with the knees slightly raisedB High-Fowler's position with the foot of the bed flatC Semi-Fowler's position with the foot of the bed flatD Semi-Fowler's position with the knees slightly raised الإجابة الصحيحة -
581
A client admitted to the hospital has been prescribed pyridostigmine as treatment for myasthemia gravis. When assessing the client for side effects of the medication, the nurse would ask the client about the presence of which occurrence?
A Mouth ulcersB Muscle cramps الإجابة الصحيحةC Feelings of depressionD Unexplained weight gain -
582
A client who experienced a fractured right ankle has a short leg cast applied in the emergency department. During discharge teaching, which information would the nurse provide to the client to prevent complications?
A Trim the rough edges of the cast after it is dry.B Weight bearing on the right leg is allowed once the cast feels dry.C Expect burning and tingling sensations under the cast for 3 to 4 days.D Keep the right ankle elevated above the heart level with pillows for 24 hours. الإجابة الصحيحة -
583
An adult client with a fractured left tibia is learning to ambulate with axillary crutches. Which assessment finding most likely reflects overuse of the muscles responsible for gripping and supporting the crutches?
A Left leg discomfortB Weak biceps brachiiC Triceps muscle spasmsD Forearm muscle weakness الإجابة الصحيحة -
584
A client diagnosed with myasthenia gravis is experiencing prolonged periods of weakness, and the primary health care provider prescribes an edrophonium test, also known as a Tensilon test. A test dose is administered and the client becomes weaker. How should the nurse interpret these results?
A Myasthenic crisis is present.B Cholinergic crisis is present. الإجابة الصحيحةC This result is a normal finding.D This result is a positive finding. -
585
The nurse notes an isolated premature ventricular contraction (PVC) on the cardiac monitor of a client recovering from anesthesia. Which action would the nurse take?
A Prepare for defibrillation.B Continue to monitor the rhythm. الإجابة الصحيحةC Prepare to administer a beta-blocker.D Notify the primary health care provider immediately. -
586
A client admitted to the hospital with a diagnosis of Pneumocystis jiroveci pneumonia is prescribed intravenous (IV) pentamidine. What intervention would the nurse plan to implement to safely administer the medication?
A Infuse over 1 hour and allow the client to ambulate.B Infuse over 1 hour with the client in a supine position. الإجابة الصحيحةC Administer over 30 minutes with the client in a reclining position.D Administer by IV push over 15 minutes with the client in a supine position. -
587
During the postoperative period, the client who underwent a pelvic exenteration reports pain in the calf area. What action would the nurse take?
A Ask the client to walk and observe the gait.B Lightly massage the calf area to relieve the pain.C Check the calf area for temperature, color, and size. الإجابة الصحيحةD Administer as needed (PRN) morphine sulfate as prescribed for postoperative pain. -
588
The client with atrial fibrillation is prescribed sotalol AF. Which assessment finding indicates that the client is experiencing an adverse effect of the medication?
A Dry mouthB DiaphoresisC Difficulty swallowingD Dizziness and feeling faint الإجابة الصحيحة -
589
The nurse is caring for a client who is receiving tacrolimus daily. Which finding indicates to the nurse that the client is experiencing an adverse effect of the medication?
A HypotensionB PhotophobiaC Profuse sweatingD Decrease in urine output الإجابة الصحيحة -
590
A client was admitted to the hospital 24 hours ago after sustaining blunt chest trauma. Which is the earliest clinical manifestation of acute respiratory distress syndrome (ARDS) the nurse should monitor for?
A Cyanosis with accompanying pallorB Diffuse crackles and rhonchi on chest auscultationC Increase in respiratory rate from 18 to 30 breaths/min الإجابة الصحيحةD Diffused haziness or "white-out" appearance of lungs on chest radiograph Syndrome/Failure -
591
The nurse, caring for a client with Buck's traction, is monitoring the client for complications of the traction. Which assessment finding indicates a complication of this form of traction?
A Weak pedal pulses الإجابة الصحيحةB Drainage at the pin sitesC Complaints of leg discomfortD Toes are warm and demonstrate a brisk capillary refill -
592
The nurse is caring for a client who had an orthopedic injury of the leg that required surgery and the application of a cast. Postoperatively, which nursing assessment is of highest priority to assure client safety?
A Monitoring for heel breakdownB Monitoring for bladder distentionC Monitoring for extremity shorteningD Monitoring for blanching ability of toe nail beds الإجابة الصحيحة -
593
The nurse is reviewing the laboratory results for a client diagnosed with chronic heart failure (HF) who is receiving torsemide 5 mg orally daily. What value would indicate to the nurse that the client might be experiencing an adverse effect of the medication?
A A chloride level of 98 mEq/L (98 mmol/L)B A sodium level of 135 mEq/L (135 mmol/L)C A potassium level of 3.1 mEq/L (3.1 mmol/L) الإجابة الصحيحةD A blood urea nitrogen (BUN) level of 15 mg/dL (5.4 mmol/L) -
594
During history taking of a client admitted with newly diagnosed Hodgkin's disease, the nurse would ask the client about which expected symptom?
A Weight gainB Night sweats الإجابة الصحيحةC Severe lymph node painD Headache with minor visual changes Non-Hodgkin's -
595
To ensure client safety, which assessment is most important for the nurse to make before advancing a client recovering from an appendectomy from liquid to solid food?
A Bowel soundsB Chewing ability الإجابة الصحيحةC Current appetiteD Food preferences -
596
The nurse is caring for an obese client on a weight loss program. Which method would the nurse use to most accurately assess the program's effectiveness?
A Monitor the client's weight. الإجابة الصحيحةB Monitor the client's intake and output.C Calculate the client's daily caloric intake.D Frequently check the client's serum protein levels. Techniques -
597
A client has fallen and sustained a leg injury. Which question would the nurse ask to help determine if the client sustained a fracture?
A "Is the pain a dull ache?"B "Is the pain sharp and continuous?" الإجابة الصحيحةC "Does the discomfort feel like a cramp?"D "Does the pain feel like the muscle was stretched?" -
598
Which arterial blood gas (ABG) values would the nurse anticipate in the client with a bowel obstruction who has a nasogastric tube attached to continuous suction?
A pH 7.25, Paco2 55, HCO3 24B pH 7.30, Paco2 38, HCO3 20C pH 7.48, Paco2 30, HCO3 23D pH 7.49, Paco2 38, HCO3 30 الإجابة الصحيحة -
599
The nurse is performing a respiratory assessment on a client being treated for an asthma attack. The nurse determines that the client's respiratory status is worsening based upon which finding?
A Loud wheezingB Wheezing on expirationC Noticeably diminished breath sounds الإجابة الصحيحةD Increased displays of emotional apprehension -
600
The nurse is assessing the casted extremity of a client for signs of infection. Which finding is indicative of the presence of an infection?
A Dependent edemaB Diminished distal pulseC Coolness and pallor of the skinD Presence of warm areas on the cast الإجابة الصحيحة -
601
The home care nurse assesses a client diagnosed with chronic obstructive pulmonary disease (COPD) who is reporting increased dyspnea. The client is on home oxygen via a concentrator at 2 L/min, and has a respiratory rate of 22 breaths/min. Which action would the nurse take?
A Determine the need to increase the oxygen.B Reassure the client that there is no need to worry.C Conduct further assessment of the client's respiratory status. الإجابة الصحيحةD Call emergency services to take the client to the emergency department. Pulmonary Disease -
602
The nurse is caring for a client who is receiving tobramycin sulfate intravenously every 8 hours for a lower urinary tract infection. Which result would indicate to the nurse that the client is experiencing an adverse effect of the medication?
A A total bilirubin of 0.5 mg/dL (8.5 mcmol/L)B An erythrocyte sedimentation rate of 15 mm/hrC A blood urea nitrogen (BUN) of 30 mg/dL (10.8 mmol/L) الإجابة الصحيحةD A white blood cell count (WBC) of 6000 mm3 (6 x 109/L) Inflammation/Infection/Trauma -
603
A client's telemetry monitor displays ventricular tachycardia. Upon reaching the client's bedside, which action would the nurse take first?
A Call a code.B Prepare for cardioversion.C Prepare to defibrillate the client.D Check the client's level of consciousness. الإجابة الصحيحة -
604
A client has developed oral mucositis as a result of radiation to the head and neck. Which measure would the nurse teach the client to incorporate in a daily home care routine to help manage this condition?
A A glass of wine per day will introduce useful bacterial to the oral cavity.B High-protein foods such as peanut butter should be incorporated in the diet.C Clean teeth and rinse mouth with a weak saline and water solution before and after each meal. الإجابة الصحيحةD Oral hygiene, including brushing and flossing, should be performed in the morning and evening. -
605
A client who is being treated for acute heart failure has the following vital signs: blood pressure (BP), 85/50 mm Hg; pulse, 96 beats/min; respirations, 26 breaths/min. The primary health care provider prescribes digoxin. To evaluate a therapeutic response to this medication, which changes in the client's vital signs would the nurse expect?
A BP 85/50 mm Hg, pulse 60 beats/min, respirations 26 breaths/minB BP 98/60 mm Hg, pulse 80 beats/min, respirations 24 breaths/min الإجابة الصحيحةC BP 130/70 mm Hg, pulse 104 beats/min, respirations 20 breaths/minD BP 110/40 mm Hg, pulse 110 beats/min, respirations 20 breaths/min -
606
A client diagnosed with hypertension has been taking a prescribed calcium channel blocker for approximately 2 months. The home care nurse monitoring the effects of therapy would determine that drug tolerance has developed if which is noted in the client?
A Decrease in weightB Increased joint painC Output greater than intakeD Gradual rise in blood pressure Blockers الإجابة الصحيحة -
607
A client experiencing trigeminal neuralgia (tic douloureux) asks the nurse for a snack and something to drink. Which is the best selection the nurse would provide for the client?
A Hot cocoa with honey and toastB Vanilla pudding and lukewarm milk الإجابة الصحيحةC Hot herbal tea with graham crackersD Iced coffee and peanut butter and crackers -
608
A client is admitted to the hospital with a suspected diagnosis of Graves' disease. On assessment, which manifestation related to the client's menstrual cycle would the nurse expect the client to report?
A Amenorrhea الإجابة الصحيحةB MenorrhagiaC MetrorrhagiaD Dysmenorrhea -
609
The nurse is performing an otoscopic examination on a client with a suspected diagnosis of mastoiditis. Which finding would the nurse expect to note if this disorder was present?
A A dull red tympanic membrane الإجابة الصحيحةB A mobile tympanic membraneC A transparent tympanic membraneD A pearly colored tympanic membrane Problems -
610
The nurse is reviewing the record of a client with a disorder involving the inner ear. Which finding would the nurse most likely note as an assessment finding in this client?
A Tinnitus الإجابة الصحيحةB Burning in the earC Itching in the affected earD Severe pain in the affected ear Problems -
611
A client with a diagnosis of diabetes mellitus has a blood glucose level of 644 mg/dL (35.8 mmol/L). The nurse interprets that this client is at risk of developing which type of acid-base imbalance?
A Metabolic acidosis الإجابة الصحيحةB Metabolic alkalosisC Respiratory acidosisD Respiratory alkalosis -
612
The nurse reviews the most recent blood gas results of a client diagnosed with asthma. The nurse notes a pH of 7.43, Pco2 of 31 mm Hg, and HCO3 of 21 mEq/L. Based on these results, the nurse determines that which acid-base imbalance is present?
A Compensated metabolic acidosisB Compensated respiratory alkalosis الإجابة الصحيحةC Uncompensated respiratory acidosisD Uncompensated metabolic alkalosis -
613
The nurse is caring for a client with a possible bowel obstruction who has been prescribed a nasogastric tube that is attached to low suction. If the client's HCO3 − is 30, which additional value is most likely to be noted in this client?
A pH 7.52 الإجابة الصحيحةB pH 7.36C pH 7.25D pH 7.20 -
614
The nurse reviews the results of a blood chemistry profile for a client who is experiencing late-stage salicylate poisoning and metabolic acidosis. Which serum study would the nurse review for data about the client's acid-base balance?
A SodiumB Potassium الإجابة الصحيحةC MagnesiumD Phosphorus -
615
An adult client suspected of having developed encephalitis has undergone a lumbar puncture to obtain cerebrospinal fluid (CSF) for analysis. After reviewing the results of the analysis, the nurse recognizes that the CSF is suggestive of the infection when which element is noted?
A ProteinB GlucoseC Lymphocytes الإجابة الصحيحةD Red blood cells -
616
A client who has sustained a burn injury receives a prescription for a regular diet. Which is the best meal for the nurse to provide to the client to promote wound healing?
A Peanut butter and jelly sandwich, apple, teaB Chicken breast, broccoli, strawberries, milk الإجابة الصحيحةC Veal chop, boiled potatoes, Jell-O, orange juiceD Pasta with tomato sauce, garlic bread, ginger ale -
617
The nurse caring for a client diagnosed with a stroke is planning care to maintain nutritional status. The nurse is concerned about the client's swallowing ability. Which food item would the nurse eliminate from this client's diet?
A Spinach الإجابة الصحيحةB CustardC Scrambled eggsD Mashed potatoes -
618
The nurse is providing care for a client with a history of nonalcoholic fatty liver disease (hepatic steatosis) who has just experienced a liver biopsy performed at the bedside. Which position would the nurse place the client in after the biopsy?
A Supine with the head elevated on one pillowB Semi-Fowler's with two pillows under the legsC Left side-lying with a small pillow under the puncture siteD Right side-lying with a folded towel under the puncture site الإجابة الصحيحة -
619
The nurse is caring for a client who is receiving cyclosporine following a kidney transplant. Which condition indicates to the nurse that the client is experiencing an adverse effect of the medication?
A AcneB SweatingC Joint painD Hyperkalemia الإجابة الصحيحة -
620
After assessment and diagnostic evaluation, it has been determined that the client has a diagnosis of Lyme disease, stage II. The nurse assesses the client for which manifestation that is most indicative of this stage?
A LethargyB HeadacheC Erythematous rashD Cardiac dysrhythmias الإجابة الصحيحة -
621
The nurse is caring for a client with a diagnosis of pemphigus vulgaris. On assessment of the client, the nurse would look for which sign characteristic of this condition?
A Turner's signB Chvostek's signC Nikolsky's sign الإجابة الصحيحةD Trousseau's sign -
622
Tretinoin gel has been prescribed for a client with acne. What is the nurse's response when the client calls and reports that, "My skin has become very red and is beginning to peel"?
A "Discontinue the medication immediately."B "Come to the clinic immediately for an assessment."C "I'll notify your primary health care provider of these results."D "This is a normal occurrence with the use of this medication." الإجابة الصحيحة -
623
The nurse is performing pin-site care on a client in skeletal traction. Which normal finding would the nurse expect to note when assessing the pin sites?
A Numbness at the pin sitesB Warm skin around the pin sitesC Clear drainage from the pin sites الإجابة الصحيحةD Redness and swelling around the pin sites -
624
The nurse prepares to transfer the client with a newly applied arm cast into the bed using which method?
A Placing ice on top of the castB Supporting the cast with the fingertips onlyC Asking the client to support the cast during transferD Using the palms of the hands and soft pillows to support the cast الإجابة الصحيحة -
625
A magnetic resonance imaging (MRI) scan is prescribed for a client with a suspected brain tumor. Which prescription would the nurse expect to be prescribed for the client before the procedure?
A An opioidB A mild sedative الإجابة الصحيحةC A corticosteroidD An antihistamine -
626
A dose of ondansetron is prescribed for a client receiving chemotherapy for a brain tumor. The nurse anticipates that the primary health care provider will prescribe the medication by which route during the chemotherapy infusion?
A OralB IntranasalC Intravenous الإجابة الصحيحةD Subcutaneous -
627
A client, admitted to the hospital for evaluation of recurrent runs of ventricular tachycardia, is scheduled for electrophysiology studies (EPS). Which statement would the nurse include in a teaching plan for this client?
A "You will continue to take your medications until the morning of the test."B "You will be sedated during the procedure and will not remember what has happened."C "This test is a noninvasive method of determining the effectiveness of your medication regimen."D "The test uses a special wire to increase the heart rate and produce the irregular beats that cause your signs and symptoms." الإجابة الصحيحة -
628
The nurse providing diet teaching to a client experiencing heart failure instructs the client to avoid which food item?
A SherbetB Steak sauce الإجابة الصحيحةC Apple juiceD Leafy green vegetables -
629
The nurse is developing a plan of care for a client diagnosed with type 1 diabetes mellitus who is also experiencing acute gastroenteritis. To maintain food and fluid intake in order to prevent dehydration, which action would the nurse plan to include?
A Offering only water until the client is able to tolerate solid foodsB Withholding all fluids until vomiting has ceased entirely for at least 4 hoursC Encouraging the client to take 8 to 12 ounces of fluid every hour while awake الإجابة الصحيحةD Maintaining a clear liquid diet for at least 5 days before advancing to solid foods -
630
The nurse has completed tracheostomy care for a client whose tracheostomy tube has a nondisposable inner cannula. Which intervention will the nurse implement immediately before reinserting the inner cannula?
A Rinsing it in sterile waterB Suctioning the client's airwayC Tapping it gently against a sterile basinD Drying it with the sterile gauze or specialized pipe cleaner الإجابة الصحيحة -
631
An anxious client enters the emergency department seeking treatment for a laceration of the finger. The client's vital signs are pulse 106 beats/min, blood pressure (BP) 158/88 mm Hg, and respirations 28 breaths/min. After cleansing the injury and reassuring the client, the nurse rechecks the vital signs and notes a pulse of 82 beats/min, BP 130/80 mm Hg, and respirations 20 breaths/min. Which factor likely accounts for the change in vital signs?
A Cooling effects of the cleansing agentB Client's adaptation to the air conditioningC Early clinical indicators of cardiogenic shockD Decline in sympathetic nervous system discharge الإجابة الصحيحة -
632
The nurse is preparing to initiate an intravenous nitroglycerin drip on a client who has experienced an acute myocardial infarction. In the absence of an arterial monitoring line, the nurse prepares to have which piece of equipment for use at the bedside to help assure the client's safety?
A DefibrillatorB Pulse oximeterC Central venous pressure (CVP) trayD Noninvasive blood pressure monitor الإجابة الصحيحة -
633
When the nasogastric (NG) tube of a client diagnosed with acute pancreatitis stops draining, which intervention would the nurse implement to maintain client safety?
A Remove and replace the tube.B Verify the tube placement according to agency procedure. الإجابة الصحيحةC Clamp the tube for 2 hours to allow the drainage to accumulate.D Retract the tube by 2 inches so that it is above a possible obstruction. -
634
A client is in ventricular tachycardia and the primary health care provider prescribes intravenous (IV) lidocaine. The nurse would dilute the concentrated solution of lidocaine with which solution?
A Lactated Ringer'sB Normal saline 0.9%C 5% Dextrose in water الإجابة الصحيحةD Normal saline 0.45% -
635
A client is scheduled to have a percutaneous transluminal coronary angioplasty (PTCA) to treat coronary artery disease. What information about the balloon-tipped catheter would the nurse plan to include when providing client education concerning the procedure?
A A mesh-like device within the catheter will be inflated causing it to spring open.B The catheter will be used to compress the plaque against the coronary blood vessel wall. الإجابة الصحيحةC The catheter will cut away the plaque from the coronary vessel wall using an embedded blade.D The catheter will be positioned in a coronary artery to take pressure measurements in the vessel. -
636
The nurse is caring for a client who has been placed in skin traction to treat a femur fracture. Which action by the nurse provides for countertraction to reduce shear and friction?
A Using a footboardB Providing an overhead trapezeC Slightly elevating the foot of the bed الإجابة الصحيحةD Slightly elevating the head of the bed -
637
A client at risk for respiratory failure is receiving oxygen via nasal cannula at 6 L/min. Arterial blood gas (ABG) results indicate pH 7.29, Pco2 49 mm Hg, Po2 58 mm Hg, and HCO3 18 mEq/L. What intervention would the nurse anticipate that the primary health care provider will prescribe for respiratory support for this client?
A Intubating for mechanical ventilation الإجابة الصحيحةB Keeping the oxygen at 6 L/min via nasal cannulaC Lowering the oxygen to 4 L/min via nasal cannulaD Adding a partial rebreather mask to the current prescription Syndrome/Failure -
638
The nurse analyzed an electrocardiogram (ECG) strip (refer to figure) for a client demonstrating left-sided heart failure and interprets the ECG strip as which rhythm?
A Atrial fibrillation الإجابة الصحيحةB Sinus dysrhythmiaC Ventricular fibrillationD Third-degree heart block -
639
The nurse admits a client with a suspected diagnosis of bulimia nervosa. While performing the admission assessment, the nurse expects to elicit which data about the client's beliefs?
A Is accepting of body sizeB Views purging as an accepted behavior الإجابة الصحيحةC Overeats for the enjoyment of eating foodD Gorges in response to losing control of diet -
640
The nurse is caring for a client who develops compartment syndrome as a result of a severely fractured arm. When the client asks why this happens, how would the nurse respond?
A A bone fragment has injured the nerve supply in the area.B An injured artery causes impaired arterial perfusion through the compartment.C Bleeding and swelling cause increased pressure in an area that cannot expand. الإجابة الصحيحةD The fascia expands with injury, causing pressure on underlying nerves and muscles. -
641
A client with an extremity burn injury has undergone a fasciotomy. The nurse prepares to provide which type of wound care to the fasciotomy site?
A Dry sterile dressingsB Hydrocolloid dressingsC Wet, sterile saline dressings الإجابة الصحيحةD One-half-strength povidone-iodine dressings -
642
The nurse is caring for a client who was recently admitted with a diagnosis of anorexia nervosa. When the nurse enters the room, the client is engaged in rigorous push-ups. Which action would the nurse implement?
A Allowing the client to complete the exercise programB Stopping the exercising and weigh the client immediatelyC Interrupting the client and offer to take the client for a walk الإجابة الصحيحةD Telling the client that he or she is not allowed to exercise rigorously -
643
The nurse assists the primary health care provider with the removal of a chest tube inserted to treat a client who experienced a pneumothorax. During the procedure, the nurse instructs the client to perform which action?
A Inhale deeply.B Breathe normally.C Breathe out forcefully.D Take a deep breath and hold it. الإجابة الصحيحة -
644
The nurse assesses the water seal chamber of a closed chest drainage system and notes fluctuations in the chamber. What action would the nurse implement?
A Unkinking the tubingB Assessing for an air leakC Documenting that the lung has reexpandedD Documenting that the lung has not yet reexpanded الإجابة الصحيحة -
645
A client has been admitted with a diagnosis of acute glomerulonephritis. During history taking, the nurse would ask the client about a recent history of which event?
A Bleeding ulcerB Myocardial infarctionC Deep vein thrombosisD Streptococcal infection Inflammation/Infection/Trauma الإجابة الصحيحة -
646
A client has just been admitted to the emergency department with reports of chest pain. Serum cardiac enzyme levels are drawn, and the results indicate an elevated serum creatine kinase (CK)-MB isoenzyme, troponin T, and troponin I. The nurse concludes that these results are compatible with what diagnosis?
A Valve diseaseB Unstable anginaC Coronary artery diseaseD New-onset myocardial infarction (MI) الإجابة الصحيحة -
647
The nurse monitors a patient diagnosed with acute pancreatitis. Which assessment finding indicates that paralytic ileus has developed?
A Inability to pass flatus الإجابة الصحيحةB Loss of anal sphincter controlC Severe, constant pain with rapid onsetD Firm, nontender mass palpable at the lower right costal margin -
648
After performing an initial abdominal assessment on a client with a diagnosis of cholelithiasis, the nurse documents that the bowel sounds are normal. When asked, how would the nurse describe this finding to the client?
A Waves of loud gurgles auscultated in all four quadrantsB Soft gurgling or clicking sounds auscultated in all four quadrants الإجابة الصحيحةC Low-pitched swishing sounds auscultated in one or two quadrantsD Very high-pitched loud rushes auscultated, especially in one or two quadrants -
649
Which important parameter would the nurse assess daily for a client diagnosed with nephrotic syndrome?
A Weight الإجابة الصحيحةB Albumin levelsC Activity toleranceD Blood urea nitrogen (BUN) level -
650
A client is being admitted with a diagnosis of urolithiasis and ureteral colic. The nurse expects to note which finding on pain assessment?
A Dull and aching pain in the costovertebral areaB Aching and cramplike pain throughout the abdomenC Pain that is sharp and radiating posteriorly to the spinal columnD Pain that is excruciating, wavelike, and radiating toward the genitalia الإجابة الصحيحة -
651
The client with heart failure states the need to use three pillows under the head and upper torso at night to be able to breathe comfortably while sleeping. The nurse documents that the client is experiencing which clinical finding?
A Orthopnea الإجابة الصحيحةB Dyspnea at restC Dyspnea on exertionD Paroxysmal nocturnal dyspnea -
652
The nurse admits a client who is in sickle cell crisis. The nurse would prepare for which intervention as a priority in the management of the client?
A Blood transfusionB Intravenous fluid therapyC Oxygen administration الإجابة الصحيحةD Pain management with an opioid -
653
A client diagnosed with renal cancer is being treated preoperatively with radiation therapy. The nurse evaluates that the client has an understanding of proper care of the skin over the treatment field when the client makes which statement?
A "I'll be able to wash the ink marks off my skin after the initial treatment."B "Direct sunlight is something I'll have to really avoid exposing my skin to." الإجابة الصحيحةC "I'll have my family bring me some unscented lotion to keep my skin soft."D "Wearing snug fitting clothing over the skin site will help provide good support." -
654
A client diagnosed with chronic kidney disease is prescribed epoetin alfa. When discussing measures needed to support this medication therapy, the nurse would include information regarding which supplement?
A Iron الإجابة الصحيحةB ZincC CalciumD Magnesium -
655
The home health nurse is performing an initial assessment on a client who has been discharged after an insertion of a permanent pacemaker for a bradydysrhythmia. Which client statement indicates that an understanding of self-care is evident?
A "I will never be able to operate a microwave oven again."B "I should expect occasional feelings of dizziness and fatigue."C "I will take my pulse in the wrist or neck daily and record it in a log." الإجابة الصحيحةD "Moving my arms and shoulders vigorously helps check pacemaker functioning." -
656
A client experiencing a major depressive episode is unable to address activities of daily living (ADLs). Which nursing intervention best meets the client's current needs therapeutically?
A Have the client's peers approach the client about how noncompliance in addressing ADLs affects the milieu.B Structure the client's day so that adequate time can be devoted to the client's assuming responsibility for ADLs.C Offer the client choices and describe the consequences for the failure to comply with the expectation of maintaining one's own ADLs.D Feed, bathe, and dress the client as needed until the client's condition improves so that these activities can be performed independently. الإجابة الصحيحة -
657
The nurse performs a neurovascular assessment on a client with a newly applied cast. The nurse would determine that there is a need for close observation and a need for follow-up if which is noted?
A Palpable pulses distal to the castB Capillary refill greater than 6 seconds الإجابة الصحيحةC Blanching of the nail bed when it is depressedD Sensation when the area distal to the cast is pinched -
658
The nurse is monitoring an unconscious client who sustained a head injury. Which observed positioning supports the suspicion that the client sustained an upper brainstem injury?
A Abnormal involuntary flexion of the extremitiesB Abnormal involuntary extension of the extremities الإجابة الصحيحةC Upper extremity extension with lower extremity flexionD Upper extremity flexion with lower extremity extension -
659
The nurse caring for a client returning to the unit after right radical mastectomy to treat breast cancer includes which intervention in the nursing plan of care for this client?
A Takes blood pressures in the right arm onlyB Draws serum laboratory samples from the right arm onlyC Positions the client supine and flat with the right arm elevated on a pillowD Checks the right posterior axilla area when assessing the surgical dressing الإجابة الصحيحة -
660
The nurse is assisting a client diagnosed with hepatic encephalopathy to fill out the dietary menu. The nurse advises the client to avoid which entree item?
A Tomato soupB Fresh fruit plateC Vegetable lasagnaD Ground beef patty الإجابة الصحيحة -
661
A client receiving total parenteral nutrition (TPN) reports nausea, polydipsia, and polyuria. To determine the cause of the client's report, the nurse would assess which client data?
A Rectal temperatureB Last serum potassiumC Capillary blood glucose الإجابة الصحيحةD Serum blood urea nitrogen and creatinine Nutrition/Malabsorption Problems -
662
A client admitted to the hospital with a diagnosis of cirrhosis demonstrates massive ascites causing dyspnea. The nurse performs which intervention as a priority measure to assist the client with this complication?
A Repositions side to side every 2 hoursB Elevates the head of the bed 60 degrees الإجابة الصحيحةC Auscultates the lung fields every 4 hoursD Encourages deep breathing exercises every 2 hours -
663
While gathering data, the nurse notes that the client has been prescribed tolterodine tartrate. The nurse would determine that the client is taking the medication to treat which disorder?
A GlaucomaB Pyloric stenosisC Renal insufficiencyD Urinary frequency and urgency Anticholinergics/Antispasmodics الإجابة الصحيحة -
664
The nurse has applied the prescribed dressing to the leg of a client with an ischemic arterial leg ulcer. Which method would the nurse use to cover the dressing?
A Apply a Kerlix roll and tape it to the skin.B Apply a large, soft pad and tape it to the skin.C Apply small Montgomery straps and tie the edges together.D Apply a Kling roll and tape the edge of the roll onto the bandage. الإجابة الصحيحة -
665
The nurse is monitoring a client in the telemetry unit who has recently been admitted with the diagnosis of chest pain and notes ventricular fibrillation rhythm on the monitoring strip. What is the initial action to be taken by the nurse?
A Notify the primary health care provider.B Initiate cardiopulmonary resuscitation (CPR). الإجابة الصحيحةC Continue to monitor the client and the heart rate patterns.D Administer oxygen with a face mask at 8 to 10 L/min. -
666
A client experiencing difficulty breathing and increased pulmonary congestion as a result of heart failure was prescribed furosemide 40 mg to be given intravenously. After an hour which assessment finding indicates that the therapy has been effective?
A The lungs are now clear upon auscultation. الإجابة الصحيحةB The urine output has increased by 400 mL.C The blood pressure has decreased from 118/64 to 106/62 mm Hg.D The serum potassium has decreased from 4.7 to 4.1 mEq (4.7 to -
667
Skin closure with heterograft will be performed on a client with a burn injury. When the client asks the nurse where the heterograft comes from, the nurse would explain it is from which source?
A A cadaverB Another animal species الإجابة الصحيحةC The burned client themselvesD A man-made synthetic source -
668
The nurse would place a client who sustained a head injury in which position to prevent increased intracranial pressure (ICP)?
A In left Sims' positionB In reverse TrendelenburgC With the head elevated on a small, flat pillowD With the head of the bed elevated at least 30 degrees الإجابة الصحيحة -
669
A client is intubated and receiving mechanical ventilation after experiencing lung aspiration. The primary health care provider has added 7 cm of positive end-expiratory pressure (PEEP) to the client's ventilator settings. The nurse would assess for which expected but adverse effect of PEEP?
A Decreased peak pressure on the ventilatorB Increased rectal temperature from 98° F to 100° FC Decreased heart rate from 78 to 64 beats/minD Systolic blood pressure decrease from 122 to 98 mm Hg Obstruction الإجابة الصحيحة -
670
The nurse is assessing the respiratory status of a client with pleural effusion after a thoracentesis has been performed. The nurse would become concerned with which assessment finding?
A Equal bilateral chest expansionB Respiratory rate of 22 breaths/minC Diminished breath sounds on the affected side الإجابة الصحيحةD Few scattered wheezes, unchanged from baseline -
671
A client is admitted to the hospital with a diagnosis of right lower lobe pneumonia. The nurse auscultates the affected lung area, expecting to note which type of breath sounds?
A AbsentB VesicularC Bronchial الإجابة الصحيحةD Bronchovesicular -
672
After a client diagnosed with pleural effusion had a thoracentesis, a sample of fluid was sent to the laboratory. Analysis of the fluid reveals a high red blood cell count. Based on this test result, what was the case of this client's pleural effusion?
A Trauma الإجابة الصحيحةB InfectionC Liver failureD Heart failure -
673
The nurse is scheduling a client diagnosed with possible diverticulosis for a series of diagnostic studies of the gastrointestinal (GI) system. Which of these studies would the nurse schedule last to avoid altering the results of the remaining tests?
A UltrasoundB ColonoscopyC Barium enema الإجابة الصحيحةD Computed tomography Diverticulosis/Diverticulitis -
674
The nurse is caring for a client who is scheduled to have a liver biopsy to rule out liver cancer. Before the procedure, it is important for the nurse to assess which parameter to assure client safety?
A Tolerance for painB Allergy to iodine or shellfishC History of nausea and vomitingD Ability to lie still and hold the breath الإجابة الصحيحة -
675
The nurse is caring for a client diagnosed with pneumonia. To ensure tolerance of the activity, the nurse would plan to take the client for a short walk after which of the following?
A Eating lunchB Taking a brief napC Using the metered-dose inhaler الإجابة الصحيحةD Assessing the client's oxygen saturation -
676
The nurse inserts an indwelling Foley catheter into the distended bladder of a postoperative client who has not voided for 8 hours. After the tubing is secured and the collection bag is hung on the bed frame, the nurse notices that 900 mL of urine has drained into the collection bag. What is the appropriate nursing action for the safety of this client?
A Check the specific gravity of the urine.B Clamp the tubing for 30 minutes and then release. الإجابة الصحيحةC Provide suprapubic pressure to maintain a steady flow of urine.D Raise the collection bag high enough to slow the rate of drainage. -
677
A client who experienced repeated pleural effusions from inoperable lung cancer is to undergo pleurodesis. What intervention would the nurse plan to implement after the primary health care provider injects the sclerosing agent through the chest tube?
A Ambulate the client.B Clamp the chest tube. الإجابة الصحيحةC Ask the client to cough and deep breathe.D Ask the client to remain in a side-lying position. -
678
A client with a posterior wall bladder injury has had surgical repair and placement of a suprapubic catheter. What intervention would the nurse plan to implement to prevent complications associated with the use of this catheter?
A Monitor urine output every shift.B Measure specific gravity once a shift.C Encourage a high intake of oral fluids.D Avoid kinking of the catheter tubing. Inflammation/Infection/Trauma الإجابة الصحيحة -
679
A client undergoes transurethral resection of the prostate (TURP). Which solution would the nurse infuse postoperatively for continuous bladder irrigation (CBI)?
A Sterile waterB Sterile normal saline الإجابة الصحيحةC Sterile Dakin's solutionD Sterile water with 5% dextrose -
680
A client diagnosed with acquired immunodeficiency syndrome (AIDS) is being admitted to the hospital for treatment of a Pneumocystis jiroveci respiratory infection. Which intervention would the nurse include in the plan of care to assist in maintaining the comfort of this client?
A Monitoring for bloody sputumB Evaluating arterial blood gas resultsC Keeping the head of the bed elevated الإجابة الصحيحةD Assessing respiratory rate, rhythm, depth, and breath sounds -
681
A client with significant flail chest has arterial blood gases (ABGs) that reveal a Pao2 of 68 and a Paco2 of 51. Two hours ago the Pao2 was 82 and the Paco2 was 44. Based on these changes, which item would the nurse assure easy access to in order to help ensure client safety?
A Intubation tray الإجابة الصحيحةB Injectable lidocaineC Chest tube insertion setD Portable chest x-ray machine -
682
A client experiencing empyema is to have a bedside thoracentesis performed. The nurse plans to have which equipment available in the event that the procedure itself is not effective?
A Code cartB A small-bore needleC Extra-large drainage bottleD Chest tube and drainage system الإجابة الصحيحة -
683
The nurse is assisting a client recovering from pneumothorax with a chest tube to get out of bed, when the chest tubing accidentally gets caught in the bed rail and disconnects. While trying to reestablish the connection, the Pleur-Evac drainage system falls over and cracks. The nurse would take which action to minimize the client's risk for injury?
A Clamp the chest tube.B Call the primary health care provider.C Apply a petroleum gauze over the end of the chest tube.D Immerse the chest tube in a bottle of sterile water or normal saline. الإجابة الصحيحة -
684
When planning care for a client diagnosed with Cushing's syndrome, the nurse would include which intervention to prevent a common complication of this disorder?
A Monitoring glucose levels الإجابة الصحيحةB Encouraging rigorous exerciseC Monitoring epinephrine levelsD Encouraging visits from friends -
685
A client who has been diagnosed with carbon monoxide poisoning is asking that the oxygen mask be removed. The nurse shares with the client that the oxygen may be safely removed once the carboxyhemoglobin level decreases to less than which level?
A 5% الإجابة الصحيحةB 10%C 15%D 25% -
686
A client is admitted to the hospital with a diagnosis of Cushing's syndrome. The nurse monitors the client for which problem that is likely to occur with this diagnosis?
A HypovolemiaB HypoglycemiaC Mood disturbances الإجابة الصحيحةD Deficient fluid volume -
687
An assessment of a client's vocal cords with suspected malignancy requires indirect visualization of the larynx. Which instruction would the nurse give the client to facilitate this procedure?
A Try to swallow.B Hold your breath.C Breathe normally. الإجابة الصحيحةD Roll the tongue to the back of the mouth. -
688
The nurse is caring for a client scheduled for a bilateral adrenalectomy for treatment of an adrenal tumor. What information would the nurse give the client about the postsurgical needs?
A "You will need to undergo chemotherapy after surgery."B "You will need to wear an abdominal binder after surgery."C "You will not need any special long-term treatment after surgery."D "You will need to take daily hormone replacements beginning after the surgery." الإجابة الصحيحة -
689
The nurse is caring for a client who is scheduled for an adrenalectomy. The nurse plans to administer which medication in the preoperative period to prevent Addisonian crisis?
A Prednisone orallyB Fludrocortisone orallyC Spironolactone intramuscularlyD Methylprednisolone sodium succinate intravenously الإجابة الصحيحة -
690
The nurse is preparing a client diagnosed with Graves' disease to receive radioactive iodine therapy. What information would the nurse share with the client about the therapy?
A After the initial dose, subsequent treatments must continue lifelong.B The radioactive iodine is designed to destroy the entire thyroid gland with just one dose.C High radioactivity levels prohibit contact with family for 4 weeks after the initial treatment.D It takes 6 to 8 weeks after treatment to experience relief from the symptoms of the disease. الإجابة الصحيحة -
691
A client arrives at the emergency department with upper gastrointestinal (GI) bleeding that began 3 hours ago. What is the priority action?
A Obtaining vital signs الإجابة الصحيحةB Inserting a nasogastric (NG) tubeC Completing an abdominal physical assessmentD Asking the client about the precipitating events Hemorrhage -
692
The client diagnosed with chronic kidney disease is scheduled for hemodialysis. When would the nurse plan to administer the client's daily dose of enalapril to ensure its effectiveness?
A During dialysisB Just before dialysisC The day after dialysisD Upon return from dialysis Converting Enzyme (ACE) Inhibitors and Chronic Kidney Disease الإجابة الصحيحة -
693
The nurse is preparing to provide postsurgical care for a client after a subtotal thyroidectomy. The nurse anticipates the need for which item to be placed at the bedside to minimize the client's risk for injury?
A Hypothermia blanketB Emergency tracheostomy kit الإجابة الصحيحةC Magnesium sulfate in a ready-to-inject vialD Ampule of saturated solution of potassium iodide -
694
The nurse is encouraging the client to cough and deep breathe after cardiac surgery to avoid developing pneumonia. The nurse ensures that which item is available to maximize the effectiveness of this procedure?
A NebulizerB Ambu bagC Suction equipmentD Incisional splinting pillow الإجابة الصحيحة -
695
The nurse is caring for a client scheduled to undergo a renal biopsy to confirm suspected malignancy. To minimize the risk of postprocedure complications, the nurse reports which laboratory results to the primary health care provider before the procedure?
A Prothrombin time: 15 seconds الإجابة الصحيحةB Potassium: 3.8 mEq/L (3.8 mmol/L)C Serum creatinine: 1.2 mg/dL (106 mcmol/L)D Blood urea nitrogen (BUN): 18 mg/dL (6.48 mmol/L) -
696
A client who survived a house fire is experiencing respiratory distress, and an inhalation injury is suspected. What would the nurse monitor to determine the presence of carbon monoxide poisoning?
A Pulse oximetryB Urine myoglobinC Sputum carbon levelsD Serum carboxyhemoglobin levels الإجابة الصحيحة -
697
A client diagnosed with acute pyelonephritis is scheduled for an intravenous pyelogram this morning. During report the nurse learns that the client vomited several times during the night and continues to report being nauseated. What intervention would the nurse implement to assure the client's safety regarding the scheduled procedure?
A Cancels the pyelogramB Monitors the client closely for any additional vomitingC Medicates the client with a standing order for metoclopramideD Requests a prescription for a 0.9% saline intravenous infusion Inflammation/Infection/Trauma الإجابة الصحيحة -
698
The nurse is planning care for a client who has experienced a T3 spinal cord injury. The nurse would include which intervention in the plan to prevent autonomic dysreflexia (hyperreflexia)?
A Assist the client to develop a daily bowel routine to prevent constipation. الإجابة الصحيحةB Teach the client to manage emotional stressors by using mental imaging.C Assess vital signs and observe for hypotension, tachycardia, and tachypnea.D Administer dexamethasone orally per the primary health care provider's prescription. -
699
A client diagnosed with left pleural effusion has just been admitted for treatment. The nurse would plan to have which procedure tray available for use at the bedside?
A IntubationB ParacentesisC Thoracentesis الإجابة الصحيحةD Central venous line insertion -
700
A client diagnosed with urolithiasis is being evaluated to determine the type of calculi that are present. The nurse would plan to keep which item available in the client's room to assist in this process?
A A urine strainer الإجابة الصحيحةB A calorie count sheetC A vital signs graphic sheetD An intake and output record -
701
The nurse is preparing to care for a client postureterolithotomy who has a ureteral catheter in place. The nurse would plan to implement which action in the management of this catheter when the client arrives from the recovery room?
A Clamp the catheter.B Place tension on the catheter.C Check the drainage from the catheter. الإجابة الصحيحةD Irrigate the catheter using 10 mL sterile normal saline. -
702
A client diagnosed with acute respiratory distress syndrome has a prescription to be placed on a continuous positive airway pressure (CPAP) face mask. What intervention would the nurse implement for this procedure to be beneficial?
A Obtain baseline arterial blood gases.B Obtain baseline pulse oximetry levels.C Apply the mask to the face with a snug fit. الإجابة الصحيحةD Remove the mask for deep breathing exercises. Syndrome/Failure -
703
The nurse is caring for a client scheduled to undergo a cardiac catheterization for the first time. Which information would the nurse share with the client regarding the procedure?
A "The procedure is performed in the operating room."B "The initial catheter insertion is quite painful; after that, there is little or no pain."C "You may feel fatigue and have various aches because it is necessary to lie quietly on a stationary x-ray table for about 4 hours."D "You may feel certain sensations at various points during the procedure, such as a fluttery feeling, flushed warm feeling, desire to cough, or palpitations." الإجابة الصحيحة -
704
The nurse admitting a client diagnosed with myocardial infarction (MI) to the coronary care unit (CCU) would plan care by implementing which intervention?
A Beginning thrombolytic therapyB Placing the client on continuous cardiac monitoring الإجابة الصحيحةC Infusing intravenous (IV) fluid at a rate of 150 mL per hourD Administering oxygen at a rate of 6 L per minute by nasal cannula -
705
The nurse is analyzing an electrocardiogram (ECG) rhythm strip on an assigned client with a suspected myocardial infarction (refer to figure). What would the nurse record as the client's PR interval?
A 0.12 second الإجابة الصحيحةB 0.20 secondC 0.24 secondD 0.40 second -
706
The nurse has developed a plan of care for a client with a diagnosis of anterior cord syndrome. Which intervention would the nurse include in the plan of care to minimize the client's long-term risk for injury?
A Change the client's positions slowly.B Assess the client for decreased sensation to touch.C Assess the client for decreased sensation to vibration.D Teach the client about loss of motor function and decreased pain sensation. الإجابة الصحيحة -
707
The nurse is caring for a client who has experienced a thoracic spinal cord injury. In the event that spinal shock occurs, which intravenous (IV) fluid would the nurse anticipate being prescribed?
A DextranB 0.9% Normal saline الإجابة الصحيحةC 5% Dextrose in waterD 5% Dextrose in 0.9% normal saline -
708
The nurse is caring for a client experiencing severe macular degeneration who will be taught to ambulate with a cane. Before cane- assisted ambulation instructions begin, what would the nurse check for as the priority to assure client safety?
A A high level of stamina and energyB Self-consciousness about using a caneC Full range of motion in lower extremitiesD Balance, muscle strength, and confidence الإجابة الصحيحة -
709
A client hospitalized with a diagnosis of thrombophlebitis is being treated with heparin infusion therapy. About 24 hours after the infusion has begun, the nurse notes that the client's partial thromboplastin time (PTT) is 65 seconds with a control of 30 seconds. What action would the nurse implement?
A Discontinue the heparin infusion.B Prepare to administer protamine sulfate.C Notify the primary health care provider of the laboratory results.D Include in report that the client is adequately anticoagulated. الإجابة الصحيحة -
710
A client is brought to the emergency department reporting chest pain. Assessment shows vital signs that include a blood pressure (BP) of 150/90 mm Hg, pulse (P) 88 beats/min, and respirations (R) 20 breaths/min. The nurse administers nitroglycerin 0.4 mg sublingually. The treatment is found to be effective when the reassessment of vital signs shows which data?
A BP 150/90 mm Hg, P 70 beats/min, R 24 breaths/minB BP 100/60 mm Hg, P 96 beats/min, R 20 breaths/min الإجابة الصحيحةC BP 100/60 mm Hg, P 70 beats/min, R 24 breaths/minD BP 160/100 mm Hg, P 120 beats/min, R 16 breaths/min -
711
A client who underwent surgical repair of an abdominal aortic aneurysm is 1 day postoperative. The nurse performs an abdominal assessment and notes the absence of bowel sounds. What action would the nurse take?
A Start the client on sips of water.B Remove the nasogastric (NG) tube.C Call the surgeon immediately.D Document the finding and continue to assess for bowel sounds. الإجابة الصحيحة -
712
A client diagnosed with multiple myeloma is receiving intravenous hydration at 100 mL per hour. Which finding indicates to the nurse that the client is experiencing a positive response to the treatment plan?
A Weight increase of 1 kilogramB Respirations of 18 breaths per minuteC Creatinine of 1.0 mg/dL (88 mcmol/L) الإجابة الصحيحةD White blood cell count of 6000 mm3 (6 x 109/L) -
713
The nurse provides discharge instructions to a client who is recovering from testicular cancer surgery. Which instruction would the nurse include?
A To avoid driving a car for at least 2 weeksB To avoid sitting for long periods for at least 2 weeksC Not to be fitted for a prosthesis for at least 3 monthsD To report any fever to the primary health care provider immediately الإجابة الصحيحة -
714
A multidisciplinary team working with the spouse of a home care client diagnosed with end-stage liver failure is teaching the spouse about pain management. Which statement by the spouse indicates the need for further teaching?
A "I will help prevent constipation with increased fluids."B "My husband can use breathing exercises to control pain."C "If the pain increases, I will report it to the nurse promptly."D "The medication causes very deep sleep that my husband needs." الإجابة الصحيحة -
715
The nurse is admitting a client with a diagnosis of hypothyroidism. What assessment would the nurse perform to obtain data related to this diagnosis?
A Inspect facial features. الإجابة الصحيحةB Auscultate lung sounds.C Percuss the thyroid gland.D Inspect ability to ambulate safely. -
716
The nurse is teaching a client diagnosed with chronic obstructive pulmonary disease (COPD) how to do pursed-lip breathing. Evaluation of understanding is evident if the client performs which action?
A Loosens the abdominal muscles while breathing outB Breathes in and then holds the breath for 30 secondsC Inhales with puckered lips and exhales with the mouth open wideD Breathes so that expiration is two to three times as long as inspiration Pulmonary Disease الإجابة الصحيحة -
717
While providing care to a client with a head injury, the nurse notes that a client exhibits this posture (refer to figure). What should the nurse document that the client is exhibiting?
A FlaccidityB Decorticate posturing الإجابة الصحيحةC Decerebrate posturingD Rigidity in the upper extremities -
718
A client prescribed lithium carbonate for the treatment of bipolar disorder has a medication blood level of 1.6 mEq/L (1.6 mmol/L). Which assessment question would the nurse ask to determine whether the client is experiencing signs of lithium toxicity associated with this level?
A "Do you hear ringing in your ears?"B "Have you noted that your vision is blurred?"C "Have you fallen recently because you are dizzy?"D "Have you been experiencing any nausea, vomiting, or diarrhea?" الإجابة الصحيحة -
719
The nurse is caring for a client who sustained a spinal cord injury that has resulted in spinal shock. Which assessment will provide relevant information about recovery from spinal shock?
A Reflexes الإجابة الصحيحةB Pulse rateC TemperatureD Blood pressure -
720
A hospitalized client awaiting repair of an unruptured cerebral aneurysm is frequently assessed by the nurse. Which assessment finding would the nurse identify as an early indication that the aneurysm has ruptured?
A Widened pulse pressureB Unilateral motor weaknessC Unilateral slowing of pupil responseD A decline in the level of consciousness الإجابة الصحيحة -
721
A visiting home care nurse finds a client unconscious in the bedroom. The client has a history of abusing the selective serotonin reuptake inhibitor, sertraline. The nurse would immediately conduct which assessment?
A PulseB Respirations الإجابة الصحيحةC Blood pressureD Urinary output -
722
A client has just undergone an upper gastrointestinal (GI) series to rule out peptic ulcer disease. Upon the client's return to the unit, what primary health care provider's prescriptions does the nurse expect to note as a part of routine postprocedure care?
A Bland dietB NPO statusC Mild laxative الإجابة الصحيحةD Decreased fluids -
723
A primary health care provider is inserting a chest tube to treat pneumothorax. Which materials should the nurse have available to be used as the first layer of the dressing at the chest tube insertion site?
A Petrolatum jelly gauze الإجابة الصحيحةB Sterile 4 x 4 gauze padC Absorbent gauze dressingD Gauze impregnated with povidone-iodine -
724
During a follow-up visit 2 weeks after pneumonectomy to treat lung cancer, the client reports numbness and tenderness at the surgical site. Which statement would the nurse make to accurately address the client's concerns?
A "This is likely to be temporary, but may last for some months." الإجابة الصحيحةB "You are having a severe problem and will probably be rehospitalized"C "This is probably caused by permanent nerve damage as a result of surgery."D "This is often the first sign of a wound infection; I will check your temperature." -
725
A client, diagnosed with a malignant tumor in the left lung is scheduled for pneumonectomy, tells the nurse that a friend had lung surgery that required chest tubes. The client asks how long to expect chest tubes to be in place. Which statement by the nurse appropriately educates the client about the presence of a chest tube postpneumonectomy?
A "They are generally removed after 36 to 48 hours."B "Not every lung surgery requires chest tubes to be used."C "They usually remain in place for a full week after surgery."D "Your type of surgery rarely requires chest tubes to be inserted after surgery." الإجابة الصحيحة -
726
A client with peripheral vascular disease has undergone angioplasty of the iliac artery. Which technique would the nurse perform to best detect bleeding from the angioplasty in the region of the iliac artery?
A Palpate the pedal pulses.B Measure the abdominal girth. الإجابة الصحيحةC Assess the client about the level of pain in the area.D Auscultate over the iliac area with a Doppler device. -
727
A client with peripheral vascular disease who underwent peripheral arterial bypass surgery 16 hours ago reports that there is increasing pain in the leg that worsens with movement and is accompanied by paresthesias. Based on these data, which action would the nurse take?
A Administer an opioid analgesic.B Apply warm moist heat for comfort.C Call the primary health care provider. الإجابة الصحيحةD Apply ice to minimize any developing swelling. -
728
A client with a spinal cord injury is at risk of developing footdrop. What intervention would the nurse use as a preventive measure?
A Mole skin–lined heel protectorsB Regular use of posterior splints الإجابة الصحيحةC Application of pneumatic bootsD Avoiding dorsal flexion of the foot -
729
To monitor for a temporary but common postsurgical complication of a transsphenoidal resection of the pituitary gland, the nurse would regularly perform which assessment?
A Pulse rateB TemperatureC Urine output الإجابة الصحيحةD Oxygen saturation -
730
The nurse is creating a discharge plan for a postoperative client who had a unilateral adrenalectomy. What area of instruction would the nurse include in the plan to minimize the client's risk for injury?
A Teaching the client to maintain a diabetic dietB Encouraging the adoption of a realistic exercise routineC Providing a detailed list of the early signs of a wound infection الإجابة الصحيحةD Explaining the need for lifelong replacement of all adrenal hormones -
731
The nurse is caring for a client who has undergone transsphenoidal surgery for a pituitary adenoma. In the postoperative period, which information would the nurse provide to the client to minimize the risk for surgery-related injury?
A Cough and deep breathe hourly.B Nasal packing will be removed after 48 hours.C Report frequent swallowing or postnasal drip. الإجابة الصحيحةD Acetaminophen is prescribed for severe postsurgical headache. -
732
A client is receiving desmopressin intranasally. Which assessment parameters would the nurse monitor to determine the effectiveness of this medication?
A Daily weight الإجابة الصحيحةB TemperatureC Apical heart rateD Pupillary response -
733
The nurse monitors the client taking amitriptyline for which common side effect of this antidepressant?
A DiarrheaB Drowsiness الإجابة الصحيحةC HypertensionD Increased salivation Antidepressants -
734
A client is admitted after attempting suicide by ingesting a prescribed antipsychotic medication. What is the most important piece of information the nurse should obtain initially?
A Where and when the medication was ingestedB The name and amount of ingested medication الإجابة الصحيحةC If the client continues to have suicidal ideationsD If there is a history of previous suicidal attempts -
735
The nurse creates a postoperative plan of care for a client undergoing an arthroscopy. The nurse would include which priority action in the plan?
A Monitor intake and output.B Assess the tissue at the surgical site.C Monitor the area for numbness or tingling. الإجابة الصحيحةD Assess the complete blood cell count results. and Osteoarthritis -
736
The nurse is caring for a client diagnosed with active tuberculosis who is prescribed rifampin therapy. The nurse instructs the client to expect which side effect of this medication?
A Green urineB Yellow scleraC Orange secretions الإجابة الصحيحةD Clay-colored stools -
737
The nurse sends a sputum specimen to the laboratory for culture from a client with suspected active tuberculosis (TB). The results report that Mycobacterium tuberculosis is cultured. How would the nurse correctly analyze these results?
A The results are positive for active tuberculosis. الإجابة الصحيحةB The results indicate a less virulent strain of tuberculosis.C The results are inconclusive until a repeat sputum specimen is sent.D The results are unreliable unless the client has also had a positive tuberculin skin test (TST). -
738
A coronary care unit (CCU) nurse is caring for a client admitted with acute myocardial infarction (MI). The nurse would monitor the client for which most common complication of MI?
A Heart failureB Cardiogenic shockC Cardiac dysrhythmias الإجابة الصحيحةD Recurrent myocardial infarction -
739
A client is experiencing acute cardiac and cerebral symptoms as a result of excess fluid volume. Which measure would the nurse implement to increase the client's comfort until specific therapy is prescribed by the primary health care provider?
A Cover the client with warm blankets.B Minimize visual and auditory stimuli present.C Elevate the client's head to at least 45 degrees. الإجابة الصحيحةD Initiate oxygen at 4 L/min by nasal cannula. -
740
The nurse has a prescription to ambulate a client with a nephrostomy tube four times a day. The nurse determines that the safest way to ambulate the client while maintaining the integrity of the nephrostomy tube is to implement which intervention?
A Change the drainage bag to a leg collection bag. الإجابة الصحيحةB Tie the drainage bag to the client's waist while ambulating.C Use a walker to hang the drainage bag from while ambulating.D Tell the client to hold the drainage bag higher than the level of the bladder. Inflammation/Infection/Trauma -
741
A client newly diagnosed with polycystic kidney disease asks the nurse to explain again what the most serious complication of the disorder might be. The nurse would provide the client with information concerning which condition?
A Diabetes insipidusB End-stage renal disease (ESRD) الإجابة الصحيحةC Chronic urinary tract infection (UTI)D Syndrome of inappropriate antidiuretic hormone (SIADH) secretion Disease -
742
A client is receiving cisplatin as part of a treatment plan for esophageal cancer. On assessment of the client, which findings indicate that the client is experiencing an adverse effect of the medication?
A Tinnitus الإجابة الصحيحةB Increased appetiteC Excessive urinationD Yellow halos in front of the eyes -
743
A client is scheduled for a subtotal gastrectomy (Billroth II procedure) to treat stomach cancer. The nurse explains that the procedure will have which surgical results?
A Proximal end of the distal stomach is anastomosed to the duodenum.B Entire stomach is removed and the esophagus is anastomosed to the duodenum.C Lower portion of the stomach is removed and the remainder is anastomosed to the jejunum. الإجابة الصحيحةD Antrum of the stomach is removed and the remaining portion is anastomosed to the duodenum. -
744
A client diagnosed with diabetes mellitus receives 8 units of regular insulin subcutaneously at 7:30 am. The nurse would be most alert to signs of hypoglycemia at what time during the day?
A 1:30 pm to 3:30 pmB 3:30 pm to 5:30 pmC 9:30 am to 11:30 am الإجابة الصحيحةD 11:30 am to 1:30 pm -
745
After undergoing a thyroidectomy, a client is monitored for signs of damage to the parathyroid glands postoperatively. The nurse would determine which finding suggests damage to the parathyroid glands?
A FeverB Neck painC HoarsenessD Tingling around the mouth الإجابة الصحيحة -
746
The nurse is performing an admission assessment on a client admitted with a diagnosis of Raynaud's disease. The nurse assesses for the associated symptoms by performing which actions?
A Checking for a rash on the digitsB Observing for softening of the nails or nail bedsC Palpating for a rapid or irregular peripheral pulseD Palpating for diminished or absent peripheral pulses الإجابة الصحيحة -
747
The nurse is conducting a health history on a client diagnosed with hyperparathyroidism. Which question asked of the client would elicit information about this condition?
A "Do you have tremors in your hands?"B "Are you experiencing pain in your joints?" الإجابة الصحيحةC "Have you had problems with diarrhea lately?"D "Do you notice any swelling in your legs at night?" -
748
A client seeks medical attention for intermittent signs and symptoms that suggest a diagnosis of Raynaud's disease. The nurse should assess the trigger of these signs/symptoms by asking which question?
A "Does being exposed to heat seem to cause the episodes?"B "Do the signs and symptoms occur while you are asleep?"C "Does drinking coffee or ingesting chocolate seem related to the episodes?" الإجابة الصحيحةD "Have you experienced any injuries that have limited your activity levels lately?" -
749
A client diagnosed with pneumonia reports a decreased sense of taste that has greatly affected the motivation to eat and drink. Which action would the nurse take to help increase the client's appetite?
A Offer in-between meal snacks.B Provide three large meals daily.C Provide mouth care before meals. الإجابة الصحيحةD Offer to sit with the client during meals. -
750
A client is experiencing pulmonary edema as an exacerbation of chronic left-sided heart failure. The nurse would assess the client for what manifestation?
A Weight lossB Bilateral crackles الإجابة الصحيحةC Distended neck veinsD Peripheral pitting edema -
751
A client seeks treatment in an ambulatory clinic for hoarseness that has persisted for 8 weeks. Based on the symptom, the nurse interprets that the client is at risk for which disorder?
A Thyroid cancerB Acute laryngitisC Laryngeal cancer الإجابة الصحيحةD Bronchogenic cancer -
752
A client is admitted to the cardiac intensive care unit after coronary artery bypass graft (CABG) surgery. The nurse notes that in the first hour after admission, the mediastinal chest tube drainage was 75 mL. During the second hour, the drainage has dropped to 5 mL. The nurse interprets this data and implements which intervention?
A Identifies that the tube is draining normallyB Assesses the tube to locate a possible occlusion الإجابة الصحيحةC Auscultates the lungs for appropriate bilateral expansionD Assists the client with frequent coughing and deep breathing -
753
The nurse is assessing a client diagnosed with pleurisy 48 hours ago. When auscultating the chest the nurse is unable to detect the pleural friction rub, which was auscultated on admission. This change in the client's condition confirms which event has occurred?
A The prescribed medication therapy has been effective.B The client has been taking deep breaths as instructed.C The effects of the inflammatory reaction at the site decreased.D There is now an accumulation of pleural fluid in the inflamed area. الإجابة الصحيحة -
754
When a client experiences frequent runs of ventricular tachycardia, the primary health care provider prescribes flecainide. Because of the effects of the medication, which nursing intervention is specific to this client's safety?
A Monitor the client's urinary output.B Assess the client for neurological problems.C Ensure that the bed rails remain in the up position.D Monitor the client's vital signs and electrocardiogram (ECG) frequently. الإجابة الصحيحة -
755
A client admitted 2 days ago with a diagnosis of moderate depression begins smiling and reporting that the crisis is over. Which priority modification to the treatment plan would occur based on the behavioral cues of the client?
A Allowing off-unit privileges PRNB Suggesting a reduction of medicationC Allowing increased "in-room" activitiesD Increasing the level of suicide precautions الإجابة الصحيحة -
756
The nurse is planning care for a suicidal client who is hallucinating and delusional. Which intervention would the nurse incorporate into the nursing care plan to best assure client safety?
A Check the client's location every 15 minutes.B Begin suicide precautions with 30-minute checks.C Initiate one-to-one suicide precautions immediately. الإجابة الصحيحةD Ask the client to report suicidal thoughts immediately. -
757
The nurse is planning care for a client with a prescription for an anticoagulant agent as part of treatment for a deep vein thrombosis. Which would the nurse identify as a potential concern for this client?
A FatigueB Bruising الإجابة الصحيحةC InfectionD Dehydration -
758
A client reporting abdominal pain has a diagnosis of acute abdominal syndrome but the cause has not been determined. Which prescription would the nurse question at this time?
A Clear liquid diet only الإجابة الصحيحةB Insertion of a nasogastric tubeC Administration of an analgesicD Insertion of an intravenous (IV) line -
759
A client with a diagnosis of subarachnoid hemorrhage secondary to ruptured cerebral aneurysm has been placed on aneurysm precautions. To promote safety, the nurse would ensure that which intervention is provided to the client?
A Liquid dietB Enemas as neededC Help with ambulationD Daily stool softeners الإجابة الصحيحة -
760
The nurse is caring for a client immediately after a bronchoscopy. The client received intravenous sedation and a topical anesthetic for the procedure. Which priority nursing intervention would the nurse perform to provide a safe environment for the client at this time?
A Place pads on the side rails.B Connect the client to a bedside ECG.C Remove all food or fluids within the client's reach. الإجابة الصحيحةD Place a water-seal chest drainage set at the bedside. -
761
A client with a history of silicosis is admitted diagnosed with respiratory distress and impending respiratory failure. The nurse would plan to have which supplies/equipment readily available at the client's bedside to ensure a safe environment?
A Code cartB Intubation tray الإجابة الصحيحةC Thoracentesis trayD Chest tube and drainage system -
762
The nurse is admitting a client with an arteriovenous (AV) fistula in the right arm for hemodialysis. Which strategy would the nurse plan to implement to best prevent injury to the AV fistula site?
A Applying an allergy bracelet to the right armB Placing an alert bracelet per agency procedure on the client's right الإجابة الصحيحةC Putting a large note about the access site on the front of the medical recordD Telling the client to inform all caregivers who enter the room about the presence of the access site and Chronic Kidney Disease -
763
The nurse performing an admission assessment notes that a client diagnosed with gastroesophageal reflux disease (GERD) has been prescribed metoclopramide for a prolonged period. The nurse would immediately call the primary health care provider if which signs/symptoms were then noted by the nurse?
A Dry mouthB Anxiety or irritabilityC Excessive drowsinessD Uncontrolled rhythmic movements of the face or limbs Reflux Disease الإجابة الصحيحة -
764
A client with a diagnosis of schizophrenia and psychosis is pacing, agitated, and presenting with aggressive gestures. The client's speech pattern is rapid, and the client's affect is belligerent. Which priority nursing intervention based on these objective data would the nurse implement?
A Provide safety for the client and other clients on the unit. الإجابة الصحيحةB Bring the client to a less stimulated area to regain control.C Provide the clients on the unit with a sense of comfort and safety.D Assist the staff in caring for the client in a controlled environment. -
765
To ensure that the client diagnosed with cancer has adequate and safe pain control, which plan would the nurse implement?
A Rely primarily on prescription and over-the-counter medications to relieve pain.B Keep a baseline level of pain so that the client does not become sedated or addicted.C Try multiple medication modalities for pain relief to get the maximum pain relief effect.D Start with low doses of medication and gradually increase to a safe dose that relieves pain. الإجابة الصحيحة -
766
A client remains in diagnosed atrial fibrillation with rapid ventricular response despite prescribed pharmacological intervention. Synchronous cardioversion is scheduled to convert the rapid rhythm. Which action would the nurse plan to take to ensure safety and prevent complications of this procedure?
A Cardiovert the client at 360 joules.B Sedate the client before cardioversion.C Ensure that emergency equipment is available.D Check that the defibrillator is set on the synchronous mode. الإجابة الصحيحة -
767
A client with a diagnosis of thrombophlebitis is being treated with prescribed heparin sodium therapy. In planning a safe environment, the nurse would ensure that which medication is available if the client develops a significant bleeding problem?
A RetaplaseB PhytonadioneC Protamine sulfate الإجابة الصحيحةD Fresh frozen plasma -
768
The nurse is teaching a client with a diagnosis of cardiomyopathy about home care safety measures. Which instruction is most important for the nurse to include?
A Reporting painB Appropriate vasodilator administrationC Avoiding over-the-counter medicationsD Moving slowly from a sitting to a standing position Structural Heart Disorders الإجابة الصحيحة -
769
The nurse instructs a client with a diagnosis of atrial fibrillation who has been prescribed warfarin to use an electric razor for shaving. Which premise best supports the rationale for this instruction?
A Cuts need to be avoided. الإجابة الصحيحةB Any cut may cause infection.C Electric razors can be disinfected.D All straight razors contain bacteria. -
770
The nurse assesses a client 24 hours following an above-the-knee amputation. Which action would the nurse take to ensure that the client's residual limb is placed in the most appropriate position?
A Elevate the foot of the bed.B Put the bed in reverse Trendelenburg.C Position the residual limb flat on the bed. الإجابة الصحيحةD Keep the residual limb slightly elevated with the client lying on the operative side. -
771
The nurse is admitting a 56-year-old client with a diagnosis of exacerbation of chronic obstructive pulmonary disease (COPD) and learns that the client received immunization for pneumococcal pneumonia 6 years ago. Which consideration is essential to include in the plan of care during the client's hospital admission?
A Offer revaccination to the client. الإجابة الصحيحةB Document the previous immunization on the client record.C Instruct the client that this vaccine provides lifelong immunity.D Explain to the client that he can be revaccinated only during the fall months. Pulmonary Disease -
772
The nurse prepares a client with the diagnosis of right pleural effusion for a thoracentesis; however, the client experiences severe dizziness when sitting upright. Which alternate position would the nurse assist the client into to maintain safety during the procedure?
A Right side-lying with the head of the bed flatB Prone with the head turned toward the affected sideC Sims' position with the head of the bed elevated 45 degreesD Left side-lying with the head of the bed elevated 45 degrees الإجابة الصحيحة -
773
The nurse is assessing a client with a lower leg cast who has just been measured and fitted for crutches. Which observation would help the nurse determine if the client's crutches are fitted correctly?
A The top of the crutch is even with the axilla.B The elbow is straight when the hand is on the handgrip.C The client's axilla is resting on the crutch pad during ambulation.D The elbow is at a 30-degree angle when the hand is on the handgrip. الإجابة الصحيحة -
774
The nurse observes that a postoperative client has episodes of extreme agitation. Which is the best nursing measure to implement to prevent escalating the agitation?
A Gently hold the client's hand while speaking.B Wait to approach until the client's agitation has subsided.C Speak in a calm tone while moving slowly toward the client. الإجابة الصحيحةD Communicate with the client from the entrance to the room. -
775
The nurse is caring for an adolescent client with a diagnosis of conjunctivitis. Which instruction is most appropriate for the nurse to relate to the adolescent?
A Avoid using all eye makeup to prevent possible reinfection.B Apply hot compresses to decrease pain and lessen irritation.C Obtain a new set of contact lenses for use after the infection clears. الإجابة الصحيحةD Isolate for 3 days after beginning antibiotic eye drops to avoid the spread of infection. -
776
A postoperative client begins to drain small amounts of bright red blood from the tracheostomy tube 24 hours after a laryngectomy. Which priority action would the nurse implement?
A Notify the surgeon. الإجابة الصحيحةB Increase the frequency of suctioning.C Add moisture to the oxygen delivery system.D Document the character and amount of drainage. -
777
The nurse is preparing to administer oxygen to a client with a diagnosis of chronic obstructive pulmonary disease (COPD) and is at risk for carbon dioxide narcosis. The nurse would check to see that the oxygen flow rate is prescribed at which rate?
A 2 to 4 L/min الإجابة الصحيحةB 4 to 5 L/minC 6 to 8 L/minD 8 to 10 L/min Pulmonary Disease -
778
A client undergoes a subtotal thyroidectomy. The nurse ensures that which priority item is at the client's bedside upon arrival from the post-anesthesia care unit (PACU)?
A An apnea monitorB A suction unit and oxygen الإجابة الصحيحةC A blood transfusion warmerD An ampule of phytonadione -
779
A client suspected of having developed tuberculosis is to undergo pleural biopsy at the bedside. Knowing the potential complications of the procedure, what equipment would the nurse plan to have available at the bedside?
A Intubation trayB Morphine sulfate injectionC Portable chest x-ray machineD Chest tube and drainage system الإجابة الصحيحة -
780
The nurse manager of a hemodialysis unit observes a new nurse preparing hemodialysis on a client with a diagnosis of chronic kidney disease. The nurse manager would note that the new nurse needs further teaching and intervene if which action is carried out by the new nurse?
A Uses sterile technique for needle insertionB Wears full protective clothing such as goggles, mask, gown, and glovesC Covers the connection site with a bath blanket to enhance extremity warmth الإجابة الصحيحةD Puts on a mask and gives one to the client to wear during connection to the machine and Chronic Kidney Disease -
781
A client is being admitted to the hospital following insertion of a radiation implant after being diagnosed with cervical cancer. Which priority action would the nurse implement in the care of this client?
A Encourage the family to visit.B Admit the client to a private room. الإجابة الصحيحةC Place the client on protective isolation.D Encourage the client to take frequent rest periods. -
782
The client with a diagnosis of bladder cancer is to undergo weekly intravesical chemotherapy for the next 8 weeks. Which statement by the client would indicate to the nurse that the client understands how to manage urine as a biohazard?
A Void into a bedpan and then empty the urine into the toilet.B Purchase extra bottles of scented disinfectant for daily bathroom cleansing.C Have one bathroom strictly set aside for the client's use for the next 8 weeks.D Disinfect the toilet with household bleach after voiding for 6 hours after a treatment. الإجابة الصحيحة -
783
The nurse is preparing the bedside for a postoperative parathyroidectomy client. The nurse would ensure that which specific priority item is at the client's bedside?
A Cardiac monitorB Tracheotomy set الإجابة الصحيحةC Intermittent gastric suctionD Underwater seal chest drainage system -
784
A client with a diagnosis of an acute respiratory infection and sinus tachycardia is admitted to the hospital. The nurse would develop a plan of care for the client and include which intervention?
A Limiting oral and intravenous fluidsB Measuring the client's pulse once each shiftC Providing the client with short, frequent walksD Eliminating sources of caffeine from meal trays Airway الإجابة الصحيحة -
785
The nurse is planning care for a client with a diagnosis of acute glomerulonephritis. Which action would the nurse instruct the assistive personnel (AP) to implement in the care of the client?
A Ambulate the client frequently.B Encourage a diet that is high in protein.C Monitor the temperature every 2 hours.D Remove the water pitcher from the bedside. Inflammation/Infection/Trauma الإجابة الصحيحة -
786
The nurse is caring for a client with a diagnosis of a C-6 spinal cord injury during the spinal shock phase. Which action would the nurse implement when preparing the client to sit in a chair?
A Apply knee splints to stabilize the joints during transfer.B Teach the client to lock the knees during the pivoting stage of the transfer.C Administer a vasodilator in order to improve circulation of the lower limbs.D Raise the head of the bed slowly to decrease orthostatic hypotensive episodes. الإجابة الصحيحة -
787
The nurse notes that a client's lithium level is 3.9 mEq/L (3.9 mmol/L). Based on this data, which priority intervention would the nurse implement?
A Determining visual acuityB Assisting with ambulationC Monitoring intake and outputD Instituting seizure precautions الإجابة الصحيحة -
788
The nurse observes a client looking frightened and reporting, "feeling out of control." Which therapeutic approach by the nurse is most appropriate to maintain a safe environment?
A Administer a PRN antianxiety medication immediately.B Provide isolation for the client in the unit's "time-out" room.C Observe the client in an ongoing manner but do not intervene.D Encourage the client to talk about her or his feelings in a quiet setting. الإجابة الصحيحة -
789
A client with a diagnosis of urolithiasis is scheduled for extracorporeal shock wave lithotripsy. Which information would the nurse provide to ensure that the client understands the procedure?
A There is usually no discomfort involved with this procedure.B Hematuria is not a side effect associated with this procedure.C The stone granules are passed in the urine within a few days after the procedure. الإجابة الصحيحةD The stone is broken up by a vibrating needle that is inserted into the urinary tract. -
790
A client with a diagnosis of chronic kidney disease has an indwelling peritoneal catheter in the abdomen for peritoneal dialysis. While bathing, the client spills water on the abdominal dressing. Which action would the nurse perform to best assure client safety?
A Change the dressing. الإجابة الصحيحةB Reinforce the dressing.C Flush the peritoneal dialysis catheter.D Scrub the catheter with povidone-iodine. and Chronic Kidney Disease -
791
The nurse is planning activities for a client diagnosed with depression who was just admitted to the hospital. Which therapeutic action should be implemented as part of the nurse's plan?
A Provide an activity that is quiet and solitary in nature.B Plan nothing until the client asks to participate in the milieu.C Offer the client a menu of activities and insist that the client participate in all of them.D Provide a structured daily program of activities and encourage the client to participate. الإجابة الصحيحة -
792
An older client had an open reduction with internal fixation (ORIF) for a hip fracture 4 days ago. Which measure would the nurse implement to provide safe care?
A Provide ice chips instead of drinking water.B Instruct the client to call for help before getting up. الإجابة الصحيحةC Minimize opioid administration to prevent dizziness.D Tell the client to roll to the affected side first before getting up. -
793
The nurse assisting in the care of a client who is to be cardioverted would plan to set the monophasic defibrillator to which starting energy levels range, depending on the specific primary health care provider prescription?
A 50 to 100 joules الإجابة الصحيحةB 200 to 250 joulesC 250 to 300 joulesD 350 to 400 joules -
794
The nurse has a prescription to get the client out of bed to a chair on the first postoperative day after total knee replacement surgery. Which action is most appropriate for the nurse to plan to implement to protect the knee joint?
A Applying both ice and a compression dressing to the knee while sittingB Obtaining a walker to minimize weight-bearing by the client on the affected legC Applying a knee immobilizer and then elevating the affect leg while sitting الإجابة الصحيحةD Lifting the client to the bedside chair, leaving the continuous passive motion (CPM) machine in place -
795
A client is admitted to the psychiatric unit after a suicide attempt. The nurse would plan which intervention as the most important to maintain client safety?
A Assigning a staff member to remain with the client at all times الإجابة الصحيحةB Requesting that the client promise to alert staff of suicidal thoughtsC Removing the client's personal clothing and replacing them with a hospital gownD Placing the client in a seclusion room where all dangerous articles are removed solutions -
796
The nurse prepares a client diagnosed with chronic bronchitis being discharged from the hospital to receive oxygen therapy at home. Which action would the nurse include in client teaching about oxygen safety?
A Holding the oxygen tank on your lap when travelingB Checking the oxygen level of the tank on a regular basis الإجابة الصحيحةC Lighting candles at least a few feet away from the oxygen tankD Reporting low oxygen levels in the tank to the primary health care provider (PHCP) Airway -
797
The home care nurse assesses the client's environment for potential safety hazards related to mobility issues causes by osteoarthritis. Which observation requires the nurse to counsel the client and family about the potential for injury?
A Fluorescent light bulbs in every table lampB Trash can next to the client's favorite chairC Stairway with a landing that leads to bedrooms الإجابة الصحيحةD Extension cord tucked away between the seating area and wall and Osteoarthritis -
798
The nurse has applied the patch electrodes of an automatic external defibrillator (AED) to the chest of a client who is pulseless. The defibrillator has interpreted the rhythm to be ventricular fibrillation. Which priority action would the nurse prepare to implement next?
A Administer rescue breathing during the defibrillation.B Perform cardiopulmonary resuscitation (CPR) for 1 minute before defibrillating.C Charge the machine and immediately push the "discharge" buttons on the console.D Order any personnel away from the client, charge the machine, and defibrillate through the console. الإجابة الصحيحة -
799
When planning the discharge of a client with a diagnosis of chronic anxiety, the nurse develops goals to promote a safe environment at home. Which topic is an appropriate maintenance goal for the client to focus on?
A Identifying anxiety-producing situations الإجابة الصحيحةB Maintaining contact with a crisis counselorC Techniques for ignoring feelings of anxietyD Eliminating all anxiety from daily situations -
800
The nurse is planning to instruct a client with a diagnosis of chronic vertigo about safety measures to prevent exacerbation of symptoms or injury. Which instruction is most important for the nurse to incorporate in a teaching plan?
A Turn the head slowly when spoken to.B Remove throw rugs and clutter in the home. الإجابة الصحيحةC Drive at times when the client does not feel dizzy.D Walk to the bedroom and lie down when vertigo is experienced. -
801
A client receiving prescribed heparin therapy for a diagnosis of an acute myocardial infarction has an activated partial thromboplastin time (aPTT) value of 100 seconds. Before reporting the results to the primary health care provider, the nurse verifies that which medication is available for use if prescribed?
A Vitamin KB Vitamin B12C Methylene blueD Protamine sulfate الإجابة الصحيحة -
802
The nurse is preparing to ambulate a client with a diagnosis of Parkinson's disease who has recently been prescribed levodopa. Which information is most important for the nurse to assess before ambulating the client?
A The client's history of fallsB Assistive devices used by the clientC The client's postural (orthostatic) vital signs الإجابة الصحيحةD The degree of intention tremors exhibited by the client -
803
The nurse prepares to transfer a client who has residual right- sided weakness as a result of a stroke from the bed to the wheelchair. With the client dangling on the side of the bed, which location would the nurse best position the wheelchair in for safety?
A Directly in front of the clientB At a right angle to the client's left leg الإجابة الصحيحةC Ninety degrees to the client's right legD At a right angle to the client's right leg -
804
The nurse monitors a client who has been diagnosed with brain death as a result of a severe head injury and is a potential organ donor. Which client assessment data would indicate to the nurse that the standard of care as an organ donor has been maintained?
A Urine output: 100 mL/hr الإجابة الصحيحةB pH of arterial blood: 7.32C Capillary refill: 5 secondsD Blood pressure: 90/48 mm Hg -
805
A client diagnosed with brain death as a result of a severe head injury had received vigorous treatment to control cerebral edema. Which intervention would the nurse plan to implement as a priority to maintain viability of the kidneys before organ donation?
A Screen the donor for infection.B Administer intravenous (IV) fluids. الإجابة الصحيحةC Maintain ventilation and oxygenation.D Administer vasopressors intravenously. solutions -
806
To promote self-care, the nurse is planning to teach a client in skeletal leg traction about measures to increase bed mobility. Which item is most helpful for this client for achievement of this goal?
A Fracture bedpanB Overhead trapeze الإجابة الصحيحةC Isometric exercisesD Range-of-motion exercises -
807
The home-care nurse visits an older client diagnosed with Parkinson's disease who requires instillation of multiple eye drops. Which instruction for the administration of eye drops would the nurse plan to provide to this client who demonstrates signs/symptoms of this diagnosis?
A Administer the eye drops rapidly.B Have a family member instill the eye drops.C Lie down on a bed or sofa to instill the eye drops. الإجابة الصحيحةD Keep the eye drops in the refrigerator so that they will thicken. -
808
The nurse has given the client with a nephrostomy tube instructions to follow after hospital discharge to prevent complications. The nurse determines that the client understands the instructions if the client verbalizes the need to drink how many glasses of water per day?
A 1 to 3B 6 to 8 الإجابة الصحيحةC 10 to 12D 14 to 16 Inflammation/Infection/Trauma -
809
The nurse provides home care instructions to a client who has been diagnosed with recurrent trichomoniasis. The nurse determines the need for follow-up teaching if the client indicates she should take which action?
A Avoid sexual intercourse.B Perform good perineal hygiene.C Use the metronidazole as prescribed.D Discontinue treatment during menstruation. Problems الإجابة الصحيحة -
810
A client with a history of depression will be participating in cognitive therapy for health maintenance. The client asks the nurse, "How does this treatment work?" Which statement is most appropriate for the nurse to make to the client?
A "This treatment helps you relax and develop new coping skills."B "This treatment helps you confront your fears by gradually exposing you to them."C "This treatment helps you examine how your past life has contributed to your problems."D "This treatment helps examine how your thoughts and feelings contribute to your difficulties." الإجابة الصحيحة -
811
A client diagnosed with acquired immunodeficiency syndrome (AIDS) has a problem with nutrition resulting in a weight loss. The nurse has instructed the client regarding methods of increasing weight for health maintenance. The nurse determines that there is a need for further instruction if the client states the need to implement which measure?
A Eat low-calorie snacks between meals. الإجابة الصحيحةB Eat small, frequent meals throughout the day.C Consume nutrient-dense foods and beverages.D Keep easy-to-prepare foods available in the home. -
812
The nurse is teaching a client diagnosed with histoplasmosis infection about the prevention of future exposure to infectious sources. The nurse determines that the client needs further instruction if the client states that which is a potential source of this infection?
A Grape arbors الإجابة الصحيحةB Bird droppingsC Mushroom cellarsD Floors of chicken houses Airway -
813
The nurse is assigned to care for a client being admitted with a diagnosis of cirrhosis and ascites. Which dietary measure would the nurse expect to be prescribed for the client?
A Sodium restriction الإجابة الصحيحةB Increased fat intakeC Decreased carbohydratesD Calorie restriction of 1500 daily -
814
The nurse provides discharge teaching to a client after a vasectomy. Which statement by the client indicates the need for further teaching?
A "I can use a scrotal support if I need to."B "I don't need to practice birth control any longer." الإجابة الصحيحةC "I can resume sexual intercourse whenever I want."D "I can use an ice bag and take an analgesic for pain or swelling." Problems/Fertility/Infertility -
815
A nursing instructor asks a student to identify risk factors for and methods of preventing prostate cancer. Which statement by the student indicates the need for further teaching?
A "Smoking increases the risk for this type of cancer."B "A high-fat diet will assist in preventing this type of cancer." الإجابة الصحيحةC "A history of a sexually transmitted infection is a risk for this disease."D "Men more than 50 years old should be monitored with a yearly digital rectal exam." -
816
A clinic nurse provides information to a married couple regarding measures to prevent infertility. Which statement made by the husband indicates the need for further education?
A "Eating a nutritious diet is most important."B "Its necessary to avoid the excessive intake of alcohol."C "We need to decrease exposure to environmental hazards."D "I need to maintain warmth to my scrotum by taking hot baths frequently." Problems/Fertility/Infertility الإجابة الصحيحة -
817
The nurse is teaching a client who is preparing for discharge from the hospital after a total hip arthroplasty. Which statement by the client indicates the need for further teaching?
A "I need to avoid twisting my body when I am standing."B "I need to check my incision every day for signs of infection."C "I should not sit in one position for a prolonged period of time."D "I can cross my legs if it is more comfortable for me when I sit." الإجابة الصحيحة -
818
The clinic nurse instructs a client diagnosed with type 1 diabetes mellitus about preventing diabetic ketoacidosis on days when the client is feeling ill. Which statement by the client indicates the need for further teaching?
A "I need to stop my insulin if I am vomiting." الإجابة الصحيحةB "I need to call my doctor if I am ill for more than 24 hours."C "I need to eat 10 to 15 g of carbohydrates every 1 to 2 hours."D "I need to drink small quantities of fluid every 15 to 30 minutes." -
819
The nurse is instructing a client with diabetes mellitus regarding hypoglycemia. Which statement by the client indicates the need for further teaching?
A "Hypoglycemia can occur at any time of the day or night."B "I should drink 6 to 8 ounces of milk if hypoglycemia occurs."C "If I feel sweaty or shaky, I might be experiencing hypoglycemia."D "If hypoglycemia occurs, I need to take my regular insulin as prescribed." الإجابة الصحيحة -
820
A client diagnosed with nephrolithiasis arrives at the clinic for a follow-up visit. The laboratory analysis of the stone that the client passed 1 week ago indicates that the stone is composed of calcium oxalate. On the basis of this analysis, the nurse would tell the client that it is best to avoid which food to minimize the risk of recurrence?
A PastaB LentilsC LettuceD Spinach الإجابة الصحيحة -
821
The nurse is providing home care dietary instructions to a client who has been hospitalized for pancreatitis. Which food would the nurse instruct the client to avoid to prevent recurrence?
A Chili الإجابة الصحيحةB BagelsC Lentil soupD Watermelon -
822
The home care nurse visits a client who was recently diagnosed with cirrhosis and provides home care management instructions to the client. Which statement by the client indicates the need for further teaching?
A "I will obtain adequate rest."B "I should monitor my weight regularly."C "I will take acetaminophen if I get a headache." الإجابة الصحيحةD "I should include sufficient carbohydrates in my diet." -
823
A client has a history of urolithiasis related to hyperuricemia. To prevent the formation of future stones, the nurse instructs the client to avoid which food?
A Liver الإجابة الصحيحةB CarrotsC White riceD Skim milk -
824
The community health nurse is conducting a health screening clinic. The nurse interprets that which client participating in the screening is the highest priority client to provide instruction to lower the risk of developing respiratory disease?
A A smoker who works in an acute care hospitalB A person who works with lawn care pesticidesC A person who does woodworking as a hobby for 8 yearsD A smoker who has cracked asbestos lining on the basement pipes الإجابة الصحيحة -
825
The nurse has conducted teaching, with a client who experienced pulmonary embolism, about methods to prevent recurrence after discharge. Which client statement demonstrates understanding of the teaching?
A "I will limit the intake of fluids."B "I will sit down whenever possible."C "I am planning to continue to wear supportive stockings." الإجابة الصحيحةD "I will cross my legs only at the ankle and not at the knees." -
826
A client is being discharged from the hospital to home with an indwelling urinary catheter after the surgical repair of the bladder after trauma. The nurse determines that the client understands the principles of catheter management to prevent complications if the client states to follow which instruction?
A Cleanse the perineal area with soap and water once a day.B Keep the drainage bag lower than the level of the bladder. الإجابة الصحيحةC Limit fluid intake so that the bag will not become full so quickly.D Coil the tubing and place it under the thigh when sitting to avoid tugging on the bladder. Inflammation/Infection/Trauma -
827
The nurse is teaching a client diagnosed with atrial fibrillation about the need to begin long-term anticoagulant therapy. Which explanation would the nurse use to best describe the reasoning for this therapy?
A "Because of this dysrhythmia, blood backs up in the legs and puts you at risk for blood clots."B "This dysrhythmia decreases the volume of blood flowing from the heart, which can lead to blood clots forming in the brain."C "The antidysrhythmic medications you are taking cause blood clots as a side effect, so you need this medication to prevent them."D "Because the atria are quivering, blood flows sluggishly through them, and clots can form along the heart wall, which could then loosen and travel to the lungs or brain." الإجابة الصحيحة -
828
The client diagnosed with prostatitis asks the nurse, "Why do I need to take a stool softener? The problem is with my urine, not my bowels!" Which response would the nurse make to the client?
A "This is a standard medication prescription for anyone with a urine problem."B "This will keep the bowel free of feces, which helps decrease the swelling inside."C "Being constipated puts you at more risk for developing complications of prostatitis."D "This will help you prevent constipation because straining is painful with prostatitis." Inflammation/Infection/Trauma الإجابة الصحيحة -
829
A client diagnosed with Parkinson's disease has begun therapy with levodopa. The nurse determines that the client understands the action of the medication if the client verbalizes that results may not be apparent for what period of time?
A 1 weekB 24 hoursC 5 to 7 daysD 2 to 3 weeks الإجابة الصحيحة -
830
A client is being discharged to home after prostatectomy for treatment of benign prostatic hyperplasia. Which instruction would the note plan to provide to the client as part of the discharge teaching?
A Mowing the lawn is allowed after 1 week.B Avoid lifting more than 50 pounds for 4 to 6 weeks after surgery.C Drink at least 15 glasses of water a day to minimize clot formation.D Notify the primary health care provider if fever, increased pain, or an inability to void occurs. Inflammation/Infection/Trauma الإجابة الصحيحة -
831
The nurse is teaching a client with acute kidney injury to include proteins in the diet that are considered high quality or complete proteins. The nurse determines that the client needs further teaching if he indicates that which food item is considered high quality?
A FishB EggsC ChickenD Broccoli and Chronic Kidney Disease الإجابة الصحيحة -
832
The home care nurse visits a client who had a stroke (brain attack) with resultant unilateral neglect who was recently discharged from the hospital. Which instruction would the nurse provide to the family regarding care?
A Assist the client from the affected side. الإجابة الصحيحةB Place personal items directly in front of the client.C Discourage the client from scanning the environment.D Assist the client with grooming the unaffected side first. -
833
The nurse has completed discharge teaching with a client who has had surgery for lung cancer. The nurse determines that the client needs additional teaching about the elements of home management if the client verbalizes the need to follow which instruction?
A Avoid exposure to crowds.B Deal with any increases in pain independently. الإجابة الصحيحةC Sit up and lean forward to breathe more easily.D Call the primary health care provider if shortness of breath occurs. -
834
The nurse has given the client with a nonplaster (fiberglass) leg cast instructions regarding cast care at home. The nurse determines that the client needs further teaching if the client makes which statement?
A "I should avoid walking on wet, slippery floors."B "I'm not supposed to scratch the skin underneath the cast."C "It's all right to wipe dirt off of the top of the cast with a damp cloth."D "If the cast gets wet, I can dry it with a hair dryer turned to the hot setting." الإجابة الصحيحة -
835
The nurse provides home care instructions to a client diagnosed with advanced breast cancer who has an implanted vascular access port. Which statement by the client indicates the need for further teaching?
A "I should keep the site clean and dry."B "If the site becomes red, I will notify my doctor."C "I should pump the port daily to maintain patency." الإجابة الصحيحةD "The port will need to be flushed with saline to maintain patency." -
836
The nurse has completed instructions regarding diet and fluid restriction for the client diagnosed with chronic kidney disease. The nurse determines that the client understands the information presented if the client selected which dessert from the dietary menu?
A Jell-OB SherbetC Ice creamD Angel food cake and Chronic Kidney Disease الإجابة الصحيحة -
837
The nurse has given instructions to the client diagnosed with chronic kidney disease about reducing pruritus from uremia. The nurse determines that the client needs further teaching if the client states the intention to use which item for skin care?
A Mild soapB Oil in the bath waterC Lanolin-based lotionD Alcohol cleansing pads and Chronic Kidney Disease الإجابة الصحيحة -
838
The nurse provides information to a client who is scheduled for the implantation of an implantable cardioverter defibrillator (ICD) regarding care after implantation. The nurse tells the client that there is a need to keep a diary. What information would the nurse provide concerning the primary purpose of the diary?
A Analyze which activities to avoid.B Document events that precipitate a countershock.C Provide a count of the number of shocks delivered.D Record a variety of data that are useful for the primary health care provider during medical management. الإجابة الصحيحة -
839
The nurse is evaluating a hypertensive client's understanding of dietary modifications to control the disease process. The nurse determines that the client's understanding is satisfactory if the client made which meal selections?
A Corned beef, fresh carrots, boiled potatoB Hot dog on a bun, sauerkraut, baked beansC Turkey, baked potato, salad with oil and vinegar الإجابة الصحيحةD Scallops, French fries, salad with bleu cheese dressing -
840
The nurse has completed instructions with a client diagnosed with atrial fibrillation who will be taking warfarin sodium indefinitely. Which statement by the client indicates the need for further teaching?
A "I need to use a soft toothbrush."B "I need to avoid drinking alcohol while taking this medication."C "I can continue to take my NSAIDs as previously prescribed." الإجابة الصحيحةD "I should carry identification regarding the medication being taken." -
841
The home care nurse has given instructions to a client who was recently discharged from the hospital regarding the care of an arterial ischemic leg ulcer. The nurse determines that there is a need for further teaching if the client makes which statement?
A "I should inspect my feet daily."B "I should wear shoes and socks."C "I should cut my toenails straight across."D "I should raise my legs above the level of my heart periodically." الإجابة الصحيحة -
842
A client diagnosed with chronic kidney disease is about to begin hemodialysis therapy. The client asks the nurse about the frequency and scheduling of hemodialysis treatments. What information would the nurse provide to the client regarding the typical hemodialysis schedule?
A It is 2 hours of treatment 6 days per week.B It is 5 hours of treatment 2 days per week.C It is 2 to 3 hours of treatment 5 days per week.D It is 3 to 4 hours of treatment 3 days per week. and Chronic Kidney Disease الإجابة الصحيحة -
843
The nurse is giving instructions to an adult client diagnosed with heart failure who is beginning therapy with digoxin. To detect early complications of therapy, which action would the nurse teach the client to perform?
A Take the pulse daily. الإجابة الصحيحةB Have electrolyte levels drawn weekly.C Monitor the blood pressure once a week.D Measure the weight each morning before breakfast. -
844
The nurse has completed teaching with a hemodialysis client regarding the self-monitoring of the fluid status between hemodialysis treatments. The nurse determines that the client understands the information given if the client states the need to record which item(s) on a daily basis?
A ActivityB Pulse and respiratory rateC Intake, output, and weight الإجابة الصحيحةD Blood urea nitrogen and creatinine levels and Chronic Kidney Disease -
845
Diltiazem hydrochloride is prescribed for the client with Prinzmetal angina. The nurse provides instructions to the client regarding this medication. Which statement by the client indicates the need for further teaching?
A "I will take the medication after meals." الإجابة الصحيحةB "I will rise slowly when getting out of bed in the morning."C "I will call the primary health care provider if shortness of breath occurs."D "I will avoid activities that require alertness until my body gets used to the medication." Blockers -
846
The nurse has provided instructions to a client being discharged from the hospital to home after an abdominal aortic aneurysm (AAA) resection. The nurse determines that the client understands the instructions if the client states that which is an appropriate activity?
A Mowing the lawnB Playing a game of 18-hole golfC Lifting objects up to 30 poundsD Walking as tolerated, including outdoors الإجابة الصحيحة -
847
The nurse is planning dietary counseling for the client diagnosed with chronic heart failure taking triamterene. The nurse plans to include which item in a list of foods that are acceptable?
A BananasB OrangesC Baked potatoD Canned pears الإجابة الصحيحة -
848
Cyclophosphamide is prescribed for the client diagnosed with breast cancer, and the nurse provides instructions to the client regarding the medication. Which statement by the client indicates the need for further teaching?
A "If I lose my hair, it will grow back."B "If I develop a sore throat, I should notify the doctor."C "I need to limit my fluid intake while taking this medication." الإجابة الصحيحةD "I need to avoid contact with anyone who recently received a live virus vaccine." -
849
The community health nurse has reviewed information about the population of a local community and has determined that there are groups in the population that are at high risk for infection with tuberculosis (TB). The nurse targets which high-risk group for screening?
A French CanadiansB White, Anglo-Saxon AmericansC Older clients in long-term-care facilities الإجابة الصحيحةD Adolescents between the ages of 13 and 17 years -
850
The mother of a teenage client diagnosed with an anxiety disorder is concerned about her daughter's progress after discharge. She states that her daughter "stashes food, eats all the wrong things that make her hyperactive," and "hangs out with the wrong crowd." To assist the mother with preparing for her daughter's discharge, the nurse advises the mother to implement which action in order to promote optimal health?
A Restrict the daughter's socializing time with her school friends.B Consider taking time off to help her daughter readjust to the home environment.C Limit the amount of chocolate and caffeine products that are available in the home. الإجابة الصحيحةD Keep her daughter out of school until she proves that she can adjust to the school environment. -
851
The nurse assesses a client with hepatic encephalopathy for the presence of asterixis. What would the nurse do to appropriately test for asterixis?
A Examine the client's handwriting movements.B Check the stool for clay-colored pigmentation.C Ask the client to extend the wrist and the fingers. الإجابة الصحيحةD Check the serum bilirubin and liver enzyme levels. -
852
The nurse assesses cranial nerve XII in the client who sustained a stroke. To assess this cranial nerve, which action would the nurse ask the client to perform?
A Extend the arms.B Extend the tongue. الإجابة الصحيحةC Turn the head toward the nurse's arm.D Focus the eyes on an object held by the nurse. -
853
A client diagnosed with type 2 diabetes mellitus is being discharged from the hospital after an occurrence of hyperglycemic hyperosmolar state (HHS). The nurse creates a discharge teaching plan for the client and identifies which intervention as a priority?
A Exercise routinesB Controlling dietary intakeC Keeping follow-up appointmentsD Monitoring for signs/symptoms of dehydration الإجابة الصحيحة -
854
The nurse creates a plan of care for an older client diagnosed with diabetes mellitus. It is important that the nurse plans to complete which action first?
A Structure menus for adherence to diet.B Teach with videotapes showing insulin administration to ensure competence.C Encourage dependence on others to prepare the client for the chronicity of the disease.D Assess the client's ability to read label markings on syringes and blood glucose monitoring equipment. الإجابة الصحيحة -
855
The nurse is conducting a health screening on a client with a family history of hypertension. Which assessment finding would alert the nurse to the need for further teaching related to stroke (brain attack) prevention?
A Eats high-fiber grain cereal with skim milk for breakfastB Has a blood pressure of 118/78 mm Hg and has lost 10 pounds recentlyC Uses condoms for pregnancy and disease prevention and jogs 2 miles dailyD Uses oral contraceptives for pregnancy prevention and works as a manager of a busy medical-surgical unit الإجابة الصحيحة -
856
The nurse is reviewing the assessment data of a client. Which finding is most important for the client to modify to lessen the risk for coronary artery disease (CAD)?
A Elevated triglyceride levelsB Elevated serum lipase levelsC Elevated serum testosterone levelD Elevated low-density lipoprotein (LDL) levels Peripheral Vascular الإجابة الصحيحة -
857
The nurse is assessing a client who is suspected of having a diagnosis of testicular cancer. Which data will be most helpful for determining the client's risk for this type of cancer?
A Race الإجابة الصحيحةB Marital statusC Number of childrenD Number of sexual partners -
858
The nurse is providing instructions to a client and family regarding home care after left-eye cataract removal. The nurse tells the client and family about assuming which position during the postoperative period?
A Sleep only on the left side.B Sleep on the right side or the back. الإجابة الصحيحةC Bend below the waist as often as you are able.D Lower the head between the knees three times a day. -
859
A client with a compound (open) fracture of the radius has a plaster cast applied in the emergency department. The nurse provides home care instructions and tells the client to seek medical attention if which finding occurs?
A Numbness and tingling are felt in the fingers. الإجابة الصحيحةB The cast feels heavy and damp after 24 hours of application.C The entire cast feels warm during the first 24 hours after application.D Slightly bloody drainage is noted on the cast during the first 6 hours after application. -
860
The nurse is giving a client with chronic obstructive pulmonary disease (COPD) information related to the positions used to breathe more easily. The nurse teaches the client to assume which position?
A Sit bolt upright in bed with the arms crossed over the chest.B Lie on the side with the head of the bed at a 45-degree angle.C Sit in a reclining chair tilted slightly back with the feet elevated.D Sit on the edge of the bed with the arms leaning on an overbed table. Pulmonary Disease الإجابة الصحيحة -
861
The nurse has taught the client diagnosed with pleurisy about measures to promote comfort during recuperation. The nurse determines that the client has understood the information if the client states the need to follow which instruction?
A Try to take only small, shallow breaths.B Take as much pain medication as possible.C Lie on the unaffected side as much as possible.D Splint the chest wall during coughing and deep breathing. الإجابة الصحيحة -
862
A client with a diagnosis of trigeminal neuralgia is started on a regimen of carbamazepine. The nurse provides instructions to the client about the medication. What statement by the client indicates that the client understands the instructions?
A "I will report a fever or sore throat to my doctor." الإجابة الصحيحةB "Some joint pain is expected and is nothing to worry about."C "I must brush my teeth frequently to avoid damage to my gums."D "My urine may turn red in color, but this is nothing to be concerned about." -
863
The nurse teaches a preoperative client about the nasogastric (NG) tube that will be inserted in preparation for surgery. The nurse determines that the client understands when the tube will be removed during the postoperative period based on which statement by the client?
A "When my doctor says so."B "When I can tolerate food without vomiting."C "When my gastrointestinal (GI) system is healed."D "When my bowels begin to function again and I begin to pass gas." Nutrition/Malabsorption Problems الإجابة الصحيحة -
864
A client being discharged from the hospital will be taking warfarin sodium at home on a daily basis. The nurse has provided instructions to the client about the medication and determines that further teaching is needed if the client makes which statement?
A "I need to have a prothrombin time checked in 2 weeks."B "This medicine thins my blood and allows me to clot more slowly."C "I need to increase the intake of foods high in vitamin K in my diet." الإجابة الصحيحةD "If I notice any increased bleeding or bruising, I need to call my doctor." Disorders -
865
A teenager returns to the gynecological clinic for a follow-up visit for a sexually transmitted infection (STI). Which statement by the teenager indicates the need for further teaching?
A "I know you won't tell my parents I'm sick."B "I finished all of the antibiotics, just like you said."C "I always make sure that my boyfriend uses a condom."D "My boyfriend doesn't have to come in for treatment, does he?" Problems الإجابة الصحيحة -
866
The nurse is teaching a client who had been newly diagnosed with diabetes mellitus about blood glucose monitoring. The nurse would teach the client to report glucose levels that consistently exceed which level?
A 150 mg/dL (8.35 mmol/L)B 200 mg/dL (11.14 mmol/L)C 250 mg/dL (13.92 mmol/L) الإجابة الصحيحةD 350 mg/dL (19.5 mmol/L) -
867
A client is diagnosed with thromboangiitis obliterans (Buerger's disease). The nurse places priority on teaching the client about modifications of which risk factor related to this disorder?
A Exposure to heatB Cigarette smoking الإجابة الصحيحةC Diet low in vitamin CD Excessive water intake -
868
A client has a new prescription for timolol and the nurse provides medication instructions to the client. Which statement by the client indicates a need for further teaching regarding the instructions?
A "I should change positions slowly."B "I need to report shortness of breath to the doctor."C "I need to taper or discontinue the medication when I feel well." الإجابة الصحيحةD "I have enough medication on hand to last through weekends and vacations." -
869
The nurse has completed giving medication instructions to a client receiving benazepril to treat hypertension. Which statement made by the client indicates to the nurse that the client needs further teaching?
A "I need to change positions slowly."B "I need to monitor my blood pressure every week."C "I need to use salt moderately in cooking and on foods." الإجابة الصحيحةD "I need to report signs and symptoms of infection to my doctor." Converting Enzyme (ACE) Inhibitors -
870
The nurse has given medication instructions to a client receiving lovastatin. The nurse determines that the client understands the effects of the medication if the client stated the need to adhere to the periodic evaluation of which laboratory test?
A Bleeding timesB Creatinine levelsC Blood glucose levelsD Liver function studies الإجابة الصحيحة -
871
Clonazepam has been prescribed for the client, and the nurse teaches the client about the medication. Which statement by the client indicates a need for further teaching?
A "If I experience slurred speech, it will disappear in about 8 weeks." الإجابة الصحيحةB "My drowsiness will decrease over time with continued treatment."C "I should take my medicine with food to decrease stomach problems."D "I can take my medicine at bedtime if it tends to make me feel drowsy." Sedative-Hypnotics -
872
Dipyridamole has been prescribed for the client who underwent a valve replacement, and the nurse has provided teaching to the client about the medication. Which statement indicates that the client understands the medication instructions?
A "This medication will prevent a stroke."B "This medication will prevent a heart attack."C "This medicine will protect my artificial heart valve." الإجابة الصحيحةD "This medication will help me keep my blood pressure down." -
873
The nurse is providing home care instructions to a client recovering from an acute inferior myocardial infarction (MI) with recurrent angina. What instruction would the nurse provide to this client?
A Avoid sexual intercourse for at least 4 months.B Replace sublingual nitroglycerin tablets yearly.C Participate in an exercise program that includes overhead lifting and reaching.D Recognize the adverse effects of acetylsalicylic acid (aspirin), which include tinnitus and hearing loss. الإجابة الصحيحة -
874
The nurse is reviewing home care instructions with a client who has been diagnosed with type 1 diabetes mellitus and has a history of diabetic ketoacidosis (DKA). The client's spouse is present when the instructions are given. Which statement by the spouse indicates that there is a need for further teaching?
A "If he is vomiting, I shouldn't give him any insulin." الإجابة الصحيحةB "I should bring him to the doctor if he develops a fever."C "If our grandchildren are sick, they probably shouldn't come to visit."D "I should call the doctor if he has nausea or abdominal pain lasting for more than 1 or 2 days." -
875
The nurse is creating a teaching plan for the client diagnosed with Raynaud's disease. Which instruction would the nurse include?
A Daily cool baths will provide an analgesic effect.B A high-protein diet will minimize tissue malnutrition.C Vitamin K administration will prevent tendencies toward bleeding.D Keeping the hands and feet warm and dry will prevent vasoconstriction. الإجابة الصحيحة -
876
A client with peripheral arterial disease has received instructions from the nurse about how to limit the progression of the disease. The nurse determines that the client needs further teaching if which statement was made by the client?
A "I need to eat a balanced diet."B "A heating pad on my leg will help soothe the leg pain." الإجابة الصحيحةC "I need to take special care of my feet to prevent injury."D "I should walk daily to increase the circulation to my legs." -
877
The nurse is teaching a client diagnosed with hypertension about items that contain sodium and reviews a written list of items sent from the cardiac rehabilitation department. The nurse tells the client that which item is lowest in sodium content?
A AntacidsB LaxativesC ToothpasteD Demineralized water الإجابة الصحيحة -
878
The school nurse provides teaching about the hazards of smoking to a group of high school students. Which comment by a student indicates the need for further teaching?
A "Chewing tobacco is much safer than is smoking tobacco." الإجابة الصحيحةB "Smoking during pregnancy increases the risk of stillbirth."C "My health is at risk when my family smokes in the house."D "Inhaling smoke from other people is a public health issue." -
879
The nurse monitors a client for brachial plexus compromise after shoulder arthroplasty and is checking the status of the ulnar nerve. Which technique would the nurse use to assess the status of this nerve?
A Ask the client to raise the forearm above the head.B Have the client spread all of the fingers wide and resist pressure. الإجابة الصحيحةC Ask the client to move the thumb toward the palm and then back to the neutral position.D Have the client grasp the nurse's hand, and note the strength of the client's first and second fingers. -
880
A hospitalized client diagnosed with active pulmonary tuberculosis has been receiving multidrug therapy for the past month and is being prepared for discharge. Which finding indicates that respiratory isolation is no longer required and that medication therapy has been effective?
A Stools are clay colored.B Sputum cultures are negative. الإجابة الصحيحةC Tuberculin skin test is negative.D Nausea and vomiting have stopped. -
881
The nurse instructs a client with coronary artery disease who is hospitalized about a low-fat diet. Which menu does the nurse provide for the client?
A Shrimp, avocado, and tomato saladB Calf's liver, potato salad, and sherbetC Lean steak, mashed potatoes, and gravyD Turkey breast, boiled rice, and strawberries الإجابة الصحيحة -
882
A client has urinary calculi that are composed of uric acid, and the nurse teaches the client dietary measures to prevent the further development of the calculi. The nurse determines that the client understands the dietary measures if the client states that it is necessary to avoid consuming what food products?
A MilkB YogurtC Spinach, chocolate, and teaD Sardines, herring, and organ meats الإجابة الصحيحة -
883
A client has been experiencing muscle weakness for a period of several months. The primary health care provider suspects polymyositis, and the client asks the nurse about the disorder. The nurse explains to the client that which occurs in this disorder?
A Muscle fibers are inflamed. الإجابة الصحيحةB Muscle fibers are thickened.C There is a decrease in elastic tissue.D There is an increase in fibrous tissue. Injury -
884
A client diagnosed with chronic obstructive pulmonary disease (COPD) is admitted to the hospital with an exacerbation of signs and symptoms. Which factor contributed most to the change in client status?
A Decreased fat intakeB Decreased fluid intake الإجابة الصحيحةC Sleeping soundly during the nightD Anxiety about the upcoming pulmonologist visit Pulmonary Disease -
885
A client diagnosed with acquired immunodeficiency syndrome (AIDS) gets recurrent Candida infections of the mouth (thrush). The nurse has given the client instructions to minimize the occurrence of thrush and determines that the client understands the instructions if which statement is made by the client?
A "I should use a mouthwash at least once a week."B "I should use warm saline or water to rinse my mouth." الإجابة الصحيحةC "I should brush my teeth and rinse my mouth once a day."D "Increasing the amount of red meat in my diet will keep this from recurring." -
886
The nurse is teaching a client diagnosed with acquired immunodeficiency syndrome (AIDS) how to avoid foodborne illnesses. The nurse instructs the client to prevent acquiring infection from food by avoiding which item?
A Raw oysters الإجابة الصحيحةB Bottled waterC Pasteurized milkD Products with sorbitol -
887
The nurse provides home care instructions to a client diagnosed with Cushing's syndrome. The nurse determines that the client understands the hospital discharge instructions if the client makes which statement?
A "I need to eat foods low in potassium."B "I need to check the color of my stools." الإجابة الصحيحةC "I need to check the temperature of my legs twice a day."D "I need to take aspirin rather than acetaminophen for a headache." -
888
A client diagnosed with heart failure and secondary hyperaldosteronism is started on spironolactone to manage this disorder. The nurse informs the client that the need for dosage adjustment may be necessary if which medication is also being taken?
A AlprazolamB Warfarin sodiumC Potassium chloride الإجابة الصحيحةD Verapamil hydrochloride -
889
The nurse is monitoring a client diagnosed with type 1 diabetes mellitus. Today's blood work reveals a glycosylated hemoglobin level of 10%. The nurse creates a teaching plan based on the understanding that this result indicates which finding?
A A normal value that indicates that the client is managing blood glucose control wellB A value that does not offer information regarding the client's management of the diseaseC A low value that indicates that the client is not managing blood glucose control very wellD A high value that indicates that the client is not managing blood glucose control very well الإجابة الصحيحة -
890
The nurse is caring for a client who is scheduled to have a thyroidectomy and provides instructions to the client about the surgical procedure. Which statement by the client indicates an understanding of the nurse's instructions?
A "I will definitely have to continue taking antithyroid medication after this surgery."B "I need to place my hands behind my neck when I have to cough or change positions."C "I need to turn my head and neck front, back, and side to side every hour for the first 12 hours after surgery."D "I will immediately report to the emergency room if I experience tingling of my toes, fingers, and lips after surgery." الإجابة الصحيحة -
891
The nurse has been preparing a client diagnosed with chronic obstructive pulmonary disease (COPD) for discharge. Which statement by the client indicates the need for further teaching about nutrition?
A "I will rest a few minutes before I eat."B "I will not eat as much cabbage as I once did."C "I will certainly try to drink 3 L of fluid every day."D "It's best to eat three large meals a day, so that I will get all my nutrients." Pulmonary Disease الإجابة الصحيحة -
892
The nurse is preparing a client diagnosed with pneumonia for discharge. Which statement by the client should alert the nurse to the fact that the client needs further teaching before being discharged?
A "I will take all of my antibiotics, even if I do feel 100% better."B "You can toss out that incentive spirometer as soon as I leave for home." الإجابة الصحيحةC "I realize that it may be weeks before my usual sense of well- being returns."D "It is a good idea for me to take a nap every afternoon for the next couple of weeks." -
893
The nurse makes a home care visit to a client diagnosed with Bell's palsy. Which statement by the client indicates a need for further teaching?
A "I wear an eye patch at night."B "I am staying on a liquid diet." الإجابة الصحيحةC "I wear dark glasses when I go out."D "I have been gently massaging my face." -
894
The home care nurse is evaluating a client's understanding of the self-management of trigeminal neuralgia. Which client statement indicates that there is a need for further teaching?
A "I should chew on my good side."B "An analgesic will relieve my pain." الإجابة الصحيحةC "I should use warm mouthwash for oral hygiene."D "Taking my carbamazepine will help control my pain." -
895
The nurse is caring for a client diagnosed with type 1 diabetes mellitus. Because the client is at risk for hypoglycemia, which instructions would the nurse teach the client to follow?
A Keep glucose tablets handy. الإجابة الصحيحةB Monitor the urine for acetone.C Report any feelings of drowsiness.D Omit the evening dose of NPH insulin if the client has been exercising. -
896
The nurse has implemented a plan of care for a client diagnosed with a cervical 5 (C5) spinal cord injury to promote health maintenance. Which client outcome indicates the effectiveness of the plan?
A Maintenance of intact skin الإجابة الصحيحةB Regaining of bladder and bowel controlC Performance of activities of daily living independentlyD Independent transfer of self to and from the wheelchair -
897
A client who sustained a thoracic cord injury a year ago returns to the clinic for a follow-up visit, and the nurse notes a small reddened area on the coccyx. The client is not aware of the reddened area. After counseling the client to relieve pressure on the area by adhering to a turning schedule, which action by the nurse is most appropriate?
A Teaching the client to feel for reddened areasB Asking a family member to assess the skin dailyC Teaching the client to use a mirror for skin assessment الإجابة الصحيحةD Scheduling the client to return to the clinic daily for a skin check -
898
The nurse has given instructions to a client who is returning home after an arthroscopy of the knee. The nurse determines that the client understands the home care instructions if the client states the need to follow which instruction?
A Resume strenuous exercise the following day.B Stay off the leg entirely for the rest of the day.C Refrain from eating food for the remainder of the day.D Report fever or site inflammation to the primary health care provider. الإجابة الصحيحة -
899
Allopurinol has been prescribed for a client to treat gouty arthritis. The nurse teaches the client to anticipate which prescription if an acute attack occurs?
A Doubling the dose of the allopurinolB Stopping the allopurinol and taking acetylsalicylic acid (aspirin)C Stopping the allopurinol and taking a nonsteroidal anti- inflammatory drugD Adding colchicine or a nonsteroidal anti-inflammatory drug to the treatment plan الإجابة الصحيحة -
900
A client with hypertension has received a prescription for lisinopril. The nurse teaches the client that which frequent side effect may occur?
A Cough الإجابة الصحيحةB PolyuriaC HypothermiaD Hypertension Converting Enzyme (ACE) Inhibitors -
901
The nurse has provided home-care instructions to a client who is taking lithium carbonate. Which client statement indicates that the client understands the prescribed regimen?
A "I will restrict my water intake."B "I will make sure that my diet contains salt." الإجابة الصحيحةC "I will keep my medication in the refrigerator."D "I will be careful to avoid eating foods high in potassium." -
902
A client is given a prescription for an antipsychotic medication. The nurse instructs the client and family to report any signs/symptoms of pseudoparkinsonism and tells the family to monitor for what effects indicative of this medication complication?
A Tremors and hyperpyrexiaB Motor restlessness and aphasiaC Stooped posture and a shuffling gait الإجابة الصحيحةD Muscle weakness and decreased salivation -
903
The nurse is providing instructions to a client with peptic ulcer disease about symptom management. Which statement by the client indicates that teaching was effective?
A "I should eat a snack at bedtime."B "I can take aspirin to relieve gastric pain."C "I should take my antacid and famotidine at the same time."D "It is important that I eat slowly and chew my food thoroughly." الإجابة الصحيحة -
904
A client with a hiatal hernia asks the nurse about fluids that are safe to drink and that will not irritate the gastric mucosa. What fluid would the nurse tell the client to drink?
A Apple juice الإجابة الصحيحةB Orange juiceC Tomato juiceD Grapefruit juice -
905
The nurse determines that the client with gastroesophageal reflux disease (GERD) needs further teaching regarding diet if which statement is made?
A "I need to avoid coffee, tea, and chocolate."B "I should eat four to six small meals a day."C "It is important that I drink extra fluids during meals." الإجابة الصحيحةD "I need to avoid snacking for 2 to 3 hours before bedtime." Reflux Disease -
906
When preparing the client with a spinal cord injury who is experiencing bladder spasms and reflex incontinence for discharge to home, the nurse would provide which instruction to prevent the problem?
A "Avoid caffeine in your diet." الإجابة الصحيحةB "Take your temperature every day."C "Limit your fluid intake to 1000 mL per 24 hours."D "Catheterize yourself every 2 hours as needed to prevent spasm." -
907
The nurse determines that the client diagnosed with atherosclerosis understands dietary modifications to lower the risk of heart disease if which food selection is made?
A Roast beefB Fresh cantaloupe الإجابة الصحيحةC Broiled cheeseburgerD Mashed potato with gravy -
908
A client being discharged to home after angioplasty via the right femoral groin has received the catheter insertion site discharge instructions from the nurse. Which client statement indicates that the client understands the instructions?
A "Coolness or discoloration of the right foot is expected."B "I should expect a large area of bruising at the right groin."C "Temperature as high as 101° F (38.3° C) is not unusual a few days after the procedure."D "Mild discomfort in the right groin may occur, and acetaminophen should relieve the pain." الإجابة الصحيحة -
909
The nurse teaches a client with hypertension to recognize the signs/symptoms that may occur during periods of elevated blood pressure. The nurse determines that the client has a need for further teaching if the client states that which sign/symptom is associated with this condition?
A EpistaxisB DizzinessC Blurred visionD A feeling of fullness in the head الإجابة الصحيحة -
910
A client with a colostomy reports a concern about appliance odor. The nurse recommends that the client take in which deodorizing foods?
A EggsB Yogurt الإجابة الصحيحةC CucumbersD Mushrooms Nutrition/Malabsorption Problems -
911
The nurse is demonstrating colostomy care to a client with a newly created colostomy. The nurse demonstrates the correct cutting of the appliance by making the circle how much larger than the client's stoma?
A 1/8 inch الإجابة الصحيحةB 1/4 inchC 1/2 inchD 1 inch Nutrition/Malabsorption Problems -
912
The nurse teaches a client diagnosed with a spinal cord injury about measures to prevent autonomic hyperreflexia. Which statement by the client indicates the need for further teaching?
A "It is best if I avoid tight clothing and lumpy bedclothes."B "I should watch for headache, congestion, and flushed skin."C "Signs/symptoms I should watch for include fever and chest pain." الإجابة الصحيحةD "I need to pay close attention to how frequently my bowels move." -
913
The nurse is discharging a female client from the hospital who has a diagnosis of a thoracic 11 (T11) fracture with cord transection. The nurse has provided home care instructions to the client. Which action indicates the need for further teaching before discharge?
A The client jokes about no longer needing to worry about birth control. الإجابة الصحيحةB The client states that she will be careful to not eat as many dairy products.C The client verbalizes the need to eat her meals at the same time every day.D The client states that she will wash her hands, her perineum, and the catheter with soap and water before performing self- catheterization. -
914
The nurse is developing a plan of care for an older client diagnosed with dementia. The nurse develops which realistic outcome for the client?
A The client will function at the highest level of independence possible. الإجابة الصحيحةB The client will be admitted to a nursing home to have the needs of activities of daily living met.C The client will complete all activities of daily living independently within a 1- to 1½-hour time frame.D The nursing staff will attend to all of the client's activities of daily living needs during the hospital stay. -
915
A client is newly diagnosed with chronic obstructive pulmonary disease (COPD). The client returns home after a short hospitalization. The home care nurse would most importantly plan teaching strategies that are designed to do what?
A Promote membership in support groups.B Encourage the client to become a more active person.C Identify irritants in the home that interfere with breathing.D Improve oxygenation and minimize carbon dioxide retention. Pulmonary Disease الإجابة الصحيحة -
916
A client is being discharged from the hospital after a bronchoscopy that was performed a day earlier. After the discharge teaching, the client makes the following statements to the nurse. Which statement should the nurse identify as indicating a need for further teaching?
A "I will stop smoking my cigarettes."B "I can expect to cough up bright red blood." الإجابة الصحيحةC "I will get help immediately if I start having trouble breathing."D "I will use the throat lozenges as directed by my doctor until my sore throat goes away." -
917
A client who is taking an antipsychotic medication is preparing for discharge. To facilitate health promotion for this client, what instruction would the nurse provide?
A Avoid prolonged exposure to the sun. الإجابة الصحيحةB Adhere to a strict tyramine-restricted diet.C Recognize the signs and symptoms of a relapse of depression.D Have therapeutic blood levels drawn because the medication has a narrow therapeutic range. -
918
Which explanation by the nurse should best alleviate anxiety in a client with coronary artery disease about having a 12-lead electrocardiogram (ECG) diagnostic procedure?
A "It's a simple test but it's important to lie still during the procedure."B "It should only take about 20 minutes to complete the ECG tracing process."C "The ECG electrodes are painless and will record the electrical activity of your heart." الإجابة الصحيحةD "The ECG can give the primary health care provider information about the status of your heart." -
919
The spouse of a client who is scheduled for the insertion of an implantable cardioverter-defibrillator (ICD) expresses anxiety about what would happen if the device discharges during physical contact. Which information is most appropriate for the nurse to provide to the spouse?
A Physical contact should be avoided whenever possible.B The spouse would not feel or be harmed by the countershock.C The shock would be felt, but it would not cause the spouse any harm. الإجابة الصحيحةD A warning device sounds before countershock, so there is time to move away. -
920
A client who is scheduled for permanent transvenous pacemaker insertion states to the nurse, "I know I need it, but I'm not sure this surgery is a great idea." Which nursing response would best help the nurse assess the client's preoperative concerns?
A "How does your family feel about the surgery?"B "Has anyone taught you about the procedure yet?"C "You sound extremely worried. Has anyone told you that the technology is really quite safe?"D "You sound uncertain about the procedure. Can you tell me more about what has you concerned?" الإجابة الصحيحة -
921
A client with superficial varicose veins states to the nurse, "I hate these things. They're so ugly. I wish I could get them to go away." Which therapeutic response would be most appropriate for the nurse to make to the client?
A "You should try sclerotherapy. It's great."B "What makes you so upset about having ugly varicose veins?"C "What have you been told about varicose veins and their management?" الإجابة الصحيحةD "I understand how you feel, but you know, they really don't look all that bad." -
922
A client diagnosed with chronic kidney disease (CKD) has been told that hemodialysis will be required. The client becomes angry and states, "I'll never be the same now." Based on this information, which would the nurse identify as the client's primary concern?
A Anxiety about the hemodialysisB Inability to think clearly because of the treatments neededC Potential for noncompliance because of concerns about the diseaseD Altered body image because of the physical changes that may occur and Chronic Kidney Disease الإجابة الصحيحة -
923
A client with the diagnosis of hyperparathyroidism states to the nurse, "I can't stay on this diet. It is too difficult for me." Which therapeutic response by the nurse is best when intervening in this situation?
A "Why do you think you find this diet plan difficult to adhere to?"B "It really isn't difficult to stick to this diet. Just avoid milk products."C "You are having a difficult time staying on this plan. Let's discuss this." الإجابة الصحيحةD "It is very important that you stay on this diet to avoid forming renal calculi." -
924
The nurse is caring for a client with a new diagnosis of type 1 diabetes mellitus. The nurse should recognize that which teaching plan component is most important initially?
A Knowledge of the diabetic dietB Understanding of the diagnosis الإجابة الصحيحةC Monitoring of blood glucose levelsD Correct technique for administering insulin -
925
A client with a new diagnosis of type 1 diabetes mellitus has been seen for 3 consecutive days in the emergency department with hyperglycemia. During the assessment, the client states to the nurse, "I'm sorry to keep bothering you every day, but I just can't give myself those awful shots." Which therapeutic comment is most appropriate for the nurse to respond?
A "I couldn't give myself a shot either."B "You must learn to give yourself the shots."C "Let me see if we can change your medication."D "Have you had instructions on injecting yourself?" الإجابة الصحيحة -
926
The nurse requests that a client with a diagnosis of diabetes mellitus ask family members to attend an educational conference about the administration of insulin. The client questions why they need to be included. Which statement is best for the nurse to respond?
A "Family members are at risk of developing diabetes."B "Family members can take you to your appointments."C "Nurses will need someone to call and check on a client's progress."D "Families often work together toward the successful management of diabetes." الإجابة الصحيحة -
927
A client has recently been diagnosed with polycystic kidney disease. The nurse has a series of discussions with the client that are intended to help the client adjust to the disorder. Which would the nurse plan to include as part of one of these discussions?
A Ongoing fluid restrictionB The need for genetic counseling الإجابة الصحيحةC The risk of hypotensive episodesD Depression regarding massive edema Disease -
928
The spouse of a dying client states to the nurse, "I don't think I can come anymore and watch her die. It's chewing me up too much!" Which is the most therapeutic response the nurse would make to the spouse?
A "It's hard to watch someone you love die. You've been here with your wife every day. Are you taking any time for yourself?" الإجابة الصحيحةB "Focus on your wife's pain rather than yours. I know it's hard, but this isn't about what's happening to you, you know."C "I know it's hard for you, but she would know if you're not there, and you would feel so very guilty all of the rest of your days."D "I think you're making the right decision. Your wife knows you love her. You don't have to come every day. I'll take care of her." -
929
While in the dining area, an adult client at the retirement center yells, "This turkey is dry and cold! I can't stand the food here!" Which is the best response by the nurse to the client's behavior?
A "Now look what you've done! You're ruining this meal for the whole community. Aren't you ashamed of yourself?"B "I think you had better return to your apartment now. I'll make arrangements for a new meal to be served to you there."C "Let me get you another serving that is more to your liking. Would you like to see the chef and select your own serving?" الإجابة الصحيحةD "One of the things that was agreed upon was that anyone who did not use appropriate behavior would be asked to leave the dining room. Please leave now." -
930
When the home care nurse arrives, the client with a diagnosis of emphysema is smoking. Which statement by the nurse would be most therapeutic?
A "Well, I can see you never got to the stop smoking clinic."B "Now that your secret is out, may we decide what you are going to do?"C "Did you explore the stop smoking program at the senior citizens center?" الإجابة الصحيحةD "I wonder if you realize that by smoking you are slowly killing yourself." Pulmonary Disease -
931
A client reports having difficulty concentrating and is having outbursts of anger, as well as feeling "keyed up" all the time. The client reveals that the behaviors began soon after witnessing the murder of a good friend. The nurse should suspect which stressor before communicating with the client?
A Social phobiaB Panic disorderC Post-traumatic stress disorder (PTSD) الإجابة الصحيحةD Obsessive-compulsive disorder (OCD) -
932
An English-speaking Hispanic client has a newly applied long leg cast to stabilize a right proximal fractured tibia. During rounds at night, the nurse finds the client restless, withdrawn, and unusually quiet. Which nursing statement would be most appropriate?
A "Are you uncomfortable?"B "Tell me what you are feeling." الإجابة الصحيحةC "You'll feel better in the morning."D "I'll get your pain medication right away." -
933
A client diagnosed with moderate dementia is prescribed oral anticoagulant therapy while hospitalized. The nurse identifies which discharge scenario as being the best support system for successful anticoagulant therapy monitoring?
A The client has a home health aide coming to the house for 9 weeks.B The client was going to stay with a daughter in the daughter's home indefinitely. الإجابة الصحيحةC The client was going to have blood work drawn in the home by a local laboratory.D The client has a good friend living next door who would take the client to the doctor. -
934
A client who has undergone successful femoral-popliteal bypass grafting of the leg states to the nurse, "I hope everything goes well after this and that I don't lose my leg. I'm so afraid that I'll have gone through this for nothing." Which most therapeutic response would the nurse make to the client?
A "I can understand what you mean. I'd be nervous too if I were in your shoes."B "This surgery is so successful that I wouldn't be concerned at all if I were you."C "Complications are possible, but you have a good deal of control if you make the lifestyle adjustments we talked about." الإجابة الصحيحةD "Stress isn't helpful for you. You should probably just try to relax. You shouldn't worry unless something actually happens." -
935
A client is about to undergo a pericardiocentesis to help manage rapidly accumulating pericardial effusion. What is the best plan for the nurse to implement to alleviate the client's apprehension?
A Suggesting the client watch television during the procedure as a distractionB Talking to the client from the foot of the bed and assisting with the procedureC Staying beside the client to give information and encouragement during the procedure الإجابة الصحيحةD Assuring the client that even though there are other clients needing care, the client's needs are most important -
936
The nurse has created a teaching plan for a client prescribed spironolactone. On which psychosocial side effect of the medication would the nurse base the teaching plan?
A EdemaB Hair lossC Weight lossD Decreased libido الإجابة الصحيحة -
937
The nurse is caring for a client who is recovering from an episode of autonomic hyperreflexia. Which statement would the nurse make to the client to most encourage therapeutic communication?
A "How could your home care nurse let this happen?"B "Now that this problem is taken care of, I'm sure you'll be fine."C "I have some time if you would like to talk about what happened to you." الإجابة الصحيحةD "I'm sure you now understand the importance of preventing this from occurring." -
938
While assisting with bathing, the client who has sustained a spinal cord injury states, "I can't do this. I wish I were dead." Which therapeutic response would the nurse make to encourage communication?
A "Why do you say that?"B "You wish you were dead?" الإجابة الصحيحةC "Would you prefer a shower instead?"D "Are you frustrated with your limitations?" -
939
Family members of a client who attempted suicide are tearful. Which statement by the nurse would be most helpful in the management of their concerns?
A "I'll check on when you will be able to see your loved one."B "Believe me when I say that everything possible is being done."C "Don't worry. You have absolutely nothing to feel guilty about."D "I certainly can see that you are terribly worried about your loved one." الإجابة الصحيحة -
940
Which psychosocial factor obtained during an assessment of an older client places the client most at risk for abuse?
A The client resides in an apartment in a low-income neighborhood.B The client shows several signs and symptoms of clinical depression.C The client is completely dependent on family members for both food and medicine. الإجابة الصحيحةD The client has been diagnosed with and is being treated for several chronic illnesses. -
941
The nurse is caring for a dying client who states, "Will you be the executor of my will?" How would the nurse best respond to this client?
A "I must decline your offer because I am your nurse."B "I will carry out your will according to your wishes."C "It is an honor to be named the executor of your will."D "Tell me more so that I can understand your thinking." الإجابة الصحيحة -
942
A client experiencing urticaria (hives) and pruritus states to the nurse, "What am I going to do? I'm getting married next week, and I'll probably be covered in this rash and itching like crazy." Which statement made by the nurse is the most therapeutic?
A "You're troubled that this will extend into your wedding?" الإجابة الصحيحةB "It's probably just due to prewedding jitters. You'll be fine."C "The antihistamine will help a great deal, just you wait and see."D "Do you think this would really be something that could ruin your wedding?" -
943
Which statement made by a client who has experienced a spinal cord injury resulting in chronic immobility issues warrants immediate follow-up by the nurse to assure client safety?
A "I'm so angry that this happened to me."B "I really don't want to live my life like this." الإجابة الصحيحةC "I'm definitely not looking forward to going home."D "I don't know if I can make all these major adjustments to my life." -
944
The nurse is caring for a client with a diagnosis of a mild cerebral bleed resulting from a small cerebral aneurysm rupture. The client reports feeling anxious and restless about family visiting soon. Which comment by the client would assist the nurse in identifying the reason for the anxiety?
A "My son came to visit me yesterday."B "At least I can speak and answer questions."C "I have a problem turning my neck to the side."D "Look at me, I can no longer be the head of my family." الإجابة الصحيحة -
945
When planning the care of the client diagnosed with thromboangiitis obliterans (Buerger's disease), the nurse incorporates information on which support service to best help the client cope with the lifestyle changes that are needed to control the disease process?
A Pain management clinicB Smoking cessation program الإجابة الصحيحةC Consultation with a dieticianD Referral to a medical social worker -
946
A client with arterial leg ulcers tells the nurse, "I'm so discouraged. I have had this pain for more than a year now. The pain never seems to go away. I can't do anything, and I feel as though I'll never get better." The nurse determines that which is the priority client concern?
A FatigueB UneasinessC Chronic pain الإجابة الصحيحةD An acute illness -
947
A client with a diagnosis of valvular heart disease is being considered for mechanical valve replacement. Which circumstance is essential to assess before the surgery is performed?
A The physical demands of the client's lifestyleB The ability to comply with anticoagulant therapy for life الإجابة الصحيحةC The ability to participate in a cardiac rehabilitation programD The likelihood of the client experiencing body image problems Structural Heart Disorders -
948
A client who has a history of depression has been prescribed nadolol for the management of angina pectoris. Which consideration is most important when the nurse plans to counsel this client about the effects of this medication?
A Risk of tachycardiaB Probability of fatigueC High incidence of hypoglycemiaD Possible exacerbation of depression الإجابة الصحيحة -
949
The nurse is caring for a client with a diagnosis of terminal cancer of the throat. The family tells the nurse that they have spoken to the primary health care provider regarding taking their loved one home. The nurse plans to coordinate discharge planning. Which service would be most supportive to the client and the family?
A Hospice care الإجابة الصحيحةB The American Cancer SocietyC The American Lung AssociationD Local religious and social organizations -
950
The home care nurse is caring for a client with lung cancer with acute cancer pain. Which is the most appropriate way to assess the client's pain?
A The client's pain rating الإجابة الصحيحةB The nurse's impression of the client's painC Verbal and nonverbal clues from the clientD Pain relief after appropriate nursing intervention -
951
The nurse is assessing a client's suicide potential. Which question is most important for the nurse to ask the client?
A "Why do you want to hurt yourself?"B "Do you have a plan to hurt yourself?" الإجابة الصحيحةC "Has anyone in your family committed suicide?"D "Can you describe how you are feeling right now?" -
952
During the admission assessment of a client with a history of alcohol abuse for diagnosis of ruptured esophageal varices, the client says, "I deserve this. I brought it on myself." Which response is most therapeutic for the nurse to make to the client?
A "Would you like to talk to the chaplain?"B "Is there some reason you feel you deserve this?" الإجابة الصحيحةC "Not all esophageal varices are caused by alcohol."D "That is something to think about when you leave the hospital." -
953
The nurse is performing a neurological assessment on a client with a diagnosis of dementia and assessing the function of the frontal lobe of the brain. Which would the nurse assess to yield the best information about this area of functioning?
A Eye movementsB Feelings or emotionsC Level of consciousnessD Insight, judgment, and planning الإجابة الصحيحة -
954
The client who is dying states to the nurse, "I hope I am worthy of heaven." Which intervention would the nurse implement first after determining that this client is experiencing fear?
A Help the client express fears.B Assess the nature of the client's fears. الإجابة الصحيحةC Help the client identify coping mechanisms that were successful in the past.D Document verbal and nonverbal expressions of fear and other significant data. -
955
Fluoxetine hydrochloride is prescribed for a client with a diagnosis of depression. The nurse provides instructions to the client regarding the administration of the medication. Which statement by the client indicates an understanding about administration of the medication?
A "I should take the medication with my evening meal."B "I should take the medication at noon with an antacid."C "I should take the medication in the morning when I first arise." الإجابة الصحيحةD "I should take the medication right before bedtime with a snack." Reuptake Inhibitors (SSRIs) -
956
The nurse is obtaining a health history from an adolescent. Which statement by the adolescent indicates a need for follow-up assessment and intervention?
A "When I get stressed out about school, I just like to be alone."B "I find myself very moody. I'm happy one minute and crying the next."C "I don't eat any fatty foods, and I've already lost 8 pounds in 2 weeks." الإجابة الصحيحةD "I can't seem to wake up in the morning. I would sleep until noon if I could." -
957
The nurse is caring for a client who has been diagnosed with bipolar disorder and is in a manic state. The nurse determines that which group of foods would be best for this client?
A Beef stew, fruit salad, teaB Cheeseburger, banana, milk الإجابة الصحيحةC Macaroni and cheese, apple, milkD Scrambled eggs, orange juice, coffee -
958
An older client is brought to the emergency department by a family member with whom the client lives. The nurse observes that the client has poor hygiene, contractures, and pressure ulcers on the sacrum, the scapula, and the heels. Based on the nurse's assessment data, the client is suspected of which form of victimization?
A Sexual abuseB Physical abuse الإجابة الصحيحةC Emotional abuseD Psychological abuse -
959
A client diagnosed with schizophrenia is admitted to the inpatient mental health unit. When asked her name, she responds, "I am Elizabeth, the Queen of England." Which would the nurse recognize this client's statement is indicating?
A Visual illusionB Loose associationC Grandiose delusion الإجابة الصحيحةD Auditory hallucination -
960
A client who has been newly admitted to the mental health unit with a diagnosis of bipolar disorder is trying to organize a dance with the other clients on the unit. The nurse would encourage which action to decrease stimulation?
A Seek assistance from other staff members.B Engage the help of other clients on the unit to accomplish the task.C Stop the planning and firmly tell the client that this task is inappropriate.D Postpone organizing the dance and engage the client in a writing activity. الإجابة الصحيحة -
961
A client diagnosed with an obsessive-compulsive disorder spends many hours during the day and night washing hands. The nurse would initially allow the client to continue this behavior because it has what therapeutic effect for the client?
A Relieves the client's anxiety الإجابة الصحيحةB Decreases the chance of infectionC Gives the client a feeling of self-controlD Increases the client's sense of self-esteem -
962
The nurse observes an anxious client blocking the hallway, walking three steps forward and then two steps backward. Other clients are agitated and trying to get past the client. How would the nurse intervene?
A Stand alongside the client and say, "You're very anxious today." الإجابة الصحيحةB Attempt to stop the behavior and say, "You're going to get exhausted."C Take the client to the lounge and say, "Relax and watch television now."D Walk alongside the client and say, "You're not going anywhere very fast doing this." -
963
The nurse is assisting with providing a form of psychotherapy in which the client acts out situations that are of emotional significance. Based on this assessment data, which form of therapy should the nurse expect the primary health care provider has prescribed?
A Psychodrama الإجابة الصحيحةB Reality therapyC Psychoanalytic therapyD Short-term dynamic psychotherapy -
964
A client with the diagnosis of mania is placed in a seclusion room after an outburst of violent behavior that involved a physical assault on another client. Which intervention would the nurse include in the plan of care before seclusion?
A Ask the client if she understands why the seclusion is necessary.B Remain silent because verbal interaction would be too stimulating.C Tell the client that she will be allowed to come out when she can behave.D Inform the client that she is being secluded to help regain her self- control. الإجابة الصحيحة -
965
A client diagnosed with angina pectoris is extremely anxious after being hospitalized. Which would the nurse do to minimize the client's anxiety?
A Provide care choices to the client. الإجابة الصحيحةB Keep the door open and the hallway lights on at night.C Encourage the client to limit visitors to as few as possible.D Arrange for the client to share a room with a cognitively alert client. -
966
A client diagnosed with catatonic schizophrenia demonstrates severe withdrawal by lying on the bed with the body pulled into a fetal position. Which action by the nurse is most appropriate to increase interpersonal communication?
A Ask the client direct questions to encourage talking.B Leave the client alone and intermittently check on her or him.C Sit beside the client in silence and occasionally ask open-ended questions. الإجابة الصحيحةD Take the client into the dayroom with the other clients, to encourage interaction. -
967
The nurse is interviewing a client being admitted to the mental health inpatient unit who was involved in a fire 2 months ago. The client is reporting insomnia, difficulty concentrating, nervousness, hypervigilance, and frequently thinking about fires. The nurse would recognize these complaints to be indications of which disorder?
A PhobiaB Dissociative disorderC Obsessive-compulsive disorderD Post-traumatic stress disorder (PTSD) الإجابة الصحيحة -
968
The nurse obtains an electrocardiogram (ECG) rhythm strip for an adult client who is anxious about the results. The ECG shows that the heart rate is 90 beats/min. Which statement would the nurse make to the client to relieve anxiety?
A The rate is normal. الإجابة الصحيحةB There is no need to worry.C A slower heart rate is preferred.D Medication specific to the problem will be prescribed. -
969
Which behavior is a sign of depression that a client could exhibit when recovering from a myocardial infarction?
A Reports insomnia at nightB Consumes 25% of meals and shows little interest when doing client teaching الإجابة الصحيحةC Ignores activity restrictions and does not report the experience of chest pain with activityD Expresses apprehension about leaving the hospital and requests that someone stay in the room at night -
970
A client who recently had a gastrostomy feeding tube inserted refuses to participate in the plan of care, will not make eye contact, and does not speak to family or visitors. Which type of coping mechanism would the nurse assess the client is using?
A DenialB Distancing الإجابة الصحيحةC RegressionD Suppression -
971
The nurse is reviewing the preoperative teaching plan for a client scheduled for a radical neck dissection for laryngeal cancer. Which part of the nursing care plan would the nurse initially focus on?
A The financial status of the clientB Postoperative communication techniquesC Information given to the client by the surgeon الإجابة الصحيحةD The client's support systems and coping behaviors -
972
The nurse is assessing a client to determine the client's adjustment to presbycusis. Which indicates successful adaptation by the client to this problem?
A Proper use of a hearing aid الإجابة الصحيحةB Denial of a hearing impairmentC Withdrawal from social activitiesD Reluctance to answer the telephone -
973
The nurse is performing an assessment on a 16-year-old client who has been diagnosed with anorexia nervosa. Which statement by the client would the nurse identify as a priority requiring a need for further teaching?
A "I check my weight every day without fail."B "I exercise 3 to 4 hours every day to keep my slim figure." الإجابة الصحيحةC "I've been told that I am 10% below my ideal body weight."D "My best friend was in the hospital with this disorder a year ago." -
974
A client is demonstrating confusion as a result of a prolonged length of hospital stay requiring bedrest. The client receives a prescription for progressive ambulation as tolerated. Which is the best nursing intervention to use to implement the prescription?
A Ambulate to the client's bathroom three times a day.B Ambulate in the room for short distances frequently.C Ambulate in the hall progressively three times a day. الإجابة الصحيحةD Assist with range-of-motion exercises three times a day. -
975
The nurse is caring for an older client who has been placed in Buck's extension traction after a hip fracture. During the assessment of the client, the nurse notes that the client is disoriented. Which is the most appropriate nursing intervention for this client?
A Apply restraints to the client.B Ask the family to stay with the client.C Ask the laboratory to perform electrolyte studies.D Reorient the client to time, place, and person frequently. الإجابة الصحيحة -
976
A female victim of a sexual assault is being seen in the crisis center for a third visit. She states that although the rape occurred nearly 2 months ago, she still feels "as though the rape just happened yesterday." Which statement is most appropriate for the nurse to use as a response?
A "In reality, the rape did not just occur. It has been over 2 months now."B "What can you do to alleviate some of your fears about being assaulted again?"C "In time, our goal will be to help you move on from these strong feelings about your rape."D "Tell me more about those aspects of the rape that cause you to feel like the rape just occurred." الإجابة الصحيحة -
977
Which instruction would the nurse give the staff when formulating the plan of care for a client diagnosed with paranoid personality disorder?
A Have the client sign a release of information form.B Avoid laughing or whispering in front of the client. الإجابة الصحيحةC Increase the socialization of the client with unit peers.D Begin educating the client about available social supports. -
978
The nurse is assessing a client who was just admitted to the psychiatric unit. The client says, "You won't have to worry about me much longer." Which meaning would the nurse interpret from this statement?
A An intention of suicide الإجابة الصحيحةB An expression of depressionC An intention of self-mutilationD An expression of hopelessness -
979
The nurse notes that an assigned client is lying tense in bed and staring at the cardiac monitor. The client states, "There sure are a lot of wires around there. I sure hope we don't get hit by lightning." Which is the most appropriate nursing response?
A "Your family can stay tonight if they wish."B "Would you like a mild sedative to help you relax?"C "The hospital is well equipped to shield a lightning strike."D "Yes, all the wires must be scary. Let's talk about the cardiac monitor." الإجابة الصحيحة -
980
A young adult client diagnosed with a spinal cord injury tells the nurse, "It's so depressing that I'll never get to have sex again." Which is the realistic reply for the nurse to make to the client?
A "It must feel horrible to know you can never have sex again."B "It's still possible to have a sexual relationship, but it will be different." الإجابة الصحيحةC "You're young, so you'll adapt to this more easily than if you were older."D "Because of body reflexes, sexual functioning will be no different than before." -
981
A family member of a client diagnosed with a brain tumor states that he is feeling distraught and guilty for not encouraging the client to seek medical evaluation earlier. Which information would the nurse incorporate when formulating a response to the family member's statement?
A A brain tumor presents with few sights/symptoms.B It is true that brain tumors are easily recognizable.C Brain tumors are never detected until very late in their course.D The signs/symptoms of a brain tumor may be easily attributed to another cause. الإجابة الصحيحة -
982
A client has a hip fracture repair with a prosthetic implant placed. On the day after the implant, the nurse finds the client surrounded by papers from his briefcase and planning a phone meeting. The nurse plans to discuss activities with the client and would base the discussion on which information?
A Rest is an essential component of bone healing. الإجابة الصحيحةB Setting limits on a client's behavior is a mandated nursing role.C Not keeping up with his job will increase the client's stress level.D Involvement in his job will keep the client from becoming bored. -
983
A hospitalized client has participated in substance abuse therapy group sessions. Which statement by the client would best indicate that the client has assimilated session topics, understood coping response styles, and processed information effectively for self-use?
A "I'll keep all my appointments, and I'll do everything I'm supposed to. That way nothing will go wrong."B "I know I'm ready to be discharged. I feel like I'll have no problem saying no and leaving a group of friends if they are drinking."C "This group has really helped a lot. I know that it will be different when I go home. But I'm sure that my family and friends will all help me, like the people in this group have. They'll all help me, I know they will. They won't let me go back to old ways."D "I'm looking forward to leaving here, but I know that I will miss all of you. So, I'm happy, and I'm sad. I'm excited, and I'm scared. I know that I have to work hard to be strong and that everyone isn't going to be as helpful as you all have been. I know it isn't going to be easy, but I'm going to try as hard as I can." الإجابة الصحيحة -
984
A client recovering from a diagnosed head injury becomes agitated at times. Which nursing action is most appropriate when attempting to calm this client?
A Assign the client a new task to master.B Turn on the television to a musical program.C Make the client aware that the behavior is undesirable.D Talk about the family pictures on display in the client's room. الإجابة الصحيحة -
985
A client recovering from a brain attack (stroke) has become irritable and angry regarding self-limitations. Which is the best nursing approach to help the client regain motivation to keep trying to succeed as capable?
A Ignore the behavior, knowing that the client is grieving.B Allow longer and more frequent visitation by the spouse.C Use supportive statements to correct the client's behavior. الإجابة الصحيحةD Stress that the nurses are experienced and know how the client feels. -
986
An older client is admitted to the hospital with a fractured hip and is experiencing periods of confusion. The nurse develops a plan of care and would identify which psychosocial outcome as having the greatest impact on improving the client's cognitive abilities?
A Improved sleep patternsB Reduced family fears and anxietyC Meeting self-care needs independentlyD Increased ability to concentrate and participate in care الإجابة الصحيحة -
987
The nurse is caring for a terminally ill woman who is in the terminal stage of diagnosed breast cancer. The nurse would know which client behavior is characteristic of anticipatory grieving?
A Discusses thoughts and feelings related to loss الإجابة الصحيحةB Has prolonged emotional reactions and outburstsC Verbalizes unrealistic goals and plans for the futureD Ignores untreated medical conditions that require treatment -
988
A postoperative client has been vomiting and has absent bowel sounds, and paralytic ileus has been diagnosed. The primary health care provider prescribes the insertion of a nasogastric tube. The nurse explains the purpose of the tube and the insertion procedure to the client. The client says to the nurse, "I'm not sure I can take any more of this treatment." Which therapeutic response would the nurse make to the client?
A "Let's just put the tube down, so that you can get well."B "If you don't have this tube put down, you will just continue to vomit."C "You are feeling tired and frustrated with your recovery from surgery?" الإجابة الصحيحةD "It is your right to refuse any treatment. I'll notify the primary health care provider." -
989
A client who is receiving total parenteral nutrition (TPN) tells the nurse, "I'm not sure that I want to receive an infusion of lipids because it could make me obese." Which initial action would the nurse take?
A Inquire how illness affects the client's self-concept. الإجابة الصحيحةB Ask the provider to discuss the benefits of intralipids.C State that intralipids supply essential fatty acids for life.D Explain how intralipids replace dietary sources of lipids. Nutrition/Malabsorption Problems -
990
A client has been diagnosed with terminal cancer and is using opioid analgesics for pain relief. Which action by the home care nurse would best allay the client's anxiety about becoming addicted to the pain medication?
A Encouraging the client to hold off as long as possible between doses of pain medicationB Encouraging the client to take lower doses of medications even though the pain is not well controlledC Explaining to the client that the fears are justified but should be of no concern during the final stages of careD Explaining to the client that addiction rarely occurs in individuals who are taking medication appropriately to relieve pain الإجابة الصحيحة -
991
A client recovering from pneumonia is very anxious about receiving chest physiotherapy (CPT) for the first time at home. When planning for the client's care, which concept about CPT would the home care nurse use to reassure the client?
A CPT will help the client cough more often.B There are no risks associated with this procedure.C CPT will resolve all of the client's respiratory symptoms.D CPT will assist with mobilizing secretions to enhance more effective breathing. الإجابة الصحيحة -
992
A client diagnosed with cardiomyopathy stops eating, takes long naps, and turns away from the nurse when the nurse talks to the client. The nurse would make which interpretation about this behavior?
A The client is depressed. الإجابة الصحيحةB The client is noncompliant.C The client has intractable pain.D The client is unable to tolerate activity. -
993
The nurse is planning care for a client who is experiencing anxiety after a myocardial infarction. Which priority nursing intervention would be included in the plan of care?
A Answer questions with factual information. الإجابة الصحيحةB Provide detailed explanations of all procedures.C Encourage family involvement during the acute phase.D Administer an antianxiety medication to promote relaxation. -
994
A client recovering from an acute myocardial infarction will be discharged in 1 day. Which client action on the evening before discharge suggests that the client is in the denial about his medical condition?
A Requests a sedative for sleep at 10:00 pmB Expresses a hesitancy to leave the hospitalC Consumes 25% of foods and fluids given for supperD Walks up and down three flights of stairs unsupervised الإجابة الصحيحة -
995
The nurse is caring for a client diagnosed with Hodgkin's disease who will be receiving radiation and chemotherapy. Which statement by the client indicates a positive coping mechanism to be used during these treatments?
A "I won't leave the house bald."B "Losing my hair won't bother me."C "I will be one of the few who doesn't lose my hair."D "I have selected a wig, even though I will miss my own hair." Non-Hodgkin's الإجابة الصحيحة -
996
A male client is admitted to the hospital diagnosed with diabetic ketoacidosis (DKA). The client's daughter says to the nurse, "My mother died last month, and now this. I've been trying to follow all of the instructions the doctor gave my dad, but what have I done wrong?" Which therapeutic response would the nurse make to the client's daughter?
A "Tell me what you think you did wrong."B "Maybe we can keep your father in the hospital for a while longer to give you a rest."C "You should talk to the social worker about getting you someone at home who has more experience managing a diabetic's care."D "An emotional stress such as your mother's death can trigger DKA in a diabetic client, even though the prescribed regimen is being followed." الإجابة الصحيحة -
997
The nurse has been working with a victim of rape in an outpatient setting for the past 4 weeks. The nurse would recognize that which of the following is an unrealistic short-term goal for the client?
A The client will verbalize feelings about the rape event.B The client will resolve feelings of fear and anxiety related to the rape trauma. الإجابة الصحيحةC The client will experience physical healing of the wounds that were incurred during the rape.D The client will participate in the treatment plan by following through with treatment options. -
998
A client is admitted to a surgical unit with a diagnosis of cancer. The client is scheduled for surgery in the morning. When the nurse enters the room and begins the surgical preparation, the client states, "I'm not having surgery. You must have the wrong person! My test results were negative. I'll be going home tomorrow." The nurse recognizes the client's statement as indicative of which defense mechanism?
A Denial الإجابة الصحيحةB PsychosisC DelusionsD Displacement -
999
A client states to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this! After all, I'm the one who's dying." Which therapeutic response would the nurse make to the client?
A "Have you shared your feelings with your family?"B "I think we should talk more about your anger at your family."C "You're feeling angry that your family continues to hope for you to be cured?" الإجابة الصحيحةD "Well, it sounds like you're being pretty pessimistic. After all, years ago people died of pneumonia." -
1000
A client awaiting surgery for the removal of a pancreatic mass shares with the nurse concerns about not waking up after receiving the anesthesia. Which therapeutic response is most appropriate for the nurse to make to the client?
A "This is a very common concern."B "Tell me what makes you feel concerned about the anesthesia." الإجابة الصحيحةC "I had surgery a year ago and was afraid of the same thing. I did just fine."D "You have the best anesthesiologist in this hospital. There is no need to be scared." -
1001
A community health nurse visits a recently widowed retired military client. When the nurse visits, the ordinarily immaculate house is in chaos, and the client is disheveled and has an alcohol type of odor on his breath. Which therapeutic statement would the nurse make to the client?
A "I can see this isn't a good time to visit."B "You seem to be having a very troubling time." الإجابة الصحيحةC "Do you think your wife would want you to behave like this?"D "What are you doing? How much are you drinking and for how long?" -
1002
A client who is experiencing suicidal thoughts shares with the nurse that, "I was awake most of the night. It just doesn't seem worth it anymore. Why not just end it all?" Which response would the nurse make to best further assess the client?
A "Did you sleep at all last night?"B "Tell me what you mean by that." الإجابة الصحيحةC "I know you have had a stressful night."D "I'm sure that your family is worried about you." -
1003
A client who experienced a myocardial infarction (MI) 4 days ago refuses to dangle at the bedside, saying, "If my doctor tells me to do it, I will. Otherwise, I won't." Which behavior should the nurse determine that the client is displaying?
A AngerB DenialC DepressionD Dependency الإجابة الصحيحة -
1004
The nurse is assessing a client who was admitted to the hospital with a diagnosis of urinary calculi. The client received 4 mg of morphine sulfate approximately 2 hours previously. The client states to the nurse, "I'm scared to death that it'll come back." Based on these statements, which concern would the nurse identify for this client at this time?
A Fear of dyingB Lack of understanding about the disease processC Anxiety about the anticipation of recurrent severe pain الإجابة الصحيحةD Retention of urine from the obstruction of the urinary tract by calculi -
1005
A client diagnosed with myasthenia gravis is ready to return home. The client confides that she is concerned that her significant other will no longer find her physically attractive. Which client- focused action would the nurse encourage in the plan of care?
A Attend a support group.B Cease dwelling on the negative.C Reach out for help to face this fear.D Share her feelings with her partner. الإجابة الصحيحة -
1006
A client who is in halo traction states to the visiting nurse, "I can't get used to this contraption. I can't see properly on the side, and I keep misjudging where everything is." Which therapeutic response would the nurse make to the client?
A "If I were you, I would have had the surgery rather than suffer like this."B "No one ever gets used to that thing! It's horrible. Many of our sports people who are in it complain vigorously."C "Halo traction involves many difficult adjustments. Practice scanning with your eyes after standing up and before you move around." الإجابة الصحيحةD "Why do you feel like this when you could have died from a broken neck? This is the way it is for several months. You need to be more accepting, don't you think?" -
1007
An older client has been admitted to the hospital diagnosed with a hip fracture. The nurse prepares a plan of care for the client and identifies desired outcomes related to surgery and impaired physical mobility. Which statement by the client supports a positive adjustment to the surgery and impairment in mobility?
A "Hurry up and go away. I want to be alone."B "What took you so long? I called for you 30 minutes ago."C "I wish you nurses would leave me alone! You are all telling me what to do!"D "I find it a little difficult to concentrate since the surgeon talked with me about the surgery tomorrow." الإجابة الصحيحة -
1008
A client who is quadriplegic frequently makes lewd sexual suggestions and uses profanity. The nurse concludes that the client is inappropriately using displacement. Which concern would the nurse identify as being appropriate for this client?
A Disuse syndromeB Lack of coping skills الإجابة الصحيحةC Negative body imageD Lack of awareness of surroundings -
1009
A client with a diagnosis of depression states to the nurse, "I should have died. I've always been a failure." Which therapeutic response would the nurse make to the client?
A "You don't see anything positive?"B "You still have a great deal to live for."C "Feeling like a failure is part of your illness."D "You've been feeling like a failure for some time now?" الإجابة الصحيحة -
1010
Two months after a right mastectomy for breast cancer, a client comes to the office for a follow-up appointment. After being diagnosed with cancer in the right breast, the client was told that the risk for cancer in the left breast existed. When asked about her breast self-examination (BSE) practices since the surgery, the client replied, "I don't need to do that anymore." The nurse interprets this response to be using which coping mechanism?
A Denial الإجابة الصحيحةB Grief and mourningC Change in body imageD Change in role pattern -
1011
When planning for the care of the client in the terminal stages of diagnosed cancer, one of the goals is that the client verbalizes acceptance of impending death. Which client statement indicates to the nurse that this goal has been reached?
A "I just want to live until my 100th birthday."B "I would like to have my family here when I die." الإجابة الصحيحةC "I'll be ready to die when my children finish school."D "I want to go to my daughter's wedding. Then I'll be ready to die." -
1012
A client diagnosed with hyperaldosteronism has developed kidney failure and states to the nurse, "This means that I will die very soon." Which is the most appropriate therapeutic response for the nurse to make to the client?
A "You will do just fine."B "What are you thinking about?"C "You sound discouraged today." الإجابة الصحيحةD "I read that death is a beautiful experience." and Chronic Kidney Disease -
1013
A client diagnosed with diabetes mellitus has expressed frustration with learning the diabetic regimen and insulin administration. Which would be the initial action by the home care nurse?
A Attempt to identify the cause of the frustration. الإجابة الصحيحةB Call the primary health care provider to discuss the client's problem.C Offer to administer the insulin on a daily basis until the client is ready to learn.D Continue with teaching, knowing that the client will overcome any frustrations. -
1014
A client diagnosed with cancer is placed on permanent total parenteral nutrition as a means of providing nutrition. Which is the rationale for the nurse to include psychosocial support when planning care for this client?
A Death is imminent.B The client will need to adjust to the idea of living without eating by the usual route. الإجابة الصحيحةC Total parenteral nutrition requires disfiguring surgery for permanent port implantation.D Nausea and vomiting occur regularly with this type of treatment and will prevent the client from participating in social activity. -
1015
A client who is to be discharged to home with a temporary colostomy states to the nurse, "I know I've changed this thing once, but I just don't know how I'll do it by myself when I'm home alone. Can't I stay here until the surgeon puts it back?" Which therapeutic response would the nurse make to best deal with the client's concerns?
A "This is only temporary, but with your level of anxiety you need to hire a nurse companion until your surgery."B "So you're saying that, although you've practiced changing your colostomy bag once, you don't feel comfortable on your own yet?"C "Well, your insurance will not pay for a longer stay just to practice changing your colostomy, so you'll have to fight it out with them."D "Going home to care for yourself still feels pretty overwhelming? I will schedule you for home visits until you're feeling more comfortable." Nutrition/Malabsorption Problems الإجابة الصحيحة -
1016
The nurse is caring for a client who has been diagnosed with schizophrenia. The client is unable to speak, although there is no known pathological dysfunction. Based on this information, the nurse determines that the client is experiencing which type of dysfunctional communication?
A Mutism الإجابة الصحيحةB VerbigerationC Pressured speechD Poverty of speech -
1017
A client diagnosed with schizophrenia states to the nurse, "I am a spy for the FBI. I am an eye, an eye in the sky." Based on this information, the nurse knows that the client is exhibiting which abnormal thought process?
A EcholaliaB Word saladC Clang associations الإجابة الصحيحةD Loosened associations -
1018
The nurse is preparing a client for a parathyroidectomy when the client states, "I guess I'll have to wear a scarf after this surgery." Considering this statement, which concern should the nurse address?
A Denial that the surgery is necessaryB Trouble coping with the need for surgeryC Issues with potential changes to body image الإجابة الصحيحةD Anxiety about postsurgical altered function -
1019
The significant other of a client diagnosed with Graves' disease expresses concern regarding the client's bursts of temper, nervousness, and an inability to concentrate on even trivial tasks. On the basis of this information, the nurse would identify which concern for the client?
A GriefB Socialization issuesC Issues related to sensory perceptionD Trouble with coping with a disease process الإجابة الصحيحة -
1020
A client who was admitted for the treatment of thyroid storm (hyperthyroidism) is preparing for discharge. The client is anxious about the illness and is, at times, emotionally labile. Which action is most appropriate for the nurse to implement at this time?
A Assist the client with identifying coping skills, support systems, and potential stressors. الإجابة الصحيحةB Avoid teaching the client anything about the disease until he or she is emotionally stable.C Reassure the client that everything will usually be fine after returning to one's home and family.D Explain that being able to control of one's behavior must be achieved being discharge to home can occur. -
1021
The nurse is caring for a client who has been admitted to the hospital for the insertion of a subclavian central venous catheter (CVC). The client is concerned because her job requires that she frequently works with the public. With this assessment data, which client concern would be the priority when managing care?
A Poor self-careB Body image insecurity الإجابة الصحيحةC Neck range-of-motion restrictionsD Uncontrolled pain related to the CVC -
1022
A client who has been newly diagnosed with tuberculosis (TB) is hospitalized and will be on respiratory isolation for at least 2 weeks. Which intervention is most appropriate in planning to prevent psychosocial distress in the client?
A Noting whether the client has visitors الإجابة الصحيحةB Instructing all staff members to not touch the clientC Giving the client a roommate with TB who persistently tries to talkD Removing the calendar and clock in the room so that the client will not obsess about time -
1023
The nurse is interviewing a client diagnosed with chronic obstructive pulmonary disease (COPD) who has a respiratory rate of 35 breaths/min and who is experiencing extreme dyspnea. On the basis of the nurse's observations, which is the appropriate client concern?
A Lack of knowledge about COPDB Difficulty coping related with a situational crisisC Negative self-image because of neurological deficitD Restricted verbal communication because of a physical barrier Pulmonary Disease الإجابة الصحيحة -
1024
While intoxicated, a client received a severe full-thickness burn to his left leg. After an unsuccessful response to treatment, an amputation is required. After signing the informed consent form, the nurse observes that the client appears withdrawn. Which action would the nurse implement at this time?
A Let the client have some time alone to grieve about the future loss of the limb.B Teach the client that the injury was a result of alcohol abuse, and suggest counseling.C Communicate with the client in a manner that reflects back to the client that he appears to be upset. الإجابة الصحيحةD Inform the primary health care provider of the client's behavior, and request medication to assist with coping. -
1025
The nurse is caring for a client diagnosed with left-sided Bell's palsy. Which statement by the client shows a need for further teaching by the nurse?
A "My left eye is tearing a lot."B "I have trouble closing my left eyelid."C "I don't know how I'll live with this stroke." الإجابة الصحيحةD "I can't feel anything on the left side of my face." -
1026
A client has a scheduled office visit due to a new diagnosis of diabetes mellitus. The client tells the nurse that he has trouble maintaining proper health due to anxiety regarding the self- administration of insulin. Which teaching/learning strategy would the nurse initially plan to implement?
A Teach a family member to give the client the insulin.B Leave a list of instructions at the bedside for practicing the insulin injections.C Insert the needle, and have the client push in the plunger and remove the needle. الإجابة الصحيحةD Give the injection until the client feels sufficiently confident to preform it alone. -
1027
A client who is scheduled for an abdominal peritoneoscopy states to the home care nurse, "The surgeon told me to restrict food and liquids for at least 8 hours before this procedure and to use a Fleet enema 4 hours before entering the hospital. Do people ever get into trouble after this procedure?" Which is the most appropriate therapeutic response the nurse would make to the client?
A "Any invasive procedure brings risk with it. You need to report any shoulder pain immediately."B "You seem to understand the preparation very well. Are you having any concerns about the procedure?" الإجابة الصحيحةC "Trouble? There is never any trouble with this procedure. That's why the surgeon will use local anesthesia."D "There are relatively few problems, especially if you are having local anesthesia, but vaginal bleeding should be reported immediately." -
1028
A client with a T1 spinal cord injury has just learned that the cord was completely severed. The client says, "I'm no good to anyone. I might as well be dead." Which most therapeutic response would the nurse make to the client?
A "You're not a useless person at all."B "I'll ask the psychologist to see you about this."C "You appear to be feeling pretty bad about things." الإجابة الصحيحةD "It makes me uncomfortable when you talk this way." -
1029
The nurse enters the room of a client who has been diagnosed having a myocardial infarction (MI) and finds the client quietly crying. After determining that there is no physiological reason for the client's distress, how would the nurse best respond?
A "Do you want me to call your daughter?"B "Can you tell me a little about what has you so upset?" الإجابة الصحيحةC "Try not to be so upset. Psychological stress is bad for your heart."D "I understand how you feel. I'd cry, too, if I had a major heart attack." -
1030
A client diagnosed with a recent complete T4 spinal cord transection tells the nurse that he will walk again as soon as the spinal shock resolves. Which statement provides the most accurate basis for planning a response to the client?
A The client is projecting by insisting that walking is the rehabilitation goal.B To speed acceptance, the client needs reinforcement that he will not walk again.C Denial can be protective while the client deals with the anxiety created by the new disability. الإجابة الصحيحةD The client needs to move through the grieving process rapidly to benefit from rehabilitation. -
1031
The nurse is developing a plan of care for a client scheduled for an above-the-knee leg amputation. Which action would the nurse include in the plan of care when addressing the psychosocial needs of the client?
A Explain to the client that open grieving is abnormal.B Encourage the client to express feelings about body changes. الإجابة الصحيحةC Advise the client to seek psychological treatment after surgery.D Discourage sharing with others who have had similar experiences. -
1032
A client diagnosed with pulmonary edema exhibits severe anxiety. The nurse is preparing to carry out prescribed treatment. Which intervention would the nurse use to meet the needs of the client in a holistic manner?
A Ask a family member to stay with the client during the procedure.B Give the client the call bell, and encourage its use if the client feels worse.C Leave the client alone only to gather the required equipment and medications.D Stay with the client, and ask another nurse to gather needed equipment and supplies. الإجابة الصحيحة -
1033
The family of a client diagnosed with a myocardial infarction complicated by cardiogenic shock is visibly anxious and upset about the client's condition. Which would the nurse plan to implement to provide support to the family?
A Offer them coffee and other beverages on a regular basis.B Insist that they go home to sleep at night to keep up their own strength.C Ask the hospital chaplain to sit with them until the client's condition stabilizes.D Provide flexible visiting times according to the client's condition and family needs. الإجابة الصحيحة -
1034
A client having premature ventricular contractions (PVCs) states to the nurse, "I'm so afraid that something bad will happen." Which action by the nurse provides the most immediate help to the client?
A Telephoning the client's familyB Using a television to distract the clientC Having a staff member stay with the client الإجابة الصحيحةD Giving reassurance that nothing will happen to the client -
1035
A client diagnosed with Raynaud's disease tells the nurse that he has a stressful job and does not handle stressful situations well. Which life change would the nurse suggest the client to consider to help alleviate his stress?
A Change to a less stressful job.B Seek help from a psychologist.C Consider a stress management program. الإجابة الصحيحةD Use earplugs to minimize environmental noise. -
1036
A client with a history of pulmonary emboli is scheduled for the insertion of an inferior vena cava filter. The nurse checks on the client 1 hour after the primary health care provider has explained the procedure and obtained informed consent from the client. The client is lying in bed, wringing his hands, and states to the nurse, "I'm not sure about this. What if it doesn't work and I'm just as bad off as before?" Which concern for the client would the nurse identify at this time?
A Anxiety and depressionB Inability to handle the treatment regimenC Lack of knowledge about the surgical procedureD Fear about the potential risks and outcomes of surgery الإجابة الصحيحة -
1037
A client diagnosed with acute respiratory failure has an oral endotracheal tube attached to a mechanical ventilator and is about to begin the weaning process. The nurse determines that which item that was previously used to minimize the client's anxiety should now be limited?
A RadioB TelevisionC Family visitorsD Antianxiety medications الإجابة الصحيحة -
1038
A client scheduled for pulmonary angiography to rule out pulmonary embolism is fearful about the procedure and asks the nurse if the procedure involves significant pain and radiation exposure. Which therapeutic response would the nurse make to the client to provide reassurance?
A "The procedure is somewhat painful, but there is minimal exposure to radiation."B "Discomfort may occur with needle insertion, and there is minimal exposure to radiation." الإجابة الصحيحةC "There is very mild pain throughout the procedure, and the exposure to radiation is negligible."D "There is usually no pain, although a moderate amount of radiation must be used to get accurate results." -
1039
The nurse is caring for an anxious client who has an open pneumothorax and a sucking chest wound. An occlusive dressing has been applied to the site. Which intervention by the nurse would best relieve the client's anxiety?
A Staying with the client الإجابة الصحيحةB Distracting the client with televisionC Interpreting the arterial blood gas reportD Encouraging the client to cough and breathe deeply -
1040
A client diagnosed with acquired immunodeficiency syndrome (AIDS) shares with the nurse feelings of social isolation. Which strategy would the nurse suggest as the most useful way to decrease the client's stated loneliness?
A Reinstituting contact with the client's family, who live in a distant cityB Contacting a support group for clients with AIDS that is available in the local region الإجابة الصحيحةC Using the Internet or the computer to facilitate communication while maintaining isolationD Using the television and newspapers to maintain a feeling of being "in touch" with the world -
1041
A client was just told by the primary care primary health care provider that he will have an exercise stress test to evaluate his status after recent episodes of severe chest pain. As the nurse enters the examining room, the client states, "Maybe I shouldn't bother going. I wonder if I should just take more medication instead." Which therapeutic response would the nurse make to the client?
A "Can you tell me more about how you're feeling?" الإجابة الصحيحةB "Don't you really want to control your heart disease?"C "Most people tolerate the procedure well without any complications."D "Don't worry. Emergency equipment is available if it should be needed." -
1042
The nurse is giving a client diagnosed with heart failure home care instructions for use after hospital discharge. The client interrupts, saying, "What's the use? I'll never remember all of this, and I'll probably die anyway!" The nurse determines that the client's statement is most likely due to which psychosocial concern?
A Anger about the new medical regimenB The teaching strategies used by the nurseC Insufficient financial resources to pay for the medicationsD Anxiety about the ability to manage the disease process at home الإجابة الصحيحة -
1043
A client who received an implanted port for intermittent chemotherapy says, "I'm not sure if I can handle having a tube coming out of me. What will my friends think?" Which action would the nurse implement first?
A Show the client various central line catheters.B Assure the client that his friends will understand.C Explain that implanted ports are subcutaneous and not visible. الإجابة الصحيحةD Notify the primary health care provider of the client's concerns. -
1044
A client has an initial positive result of an enzyme-linked immunosorbent assay (ELISA) test for human immunodeficiency virus (HIV). The client begins to cry and asks the nurse what this means. Which knowledge would the nurse use to provide support to the client?
A The client is HIV positive, but the client's CD4 cell count is high.B The client is HIV positive, but the disease has been detected early.C There are occasional false-positive readings with this test; results can be verified by repeating it one more time.D False-positive results can occur, and more testing is needed before diagnosing the client as being HIV positive. الإجابة الصحيحة -
1045
When performing an assessment on a client who is suicidal, which question is the most appropriate for the nurse to ask?
A "Do you have a death wish?"B "Do you wish your life was over?"C "Do you ever think about ending it all?"D "Do you have any thoughts of killing yourself?" الإجابة الصحيحة -
1046
A client diagnosed with cancer of the bladder is fearful of the potential outcomes of an upcoming cystectomy and urinary diversion. Which statement made to the nurse indicates the client's fear?
A "I wish I'd never gone to the doctor at all."B "I'm so afraid that I won't live through all this." الإجابة الصحيحةC "I'll never feel like myself if I can't go to the bathroom normally."D "What if I have no help at home after going through this awful surgery?" -
1047
A client diagnosed with nephrotic syndrome asks the nurse, "Why should I even bother trying to control my diet and the edema? It doesn't really matter what I do if I can never get rid of this kidney problem, anyway!" Which would the nurse identify as the most appropriate concern for this client?
A AnxietyB Powerlessness الإجابة الصحيحةC Difficulty copingD Negative self-image Inflammation/Infection/Trauma -
1048
A client diagnosed with renal cell carcinoma of the left kidney is scheduled for a nephrectomy. The right kidney appears to be normal at this time. The client is anxious about whether dialysis will ultimately be a necessity. Which information would the nurse initially provide to the client?
A It is very likely that the client will need dialysis within 5 to 10 years.B One kidney is adequate to meet the needs of the body, as long as it has normal function. الإجابة الصحيحةC There is absolutely no chance of the client needing dialysis because of the nature of the surgery.D Dialysis could become likely, but it depends on how well the client complies with fluid restriction after surgery. -
1049
The nurse is caring for a client diagnosed with acute pulmonary edema. Which psychosocial strategy would the nurse plan to incorporate into the care of the client?
A Reducing anxiety الإجابة الصحيحةB Increasing fluid volumeC Decreasing cardiac outputD Promoting a positive body image -
1050
The rehabilitation nurse witnessed a postoperative client who had a coronary artery bypass graft and his spouse arguing after a rehabilitation session. Which would be the most appropriate therapeutic statement for the nurse to make to identify the feelings of the client?
A "You seem upset." الإجابة الصحيحةB "Oh, don't let this get you down."C "It will seem better tomorrow. Now smile."D "You shouldn't get upset. It'll affect your heart." -
1051
The nurse is monitoring the neurological status on a client with dementia and assessing the limbic system. Which would the nurse assess to yield the best information about this area of functioning?
A JudgmentB Emotions الإجابة الصحيحةC ConsciousnessD Eye movements -
1052
A client is admitted to the mental health unit with a diagnosis of panic disorder. The nurse should check the primary health care provider's prescription sheet anticipating that which medication, a benzodiazepine, was prescribed?
A DoxepinB Alprazolam الإجابة الصحيحةC ImipramineD Bupropion Sedative-Hypnotics -
1053
A client diagnosed with empyema is to undergo decortication to remove inflamed tissue, pus, and debris. On the basis of which understanding about this procedure would the nurse offer emotional support to the client?
A This problem may decrease the client's life expectancy.B The client is likely to be in excruciating pain after surgery.C The client will probably have chronic dyspnea after the surgery.D Chest tubes will be in place after surgery, and the healing process is slow. الإجابة الصحيحة -
1054
The client states to the nurse, "I'm scheduled for outpatient surgery, but I live alone and my only child lives 300 miles away. I'm afraid. What happens if something goes wrong after I go home?" Which statement by the nurse is the most therapeutic?
A "Don't worry about the details. This procedure is done all the time and generally without any problems. You'll be fine!"B "They say managed care is no care! Get an alarm system so that, if you fall, it will alert someone. If necessary, I'll come."C "Your concern is well voiced. I advise you to call your son and insist that he come home immediately! You can't be too careful."D "You seem very concerned about going home without help. Have you discussed your concerns with both your surgeon and your family?" الإجابة الصحيحة -
1055
During the nursing assessment, the client states, "My surgeon just told me that my cancer has spread, and I have less than 6 months to live." Which nursing response would be the most therapeutic?
A "I am sorry. Would you like to discuss this with me some more?" الإجابة الصحيحةB "I am sorry. There are no easy answers in times like this, are there?"C "I hope you'll focus on the fact that your doctor says you have 6 months to live and that you'll think of how you'd like to live."D "I know it seems desperate, but there have been a lot of breakthroughs. Something might come along in a month or so to change your status drastically." -
1056
A client with an endotracheal tube gets easily frustrated when trying to communicate personal needs to the nurse. Which method for communication would the nurse determine may be the best for the client?
A Use a picture or word board. الإجابة الصحيحةB Have the family interpret needs.C Devise a system of hand signals.D Use a pad of paper and a pencil. -
1057
The home care nurse visits a client who is receiving total parenteral nutrition, and the client states, "I really miss eating dinner with my family." Which statement from the nurse is the most therapeutic?
A "What you are feeling is very common."B "Tell me more about your family dinners." الإجابة الصحيحةC "In a few weeks, you may be allowed to eat."D "You can sit down to dinner even if you do not eat." Nutrition/Malabsorption Problems -
1058
A client has been prescribed imipramine. The nurse notifies the primary health care provider if which adverse effect to the medication is noted?
A Increased appetiteB Increased drowsiness الإجابة الصحيحةC Reported decrease in anxietyD Increased sense of well-being Antidepressants -
1059
A client who is to undergo thoracentesis is afraid of not being able to tolerate the procedure. The nurse interprets that the client needs honest support and reassurance, best accomplished with which information?
A "I'll be right by your side, but the procedure will be totally painless as long as you don't move."B "The procedure only takes 1 to 2 minutes, so you might try to get through it by mentally counting up to 120."C "The needle hurts when it goes in, and you must remain still. I'll stay with you throughout the entire procedure and help you hold your position." الإجابة الصحيحةD "The needle is a little bit uncomfortable going in, but this is controlled by rhythmically breathing in and out. I'll be with you to coach your breathing." -
1060
A client diagnosed with chronic respiratory failure is dyspneic. The client becomes anxious, which worsens the feelings of dyspnea. The nurse teaches the client which method to best interrupt the dyspnea–anxiety–dyspnea cycle?
A Guided imagery and limiting fluidsB Relaxation and breathing techniques الإجابة الصحيحةC Biofeedback and coughing techniquesD Distraction and increased dietary carbohydrates -
1061
The nurse is interacting with the family of a client who is unconscious as a result of a head injury. Which approach would the nurse use to help the family cope with their concerns?
A Explain equipment and procedures on an ongoing basis. الإجابة الصحيحةB Discuss displaying their grief only when not in the room with the client.C Discourage them from touching the client in order to minimize stimulation.D Explain that they need their rest so they should adhere to regular visiting hours. -
1062
The nurse admits a client who is demonstrating right-sided weakness, aphasia, and urinary incontinence. The woman's daughter states, "If this is a stroke, it's the kiss of death." What initial response would the nurse make?
A "Why would you think like that?"B "You feel your mother is dying?" الإجابة الصحيحةC "These symptoms are reversible."D "A stroke is not the kiss of death." -
1063
A client diagnosed with Parkinson's disease is having difficulty adjusting to the disorder. The nurse provides education to the family that focuses on addressing the client's activities of daily living. Which statement indicates that the teaching has been effective?
A "We should plan for only a few activities during the day."B "We should assist with activities of daily living as much as possible."C "We should cluster activities at the end of the day, to help conserve energy."D "We should encourage and praise efforts to exercise and perform activities of daily living." الإجابة الصحيحة -
1064
The nurse is caring for a depressed, withdrawn client who was responsible for an automobile accident that recently resulted in the death of a child. What is the nurse's initial action?
A Allow the client to have some time alone to grieve over the loss.B Reinforce to the client that the child's death was a result of an accident.C Communicate in a manner that acknowledges and respects the client's depressed state. الإجابة الصحيحةD Inform the primary health care provider of the client's possible need for medication to cope. -
1065
The nurse is planning the care of a client newly admitted to the mental health unit for suicidal ideations. To provide a caring, therapeutic environment, which intervention would be included in the nursing care plan?
A Placing the client in a private room to ensure privacy and confidentialityB Interacting with the client demonstrating examples of unconditional positive regard الإجابة الصحيحةC Maintaining a distance of 10 inches in order to ensure the client that personal control will be providedD Placing the client in charge of a meaningful unit activity, such as the morning chess tournament -
1066
A client diagnosed with incurable cancer has a life expectancy of a few weeks. Which response indicates that the client's partner is reacting with an expected coping response?
A Refusing to visit the clientB Expressing anger with his God الإجابة الصحيحةC Not allowing the death to occur at homeD Sending the children to live with relatives -
1067
The partner of a client who has an esophageal tube introduced for a second time tells the nurse, "I thought having this tube down the nose the first time would convince anyone to quit drinking." Which response to the statement would the nurse make?
A "I think you are a good person to stay with her."B "Alcoholism is a disease that affects the whole family."C "Have you discussed this subject at the Al-Anon meetings?"D "You sound frustrated dealing with such a drinking problem." الإجابة الصحيحة -
1068
The registered nurse is orienting a new nurse on how to care for a client diagnosed with type 2 diabetes mellitus, who was recently hospitalized for hyperglycemic hyperosmolar syndrome (HHS). When preparing for discharge from the hospital, the client expresses anxiety and concerns about the recurrence of HHS. Which response by the new nurse is best?
A "Do you have concerns about managing your condition?" الإجابة الصحيحةB "Do you think you might need to go to the nursing home?"C "If you take the correct medications, I doubt this will happen again."D "Don't worry. I'm sure your family will provide all the help you need." -
1069
A client diagnosed with angina pectoris appears to be very anxious and states, "So, I had a heart attack, right?" Which response would the nurse make to the client?
A "No. That is not why you are hospitalized."B "No, but there could be some minimal damage to your heart."C "No, not this time and we will do our best to prevent a future heart attack."D "No, but it's necessary to monitor you and control or eliminate your pain." الإجابة الصحيحة -
1070
A client diagnosed with delirium anxiously states, "Look at the spiders on the wall." Which response by the nurse addresses the client's concerns therapeutically?
A "Would you like me to kill the spiders for you?"B "While there may be spiders on the wall, they are not going to hurt you."C "I know that you are frightened, but I do not see any spiders on the wall." الإجابة الصحيحةD "You are having a hallucination; I'm sure there are no spiders in this room." -
1071
While in the hospital, a client was diagnosed with coronary artery disease (CAD). Which question by the nurse is likely to elicit the most useful response for determining the client's degree of adjustment to the new diagnosis?
A "Is there anyone to help with housework and shopping?"B "How do you feel about making changes to your lifestyle?" الإجابة الصحيحةC "Do you understand the schedule for your new medications?"D "Did you make a follow-up appointment with your provider?" -
1072
A client has been using crutches to ambulate for 1 week and now reports pain, fatigue, and frustration with crutch walking. How would the nurse respond when the client states, "I feel like I will always be crippled"?
A "Tell me what makes this so bothersome for you." الإجابة الصحيحةB "I know how you feel. I had to use crutches before too."C "Why don't you take a couple of days off of work and rest?"D "Just remember, you'll be done with the crutches in another month." -
1073
A teenaged client is discharged from the hospital after surgery with instructions to use a cane for the next 6 months. What question best demonstrates the nurse's ability to use therapeutic communication techniques to effectively assess the teenager's feelings about using a cane?
A "How do you feel about needing a cane to walk?" الإجابة الصحيحةB "Do you have questions about ambulating with a cane?"C "Are you worried about what your friends will think about your cane?"D "What types of problems do you think you'll have ambulating with a cane?" -
1074
After the surgical repair of a fractured hip, a client has consistently refused to engage in ambulation as prescribed. Which statement by the nurse will best encourage the client's need to ambulate?
A "What is it about getting out of bed that concerns you?" الإجابة الصحيحةB "If you are afraid of the pain, I can give you medication to help."C "If you don't get up and start walking, your recovery will take much longer."D "Being dependent on others must be a depressing for an active person like yourself." -
1075
The student nurse is listening to a lecture on caring for clients with thrombophlebitis. Which statement by the student nurse indicates that the teaching has been effective?
A "Elevating the affected leg is indicated." الإجابة الصحيحةB "Keeping the affected leg flat encourages healing."C "Engaging in activity as tolerated should be encouraged."D "Maintaining bathroom privileges is the most important action." -
1076
A client who is experiencing paranoid thinking involving food being poisoned is admitted to the mental health unit. Which communication technique would the nurse use to encourage the client to communicate his fears?
A Offering personal opinions about the need to eatB Asking open-ended questions and providing for silence الإجابة الصحيحةC Verbalizing reasons why the client may choose not to eatD Focusing on self-disclosure of the nurse's own food preferences -
1077
The home care nurse provides instructions about the management of pruritus to a client with hepatitis who developed jaundice. Which statement made by the client suggests to the nurse that the client needs further teaching?
A "I need to wear loose cotton clothing."B "A tepid water bath should help stop the itching."C "Keeping the house warmer is likely to lessen the itching" الإجابة الصحيحةD "I need to take the prescribed antihistamines as I'm supposed to." -
1078
The nurse has provided home care instructions to a client with prostate cancer who has been hospitalized for a transurethral resection of the prostate (TURP). Which statement by the client indicates the need for further teaching?
A "Prune juice needs to be included in my diet."B "I need to avoid strenuous activity for 4 to 6 weeks."C "My intake of water needs to be at least six to eight glasses daily."D "I can't lift or push objects that weigh more than 30 pounds." الإجابة الصحيحة -
1079
A client is being treated for an atrial dysrhythmia with quinidine gluconate. Which statement by the client indicates to the nurse that the medication instructions about what to do if a dose is missed have been understood?
A "I should call my primary health care provider."B "I should take the next prescribed dose as usual." الإجابة الصحيحةC "I should take the dose as soon as I realize I've missed it."D "I take two doses of the medication at the next scheduled time." -
1080
A client has had same-day surgery to insert a ventilating tube into the tympanic membrane. Which statement assures the nurse that the client understands the discharge instructions?
A "I will bathe rather than take a shower for at least a week." الإجابة الصحيحةB "I was told to try and avoid taking medications for pain."C "I need to wash my hair quickly; taking 2 minutes or less."D "Swimming is allowed only if I keep my head above water." Problems -
1081
The nurse has completed diet teaching for a client on a low- sodium diet for the treatment of hypertension. Which statement by the client would indicate to the nurse that there is a need for further teaching?
A "Frozen foods are usually lowest in sodium." الإجابة الصحيحةB "This diet will help lower my blood pressure."C "This diet is not a replacement for my antihypertensive medications."D "The reason I need to lower my salt intake is to reduce fluid retention." -
1082
The nurse is giving dietary instructions to a client who had a kidney transplant and has been prescribed cyclosporine. Which statement by the client indicates the need for further teaching?
A "Red meats are alright to eat."B "Orange juice is a great choice for breakfast."C "Grapefruit juice will not interfere with the medication." الإجابة الصحيحةD "Green leafy vegetables should be eaten as often as possible." -
1083
The student nurse is listening to an orthopedic lecture on preoperative education and knee surgeries. Which statement by the student nurse indicates that the teaching has been effective?
A "Crutch walking instructions should be scheduled before surgery." الإجابة الصحيحةB "Crutch walking instructions should be given on the first postoperative day."C "Crutch walking instructions should be scheduled on the second postoperative day."D "Crutch walking instructions should be scheduled at the time of discharge after surgery." -
1084
A client with a short leg plaster cast reports intense itching under the cast. The nurse provides instructions to the client regarding relief measures for the itching. Which statement by the client indicates an understanding of the measures used to relieve the itching?
A "I can use the blunt part of a ruler to scratch the area."B "I can trickle small amounts of water down inside the cast."C "I need to obtain assistance when placing an object into the cast for the itching."D "I can use a hair dryer on the cool setting and allow the air to blow into the cast." الإجابة الصحيحة -
1085
Disulfiram has been prescribed for a client, and the nurse provides instructions to the client about the medication. Which statement by the client indicates the need for further teaching?
A "I must be careful taking cold medicines."B "I will have to check my aftershave lotion."C "I'll be fine as long as I don't drink alcohol." الإجابة الصحيحةD "I need to be careful with ingredients when I cook." -
1086
The nurse has provided instructions to a client who is receiving external radiation therapy for a cancerous skin lesion. Which statement by the client indicates a need for further teaching regarding self-care related to the radiation therapy?
A "I need to eat a high-protein diet."B "I need to avoid exposure to sunlight."C "I need to wash my skin with a mild soap and pat it dry."D "I need to apply pressure on the irritated area to prevent bleeding." الإجابة الصحيحة -
1087
During a health assessment the nurse provides instructions to a client regarding the testicular self-examination (TSE). Which statement by the client indicates that the client has a need for further teaching regarding TSE?
A "I know to report any small lumps."B "I should examine myself every 2 months." الإجابة الصحيحةC "I should examine myself after I take a warm shower."D "I know it's normal to feel something that is cord-like in the back." -
1088
A client diagnosed with acquired immunodeficiency syndrome (AIDS) is reporting fatigue. The nurse educates the client on ways to conserve energy. Which statement indicates that the teaching was effective?
A "Bathe before eating breakfast."B "Sit for as many activities as possible." الإجابة الصحيحةC "Stand in the shower instead of taking a bath."D "Group all tasks to be performed early in the morning." -
1089
The nurse instructs a client diagnosed with oral candidiasis (thrush) about caring for the disorder. Which statement by the client indicates a need for further teaching?
A "I can eat foods that are liquid or pureed."B "I should eliminate spicy foods from my diet."C "It's best if I don't drink citrus juices or hot liquids."D "I need to rinse my mouth four times daily with commercial mouthwash." الإجابة الصحيحة -
1090
The nurse has given instructions about site care to a hemodialysis client who had an implantation of an arteriovenous (AV) fistula in the right arm. Which statement by the client indicates a need for further teaching?
A "I will need to sleep on my right side." الإجابة الصحيحةB "It's important that I don't carry heavy objects with the right arm."C "I will perform range-of-motion exercises routinely on my right arm."D "It's important that I report any right arm redness or drainage at the site." and Chronic Kidney Disease -
1091
The nurse provides instructions to a client with coronary artery disease about applying a nitroglycerin patch. What statement indicates that the client is using correct technique?
A "A second patch will be applied if chest pain occurs."B "I will apply the patch to a nonhairy area of the body." الإجابة الصحيحةC "I will remove the patch when bathing and reapply it after the bath."D "I will remove the patch after gently rubbing the area to activate the medication." -
1092
The nurse is giving medication instructions to a client who is receiving furosemide. Which client statement indicates a need for further teaching?
A "I need to change positions slowly."B "I need to be careful to not get overheated in warm weather."C "I need to talk to my primary health care provider about the use of alcohol."D "I need to avoid the use of salt substitutes because they contain potassium." الإجابة الصحيحة -
1093
A client with hypertension has been prescribed a clonidine patch, and the nurse has instructed the client regarding the use of the patch. Which client statement indicates a need for further teaching?
A "I intend to change the patch every 7 days."B "I need to trim the patch if an edge becomes loose." الإجابة الصحيحةC "It's important to put the patch on a hairless site on my torso."D "It's alright to leave the patch in place during bathing or showering." -
1094
Cholestyramine is prescribed for a client with coronary artery disease, and the nurse provides instructions to the client about the medication. Which client statement indicates a need for further teaching?
A "I should take this medication with meals."B "I need to mix the medication with juice or applesauce."C "I should increase my fluid intake while taking this medication."D "I should call my primary health care provider immediately if it causes constipation." الإجابة الصحيحة -
1095
The nurse is reviewing written medication instructions with a client who is prescribed colestipol hydrochloride as part of the treatment plan for coronary artery disease. Which statement by the client indicates that the teaching has been effective?
A "Vitamin C will help control unintended side effects."B "Vitamin B12 will help control unintended side effects."C "B-complex vitamins will help control unintended side effects."D "Fat-soluble vitamins will help control unintended side effects." الإجابة الصحيحة -
1096
Which assessment finding would the nurse expect to note in the child hospitalized with a diagnosis of nephrotic syndrome?
A Weight lossB ConstipationC HypotensionD Abdominal pain الإجابة الصحيحة -
1097
A client prescribed dextroamphetamine reports to the nurse difficulty falling asleep at night. The nurse instructs the client on how to minimize sleep disorders. On assessment, which statement by the client indicates that teaching has been effective?
A "I'll take the medication with a bedtime snack."B "I'll take the medication upon awaking in the morning."C "I'll take the medication two hours before going to bed."D "I'll take the medication at least 6 hours before bedtime." الإجابة الصحيحة -
1098
The nurse is caring for a client diagnosed with acquired immunodeficiency syndrome (AIDS). Which sign/symptom indicates the presence of an opportunistic respiratory infection?
A Nausea and vomitingB Fever and exertional dyspnea الإجابة الصحيحةC An arterial blood gas pH of 7.40D A respiratory rate of 20 breaths/min -
1099
An adult client seeks treatment in an ambulatory care clinic for reports of a left earache, nausea, and a full feeling in the left ear. The client has an elevated temperature. Which assessment question would the nurse ask first?
A "Do you have a history of a recent brain abscess?"B "Do you have a chronic hearing problem in the left ear?"C "Do you successfully obtain pain relief with acetaminophen?"D "Do you have a history of a recent upper respiratory infection (URI)?" Problems الإجابة الصحيحة -
1100
A client with coronary artery disease is scheduled for an arteriogram using a radiopaque dye. What is the most important information the nurse would determine before the procedure to assure the client's safety?
A Vital signsB Intake and outputC Height and weightD Allergy to iodine or shellfish الإجابة الصحيحة -
1101
A client with gastritis in a long-term care facility has had a series of gastrointestinal (GI) diagnostic tests, including an upper and lower GI series and endoscopies. Upon return to the long-term care facility, which priority assessment would the nurse focus on?
A The comfort levelB Activity toleranceC The level of consciousnessD The hydration and nutrition status الإجابة الصحيحة -
1102
A client diagnosed with cirrhosis of the liver is receiving oral triamterene daily. Which sign/symptom would indicate to the nurse that the client is experiencing an adverse effect of the medication?
A Dry skinB ExcitabilityC ConstipationD Hyperkalemia الإجابة الصحيحة -
1103
The nurse reviews the record of a client who is receiving external radiation therapy and notes documentation of a skin finding as moist desquamation. Which finding on assessment of the client would the nurse expect to observe?
A A rashB DermatitisC Reddened skinD Weeping of the skin الإجابة الصحيحة -
1104
A client who has been receiving long-term diuretic therapy is admitted to the hospital with a diagnosis of dehydration. The nurse would assess for which sign that correlates with this fluid imbalance?
A Decreased pulseB Bibasilar cracklesC Increased blood pressureD Increased urinary specific gravity الإجابة الصحيحة -
1105
On assessment of the client diagnosed with stage III Lyme disease, which clinical manifestation would the nurse expect to note?
A PalpitationsB A cardiac dysrhythmiaC A generalized skin rashD Enlarged and inflamed joints الإجابة الصحيحة -
1106
A home care nurse assesses an older client's functional status and ability to perform activities of daily living (ADLs) since being diagnosed with dementia. What is the focus area of the nurse's assessment?
A Everyday routinesB Self-care activities الإجابة الصحيحةC Household managementD Endurance and flexibility -
1107
The nurse is assessing a client diagnosed with Addison's disease for signs of hyperkalemia. Which sign/symptom would the nurse observe with this electrolyte imbalance?
A PolyuriaB Cardiac dysrhythmias الإجابة الصحيحةC Dry mucous membranesD Prolonged bleeding time -
1108
A client with acute kidney injury had arterial blood gases drawn. The results are a pH of 7.34, a partial pressure of carbon dioxide of 37 mm Hg (37 mm Hg), a partial pressure of oxygen of 79 mm Hg (79 mm Hg), and a bicarbonate level of 19 mEq/L (19 mmol/L). Which disorder would the nurse interpret that the client is experiencing?
A Metabolic acidosis الإجابة الصحيحةB Metabolic alkalosisC Respiratory acidosisD Respiratory alkalosis and Chronic Kidney Disease -
1109
The nurse interprets that which observation is related to the dysfunction of cranial nerve III (oculomotor nerve)?
A Mild drowsinessB Unilateral ptosis الإجابة الصحيحةC Diminished mental acuityD Less frequent spontaneous speech -
1110
A client diagnosed with a thrombotic brain attack experiences periods of emotional lability. What would the nurse interpret this behavior as indicating?
A That the client is not adapting well to the disabilityB That the problem is likely to get worse before it gets betterC That the client is experiencing the usual sequelae of a stroke الإجابة الصحيحةD That the client is experiencing the side effects of prescribed anticoagulants -
1111
The nurse is developing a plan of care for a client in Buck's (extension) traction. The nurse would determine that which is a priority client problem?
A Immobility الإجابة الصحيحةB Risk of infectionC Altered independenceD Insufficient sensory stimulation -
1112
The nurse performs an assessment on a client with a history of heart failure who has been taking diuretics on a long-term basis. The nurse reviews the medication record, knowing that which medication, if prescribed for this client, would place the client at risk for hypokalemia?
A Bumetanide الإجابة الصحيحةB TriamtereneC SpironolactoneD Hydrochlorothiazide -
1113
The home care nurse is preparing to visit a client diagnosed with Ménière's disease. The nurse analyzes the primary health care provider prescriptions and expects to educate the client on which dietary measure?
A A low-fiber diet with decreased fluidsB A low-sodium diet and fluid restriction الإجابة الصحيحةC A low-fat diet with a restriction of citrus fruitsD A low-carbohydrate diet and the elimination of red meats -
1114
The nurse is caring for a client who has been diagnosed with tuberculosis. The client is receiving 600 mg of oral rifampin daily. Which laboratory finding would indicate to the nurse that the client is experiencing an adverse effect?
A A sedimentation rate of 15 mm/hrB Alanine aminotransferase (ALT) of 80 U/L الإجابة الصحيحةC A total bilirubin level of 0.3 mg/dL (5.1 mcmol/L)D A white blood cell count of 6000 mm3 (6 x 109/L) -
1115
A home care nurse is assessing a client who is prescribed prazosin. Which statement by the client would support the need for further teaching regarding medication compliance?
A "If I feel dizzy, I'll skip my dose for a few days." الإجابة الصحيحةB "I can't see the numbers on the label to know how much salt is in the food."C "I understand why I have to keep taking the pills even when my blood pressure is normal."D "If I have a cold, I shouldn't take any over-the-counter remedies without consulting my doctor." -
1116
A client manages peptic ulcer disease (PUD) with excessive amounts of oral antacids. Signs/symptoms of which acid–base imbalance would the nurse assess for?
A Metabolic acidosisB Metabolic alkalosis الإجابة الصحيحةC Respiratory acidosisD Respiratory alkalosis -
1117
The nurse is assessing a 39-year-old Caucasian client with a blood pressure (BP) of 152/92 mm Hg at rest, a total cholesterol level of 180 mg/dL (4.5 mmol/L), and a fasting blood glucose level of 90 mg/dL (5.14 mmol/L). On which risk factor for coronary artery disease would the nurse place priority?
A AgeB Hypertension الإجابة الصحيحةC HyperlipidemiaD Glucose intolerance Peripheral Vascular -
1118
What would be the nurse's priority for the postprocedure care of a client who has just returned to the unit after a scheduled intravenous pyelogram (IVP)?
A Maintaining the client on bed restB Ambulating the client in the hallwayC Encouraging the increased intake of oral fluids الإجابة الصحيحةD Encouraging the client to try to void frequently and Chronic Kidney Disease -
1119
A client diagnosed with myasthenia gravis is reporting vomiting, abdominal cramps, and diarrhea. The nurse notes that the client is hypotensive and experiencing facial muscle twitching. Which possible situation does this assessment data support?
A Myasthenic crisisB Cholinergic crisis الإجابة الصحيحةC Systemic infectionD Reaction to plasmapheresis -
1120
The nurse creates a plan of care for a client with a spica cast that covers a lower extremity. Which action would the nurse include in the plan of care to promote bowel elimination?
A Use a bedside commode.B Ambulate to the bathroom.C Administer an enema daily.D Use a low-profile (fracture) bedpan. الإجابة الصحيحة -
1121
The nurse is admitting a client who recently underwent a bilateral adrenalectomy. Which intervention is essential for the nurse to include in the client's plan of care?
A Prevent social isolation.B Consider occupational therapy.C Discuss changes in body image.D Avoid stress-producing situations. الإجابة الصحيحة -
1122
The nurse is creating a plan of care for a client prescribed bed rest. Which intervention would the nurse include in the plan to limit renal complications of prolonged immobility?
A Maintain the client in a supine position.B Provide a daily fluid intake of 1000 mL.C Limit the intake of milk and milk products. الإجابة الصحيحةD Monitor for signs of a low serum calcium level. -
1123
The nurse determines that a tuberculin skin test is positive. Which diagnostic test would the nurse anticipate will be prescribed to confirm a diagnosis of tuberculosis (TB)?
A Chest x-rayB Sputum culture الإجابة الصحيحةC Complete blood cell countD Computed tomography scan of the chest -
1124
The home care nurse is creating a plan of care for a client diagnosed with Ménière's syndrome. Which nursing intervention would the nurse include to assist the client with controlling vertigo?
A Instruct the client to cut down on cigarette smoking.B Encourage the client to increase the daily fluid intake.C Encourage the client to avoid sudden head movements. الإجابة الصحيحةD Instruct the client to increase the amount of sodium in the diet. -
1125
A client is admitted to a mental health unit with a diagnosis of anorexia nervosa. When planning care for this client, which primary intervention would health promotion focus on?
A Providing a supportive environmentB Examining intrapsychic conflicts and past issuesC Emphasizing social interaction with clients who are withdrawnD Helping the client identify and examine dysfunctional thoughts and beliefs الإجابة الصحيحة -
1126
The nurse is preparing discharge plans for a hospitalized client who attempted suicide. Which intervention would the nurse include in the plan as an immediate resource?
A Scheduling weekly follow-up appointmentsB Establishing a contact with a specific crisis resource person الإجابة الصحيحةC Encouraging family and friends to be with the client at all timesD Providing phone numbers for the primary health care provider and psychiatrist -
1127
A client is experiencing diabetes insipidus as a result of cranial surgery. Which anticipated therapy would the nurse plan to implement?
A Fluid restrictionB Administering diureticsC Increased sodium intakeD Intravenous (IV) replacement of fluid losses الإجابة الصحيحة -
1128
The nurse is caring for a client diagnosed with dementia. Which nutritional goal would the nurse plan for with this client?
A Client will be free of hallucinations.B Client will feed self with cueing within 24 hours. الإجابة الصحيحةC Client will be able to prepare simple foods by discharge.D Client will identify favorite foods by the time of discharge. -
1129
A client who was a victim of a gunshot incident states, "I feel like I am losing my mind. I keep hearing the gunshots and seeing my friend lying on the ground." Which strategy would the nurse include when initially formulating a therapeutic relationship?
A Teaching the client a variety of relaxation techniquesB Asking the psychiatrist to prescribe appropriate medicationC Encouraging the client to talk about the incident and feelings related to it الإجابة الصحيحةD Encouraging the client to think about just how lucky he or she is to still be alive -
1130
The nurse is preparing to admit a client from the postanesthesia care unit who has had microvascular decompression of the trigeminal nerve. Which essential equipment would the nurse ask the assistive personnel to make sure is at the bedside when the client arrives?
A Flashlight and pulse oximeter الإجابة الصحيحةB Cardiac monitor and suction equipmentC Padded bed rails and suction equipmentD Blood pressure cuff and cardiac monitor -
1131
The nurse is receiving a client from the emergency department who has a diagnosis of Guillain-Barré syndrome. The client's chief sign/symptom is an ascending paralysis that has reached the level of the waist. Which items would the nurse plan to have available for emergency use?
A Nebulizer and pulse oximeterB Blood pressure cuff and flashlightC Flashlight and incentive spirometerD Cardiac monitor and intubation tray الإجابة الصحيحة -
1132
The nurse is preparing to assist in the administration of a chemotherapeutic agent via intraperitoneal (IP) therapy for the treatment of ovarian cancer. In which position would the nurse plan to place the client before administering this therapy?
A SupineB Semi-Fowler's الإجابة الصحيحةC Trendelenburg'sD Dorsal recumbent -
1133
The nurse plans care for a client with alcohol abuse disorder based on which support system?
A Fresh Start, an option for families of addictsB Families Anonymous, an option for those addicted to nicotineC Al-Anon, an option for parents of children who abuse substancesD Alcoholics Anonymous, a major self-help organization for the treatment of alcohol abuse الإجابة الصحيحة -
1134
A client hospitalized after a brain attack (stroke) is prepared for discharge. The primary health care provider (PHCP) has prescribed range-of-motion (ROM) exercises for the client's right side. Which intervention would the home care nurse include when planning for the client's care?
A Implements ROM exercises to the point of pain for the clientB Considers the use of active, passive, or active-assisted exercises in the home الإجابة الصحيحةC Encourages dependence on the home care nurse to complete the exercise programD Develops a schedule involving ROM exercises every 3 hours during daylight hours -
1135
A client diagnosed with heart failure is receiving furosemide and digoxin daily. When the nurse enters the room to administer the morning doses, the client reports anorexia, nausea, and yellow vision. Which intervention would the nurse implement first?
A Administer the medications.B Contact the primary health care provider.C Check the morning serum digoxin level. الإجابة الصحيحةD Check the morning serum potassium level. -
1136
A client tells the clinic nurse that her skin is very dry and irritated. Which product would the nurse suggest that the client apply to the dry skin?
A MyoflexB AspercremeC Topical emollient الإجابة الصحيحةD Acetic acid solution -
1137
A client with a history of hypertension has been prescribed triamterene. The nurse provides information to the client about the medication and instructs the client to avoid consuming which fruit?
A PearsB ApplesC Bananas الإجابة الصحيحةD Cranberries -
1138
The nurse is asked to assist another health care team member with providing care for a client. On entering the client's room, the nurse notes that the client is placed in this position (refer to the figure). The nurse maintains the client's position knowing that this client is most likely being treated for which condition? (From Black J, Hawks J: Medical-surgical nursing: Clinical management for positive outcomes, ed 8, Philadelphia, 2009,
A Shock الإجابة الصحيحةB A head injuryC Respiratory insufficiencyD Increased intracranial pressure -
1139
A client diagnosed with obsessive-compulsive rituals often misses the unit's morning activities because of a bed-making ritual. What nursing action would be therapeutic?
A Verbalize tactful, mild disapproval of the behavior.B Discuss the social implications of the behavior with the client.C Help the client to make the bed so that the task can be finished quicker.D Offer reflective feedback, such as, "I see that you have made your bed several times." الإجابة الصحيحة -
1140
A client who has undergone internal fixation after fracturing a left hip has developed a reddened left heel. What equipment would the nurse use to manage this problem?
A TrapezeB Bed cradleC Draw sheetD Alternating pressure mattress الإجابة الصحيحة -
1141
A client begins to experience seizure activity while in bed. The nurse would provide which intervention to prevent aspiration?
A Raise the head of the bed.B Loosen restrictive clothing.C Remove the pillow and raise the padded side rails.D Position the client on the side with the head flexed forward. الإجابة الصحيحة -
1142
A client who has experienced a stroke has episodes of coughing while swallowing liquids. The client has developed a temperature of 101° F (38.3° C) and an oxygen saturation of 91% (down from 98% previously), is slightly confused, and has noticeable dyspnea. Which action would the nurse take?
A Notify the primary health care provider. الإجابة الصحيحةB Administer an acetaminophen suppository.C Encourage the client to cough and deep breathe.D Administer a bronchodilator prescribed on an as-needed basis. -
1143
Which action would the nurse implement as part of care for a client with suspected multiple myeloma after a bone biopsy?
A Monitor the vital signs once per day.B Keep the area in a dependent position.C Administer intramuscular opioid analgesics.D Monitor the site for swelling, bleeding, or hematoma formation. الإجابة الصحيحة -
1144
The nurse is caring for a client with rheumatoid arthritis who is scheduled for an arthrogram involving the use of a contrast medium. Which action by the nurse is the priority?
A Determining the presence of client allergies الإجابة الصحيحةB Asking if the client has any last-minute questionsC Telling the client to try to void before leaving the unitD Emphasizing to the client the importance of remaining still during the procedure and Osteoarthritis -
1145
The nurse responds to a call bell and finds a client lying on the floor after a fall. The nurse suspects that the client's arm may be broken. Which immediate action would the nurse take?
A Immobilize the arm. الإجابة الصحيحةB Take a set of vital signs.C Call the radiology department.D Ask the client to describe what happened. -
1146
The nurse prepares for a client in leg traction to be admitted to the nursing unit. The nurse asks the assistive personnel to obtain which essential item that will be needed to assist the client to move in bed while in leg traction?
A A foot boardB Extra pillowsC A bed trapeze الإجابة الصحيحةD An electric bed -
1147
A client admitted to the hospital with a diagnosis of a leaking cerebral aneurysm is scheduled for surgery. Which intervention would the nurse implement during the preoperative period?
A Place the client on bed rest. الإجابة الصحيحةB Allow the client to ambulate only in the room.C Obtain a bedside commode for the client's use.D Encourage the client to be up at least twice per day. -
1148
The nurse is evaluating the effects of care for the client with nephrotic syndrome. Which diagnostic result demonstrates the least amount of improvement over 2 days of care?
A Initial weight 208 pounds, down to 203 poundsB Blood pressure 160/90 mm Hg, down to 130/78 mm HgC Serum albumin 1.9 g/dL (19 g/L), up to 2.0 g/dL (20 g/L) الإجابة الصحيحةD Daily intake and output record of 2100 mL intake and 1900 mL output and 2000 mL intake and 2900 mL output Inflammation/Infection/Trauma -
1149
A client is being discharged after the application of a plaster leg cast. The nurse determines that the client understands the proper care of the cast when the client states the need to engage in which action?
A Avoid getting the cast wet. الإجابة الصحيحةB Cover the casted leg with warm blankets.C Use the fingertips to lift and move the leg.D Use a padded coat hanger end to scratch under the cast. -
1150
The client recovering from an acute kidney injury demonstrates an understanding of the therapeutic dietary regimen when indicating a need to limit which dietary factor?
A FatsB VitaminsC Potassium الإجابة الصحيحةD Carbohydrates and Chronic Kidney Disease -
1151
The nurse teaches the client with a history of anxiety and command hallucinations to harm self or others appropriate management techniques. Which client statement indicates that the client understands these techniques?
A "I can go to group and talk about my feelings to hurt myself or others."B "If I take my prescribed medication as I'm supposed to, I won't be as anxious."C "I can call my counselor so that I can talk about my feelings and not hurt anyone." الإجابة الصحيحةD "If I get enough sleep and eat well, I won't be as likely to get anxious and hear things." -
1152
The nurse has given the client with coronary artery disease information about the use of sublingual nitroglycerin tablets prescribed for as-needed use if chest pain occurs. Which client statement helps assure the nurse that the client understands how to self-administer the medication?
A "I will keep the nitroglycerin in a shirt pocket close to my body."B "I won't take the medication until the chest pain actually begins and intensifies."C "If I get a headache when I first start taking the nitroglycerin, then I will take an aspirin"D "I will discard unused nitroglycerin tablets 3 to 6 months after the bottle is opened, and obtain a new prescription." الإجابة الصحيحة -
1153
A client who had a laryngectomy for laryngeal cancer has started oral intake. The nurse determines that the first stage of dietary advancement has been tolerated when the client ingests which type of diet without aspirating or choking?
A BlandB Full liquidsC Clear liquidsD Semisolid foods الإجابة الصحيحة -
1154
An older client is a victim of elder abuse. He and his family have been attending counseling sessions for the past month. Which statement, made by the abusive family member, would indicate an understanding of more positive coping skills?
A "I will be more careful to make sure that my father's needs are 100% met."B "I am so sorry and embarrassed that the abusive event occurred. It won't happen again."C "I feel better equipped to care for my father now that I know where to turn if I need assistance." الإجابة الصحيحةD "Now that my father is going to move into my home with me, I will have to stop drinking alcohol." -
1155
A client with gastritis has just taken a dose of trimethobenzamide. When the client states relief of which sign/symptom, it is appropriate for the nurse to determine that the medication has been effective?
A Nausea الإجابة الصحيحةB HeartburnC ConstipationD Abdominal pain -
1156
A client has begun medication therapy with betaxolol. The nurse determines that the client is experiencing the intended effect of therapy if which observation is noted?
A Edema present at 3+B Weight loss of 5 pounds within 2 daysC Pulse rate increased from 58 to 74 beats/minD Blood pressure decreased from142/94 mm Hg to 128/82 mm Hg الإجابة الصحيحة -
1157
The nurse has taught a client with asthma who is prescribed a xanthine bronchodilator about beverages to avoid. The nurse determines that the client understands the information if the client chooses which beverage from the dietary menu?
A ColaB CoffeeC Chocolate milkD Cranberry juice Agents الإجابة الصحيحة -
1158
A client is prescribed glipizide once daily. What intended effect of this medication would the nurse observe for?
A Weight lossB Resolution of infectionC Decreased blood glucose الإجابة الصحيحةD Decreased blood pressure -
1159
A client regularly takes nonsteroidal antiinflammatory drugs (NSAIDs) and misoprostol has been added to the medication regimen. The nurse would monitor the client for the relief of which sign/symptom?
A DiarrheaB BleedingC InfectionD Epigastric pain الإجابة الصحيحة -
1160
A client has received a dose of an as-needed medication loperamide. The nurse evaluates the client after administration to determine if the client has relief of which sign/symptom?
A Diarrhea الإجابة الصحيحةB Tarry stoolsC ConstipationD Abdominal pain Nutrition/Malabsorption Problems -
1161
A client has been taking nadolol for the past month. Which finding would indicate a therapeutic effect of the medication?
A The client is afebrile.B The client has clear breath sounds.C The client reports no episodes of headache.D The client has a blood pressure of 118/72 mm Hg. الإجابة الصحيحة -
1162
The nurse is assigned to care for a client diagnosed with acquired immunodeficiency syndrome (AIDS) who is receiving amphotericin B for a fungal respiratory infection. When evaluating the effects of the medication, which would indicate an adverse effect?
A Hypokalemia الإجابة الصحيحةB HypernatremiaC HypochloremiaD Hypercalcemia -
1163
A client is seen in the health care clinic, and a diagnosis of conjunctivitis is made. The nurse provides instructions to the client regarding the care of the disorder while at home. Which statement by the client indicates the need for further teaching?
A "I can use an ophthalmic analgesic ointment at night if I have eye discomfort."B "I do not need to be concerned about spreading this infection to others in my family." الإجابة الصحيحةC "I should apply warm compresses before instilling antibiotic drops if purulent discharge is present in my eye."D "I should perform saline eye irrigation before instilling the antibiotic drops into my eye if purulent discharge is present." -
1164
An adult client with hyperkalemia is prescribed sodium polystyrene sulfonate. Which serum potassium level is a clinical indicator of effective therapy?
A 4.9 mEq/L (4.9 mmol/L) الإجابة الصحيحةB 5.4 mEq/L (5.4 mmol/L)C 5.8 mEq/L (5.8 mmol/L)D 6.2 mEq/L (6.2 mmol/L) Electrolytes -
1165
The nurse assesses a client after abdominal surgery who has a nasogastric (NG) tube in place that is connected to suction. Which observation by the nurse indicates most reliably that the tube is functioning properly?
A The suction gauge reads low intermittent suction.B The client indicates that pain is a 3 on a scale of 0 to 10.C The distal end of the NG tube is pinned to the client's gown.D The client denies nausea and has 250 mL of fluid in the suction collection container. Nutrition/Malabsorption Problems الإجابة الصحيحة -
1166
The nurse is caring for a client who has returned from the postanesthesia care unit after prostatectomy. The client has a three- way Foley catheter with an infusion of continuous bladder irrigation (CBI). Which color description of the urinary drainage would lead the nurse to determine that the flow rate is adequate?
A Dark cherryB Clear as waterC Pale yellow or slightly pink الإجابة الصحيحةD Concentrated yellow with small clots Inflammation/Infection/Trauma -
1167
The nurse caring for a client with Graves' disease is concerned about the client's calorie intake because of the resulting hypercatabolic state of the disorder. Which situation indicates a successful outcome for this concern?
A The client verbalizes the need to avoid snacking between meals.B The client discusses the relationship between mealtime and the blood glucose level.C The client maintains a normal weight or gradually gains weight if it is below normal. الإجابة الصحيحةD The client demonstrates knowledge regarding the need to consume a diet that is high in fat and low in protein. -
1168
The nurse is reviewing the results of a client's phenytoin level that was drawn that morning. The nurse is preparing to discharge once the level is therapeutic. Which result indicates that this goal has been met?
A 3 mcg/mL (11.9 mcmol/L)B 8 mcg/mL (31.7 mcmol/L)C 15 mcg/mL (59.5 mcmol/L) الإجابة الصحيحةD 24 mcg/mL (95.2 mcmol/L) -
1169
The nurse is caring for a client who is placed in seclusion because of violent behavior. Which client statement indicates to the nurse that the seclusion is no longer necessary?
A "I am in control of myself now." الإجابة الصحيحةB "I need to use the restroom right away."C "I'd like to go back to my room and be alone for a while."D "I can't breathe in here. It feels like the walls are closing in on me." -
1170
The nurse has created a plan of care to include interventions focused on reassuming self-care for a client who is in traction. The nurse evaluates the plan of care and determines that which observation indicates a successful outcome?
A The client denies a need for assistance with care.B The client allows the family to perform the care.C The client assists in self-care as much as possible. الإجابة الصحيحةD The client allows the nurse to complete the care on a daily basis. -
1171
The nurse has provided self-care activity instructions to a client after the insertion of an internal cardioverter-defibrillator (ICD). The nurse determines that there is a need for further teaching if the client makes which statement?
A "I need to avoid doing anything where there would be rough contact with the ICD insertion site."B "I can perform activities and operate heavy equipment such as my lawn mower or tractor as I need to." الإجابة الصحيحةC "I should try to avoid doing strenuous things that would make my heart rate go up to or above the rate cut-off on the ICD."D "I should keep away from electromagnetic sources such as transformers, large electrical generators, and metal detectors, as well as running motors." -
1172
Which manifestations associated with thyroid storm indicate the need for immediate nursing intervention?
A Polyuria, nausea, and severe headachesB Polydipsia, translucent skin, and obesityC Fever, tachycardia, and systolic hypertension الإجابة الصحيحةD Profuse diaphoresis, flushing, and constipation -
1173
A client is hospitalized for ingesting an overdose of acetaminophen. The nurse prepares to administer which specific antidote for this medication overdose?
A FlumazenilB PhytonadioneC N-acetylcysteine الإجابة الصحيحةD Naloxone hydrochloride -
1174
The nurse is caring for a client at risk for suicide. Which client behavior best indicates that the client may be contemplating suicide?
A Sharing that she or he is finally happy الإجابة الصحيحةB Sitting and crying for long periods of timeC Preferring to spend long periods of time aloneD Reporting a variety of sleep pattern disturbances -
1175
The nurse notes that the client brought to the emergency department after an episode of fainting is receiving olanzapine. Which disorder or condition would the nurse suspect the client is experiencing?
A Schizophrenia الإجابة الصحيحةB Dementia disorderC Personality disorderD Major depressive disorder Antidepressants -
1176
The nurse assesses a client scheduled for a thyroidectomy for psychosocial problems that may cause preoperative anxiety. Considering the nature of the surgery, which client fear is a realistic source of anxiety?
A Sexual dysfunction and infertilityB Imposed dietary restrictions after dischargeC Developing gynecomastia and hirsutism postoperativelyD Changes in body image secondary to the location of the incision الإجابة الصحيحة -
1177
The nurse reviewing the electrocardiogram (ECG) rhythm strip of a client with a history of a myocardial infarction (MI) notes that the PR intervals are 0.16 seconds. The nurse would arrive at which interpretation of this assessment data?
A A normal finding الإجابة الصحيحةB An abnormal findingC An impending reinfarctionD First-degree atrioventricular (AV) block -
1178
Which sign/symptom indicates that a client being treated with haloperidol may be experiencing an adverse effect of this medication?
A NauseaB HypotensionC Blurred visionD Excessive drooling الإجابة الصحيحة -
1179
The nurse teaches the client diagnosed with acute gouty arthritis about the prescribed indomethacin therapy. The nurse determines that there is a need for further teaching when the client makes which statement?
A "I'll rest if I am having pain."B "I need to call the office if I notice a rash."C "I can take a pill whenever I need to for pain." الإجابة الصحيحةD "I'll watch for indications that my feet or fingers are swollen." Analgesics -
1180
The charge nurse determines that the new nurse understands the concepts associated with suicide and suicide intentions when the new nurse makes which statement?
A "Only the psychotic individual commits suicide."B "Suicidal attempts are attention-seeking behaviors."C "Suicide runs in the family, so there is nothing that health care personnel can do about it."D "Many individuals who commit suicide have talked about their suicidal intentions to others." الإجابة الصحيحة -
1181
A client wanders in and out of other clients' rooms, taking their possessions while singing to himself and then giggling for no apparent reason. The nurse reacts therapeutically by taking which action?
A Putting arms around the client, saying, "You're okay. You just need a hug."B Saying, "I can see you are very anxious today. Let's go and play the piano." الإجابة الصحيحةC Taking the client to the seclusion room until he cooperates with unit rules.D Taking the client to the lounge and saying, "Sit here and try to behave yourself." -
1182
During electroconvulsive therapy (ECT), the client receives oxygen by mask via positive pressure ventilation. The nurse understands that positive pressure ventilation is necessary for which reason?
A Seizure activity depresses respirations.B Anesthesia is routinely administered during the ECT procedure.C Muscle relaxants are given to prevent injury during the seizure. الإجابة الصحيحةD Decreased oxygen to the brain increases confusion and disorientation. -
1183
The nurse is monitoring a client with a diagnosis of chronic kidney disease (CKD). Which assessment finding would the nurse report to the primary health care provider?
A PallorB FatigueC LethargyD Petechiae and Chronic Kidney Disease الإجابة الصحيحة -
1184
The nurse providing emergency treatment for a client in ventricular tachycardia is preparing to defibrillate the client. Which nursing action provides for the safest environment during a defibrillation attempt?
A Ensuring that no lubricant is on the paddlesB Placing the charged paddles one at a time on the client's chestC Holding the client's upper torso stable while the defibrillation is performedD Assuring that all assisting personnel are clear of the client and the client's bed الإجابة الصحيحة -
1185
Which adverse effect of heparin sodium therapy, delivered continuously by intravenous infusion, would the nurse monitor the client for?
A TinnitusB Ecchymoses الإجابة الصحيحةC Increased pulse rateD Decreased blood pressure Disorders -
1186
A client, admitted to the emergency department reporting severe, radiating chest pain, is extremely restless, frightened, and dyspneic. Immediate admission prescriptions include oxygen by nasal cannula at 4 L per minute; troponin, creatinine phosphokinase, and isoenzymes blood levels; a chest x-ray; and a 12-lead electrocardiogram (ECG). Which action would the nurse take first?
A Obtain the 12-lead ECG.B Draw the blood specimens.C Apply the oxygen to the client. الإجابة الصحيحةD Schedule the chest x-ray study. -
1187
Chemical cardioversion is prescribed for the client diagnosed with atrial fibrillation. The nurse who is assisting in preparing the client would expect that which medication specific for chemical cardioversion would be prescribed?
A LidocaineB NifedipineC Amiodarone الإجابة الصحيحةD Nitroglycerin -
1188
The home health nurse cares for an obese adult client. In the client's medical record, the nurse reads, "The client has a sprained right ankle, has not exercised for more than 1 week, and has missed the last two physical therapy appointments." The client says, "I attend therapy for my ankle and I do my exercises three times a day." Which response would the nurse use with the client?
A "Show me the exercises that you perform in physical therapy." الإجابة الصحيحةB "You will never heal if you skip the physical therapy sessions."C "Your progress sounds fine. Is more physical therapy scheduled?"D "I see that you missed the last two physical therapy appointments." Injury -
1189
A client demonstrating unstable ventricular tachycardia (VT) loses consciousness and becomes pulseless after an initial treatment with a dose of lidocaine intravenously. Which item would the nurse caring for the client immediately obtain?
A A pacemakerB A defibrillator الإجابة الصحيحةC A second dose of lidocaineD An electrocardiogram machine -
1190
The nurse has done preoperative teaching with a client with pulmonary embolism scheduled for percutaneous insertion of an inferior vena cava (IVC) filter. Which client statement indicates the need for further teaching about the procedure?
A "This is done under general anesthesia." الإجابة الصحيحةB "This procedure is rarely associated with complications."C "It may cause congestion when clots get trapped at the filter."D "This could possibly eliminate the need for anticoagulant therapy." -
1191
A client with a head injury and a feeding tube continuously tries to remove the tube. The nurse contacts the primary health care provider who prescribes the use of restraints. After checking the agency's policy and procedure regarding the use of restraints, the nurse uses which method in restraining the client?
A BeltB WaistC WristD Mitten الإجابة الصحيحة -
1192
A client has been defibrillated at 360 joules (monophasic) and the attempts to convert the ventricular fibrillation (VF) were unsuccessful. Based on an evaluation of the situation, the nurse determines that which action is best?
A Terminating the resuscitation effortB Preparing for the administration of sodium bicarbonate intravenouslyC Performing cardiopulmonary resuscitation (CPR) for five cycles or about 2 minutes الإجابة الصحيحةD Performing CPR for 5 minutes, then defibrillating three more times at 400 joules -
1193
The home care nurse visits a client who started wandering around at 10:00 pm each evening and got out of the house for the first time last night. The family asks for help. Which therapeutic response would the nurse make to the family?
A "What prevented her from leaving the house in the past?" الإجابة الصحيحةB "You cannot handle this alone because she could get hurt."C "I think you need to consider a nursing home immediately."D "This is a common problem known as sundowner's syndrome." -
1194
The home care nurse is doing an assessment interview with an older adult client who asks the nurse to buy some groceries for her because she is not feeling well today. Which statement would the nurse use in response?
A "Do you often need help with food shopping?"B "Let's discuss how we can solve this problem." الإجابة الصحيحةC "Do you have any support systems for shopping?"D "I wish I could but I don't have time to run errands." -
1195
The nurse is caring for a client who is being treated with an intravenous (IV) bolus of lidocaine hydrochloride. What would the nurse monitor when considering the actions and the effects of this medication?
A Urinary pHB Radial pulseC TemperatureD Blood pressure الإجابة الصحيحة -
1196
The nurse has conducted a stress management seminar for clients in an ambulatory care setting. Which statement by a client would indicate a need for further teaching?
A "I can use those guided imagery techniques I've learned anywhere and anytime."B "Biofeedback might be nice, but I don't like the idea of having to use equipment."C "Using confrontation with coworkers should solve my problems at work quickly." الإجابة الصحيحةD "The progressive muscle relaxation technique should ease my tension headaches." -
1197
The nurse is caring for a client with a diagnosis of peptic ulcer disease. When monitoring the client for possible gastrointestinal perforation, the nurse identifies the importance of what assessment data?
A Slow, strong pulsesB Increase in bowel soundsC Positive guaiac stool testsD Sudden, severe abdominal pain الإجابة الصحيحة -
1198
The nurse is evaluating the effectiveness of antimicrobial therapy for a client diagnosed with infective endocarditis. The nurse determines that which finding is the least reliable indicator of effectiveness?
A Clear breath soundsB Systolic heart murmur الإجابة الصحيحةC Temperature of 98.8° FD Negative blood cultures Structural Heart Disorders -
1199
The nurse notes that the client's continuous electrocardiogram (ECG) complexes are very small and hard to evaluate. Which setting on the ECG monitor console would the nurse check?
A Power buttonB Low rate alarmC High rate alarmD Amplitude or "gain" الإجابة الصحيحة -
1200
The nurse is monitoring a client who has received antidysrhythmic therapy for the treatment of premature ventricular contractions (PVCs). Which observation in the PVCs would indicate to the nurse that this therapy is ineffective?
A Occur in pairs الإجابة الصحيحةB Unifocal in appearanceC Fewer than 6 per minuteD Fall after the end of the T wave -
1201
The nurse is reviewing the client's arterial blood gas results. Which finding would indicate that the client is experiencing respiratory acidosis?
A pH 7.5, Pco2 of 30B pH 7.3, Pco2 of 50 الإجابة الصحيحةC pH 7.3, HCO3 of 19D pH 7.5, HCO3 of 30 -
1202
The nurse is assigned to care for a client with pneumothorax who has a chest tube attached to closed chest drainage. Which assessment data would the nurse identify as an indicator that the client's lung has completely expanded?
A Pleuritic chest pain has resolved.B The oxygen saturation is greater than 92%.C Fluctuations in the water-seal chamber ceased. الإجابة الصحيحةD Suction in the chest drainage system is no longer needed. -
1203
The nurse evaluates the arterial blood gas (ABG) results of a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which Po2 finding would indicate that the oxygen level was adequate?
A 45 mm HgB 50 mm HgC 60 mm HgD 80 mm Hg Pulmonary Disease الإجابة الصحيحة -
1204
A client with hypertension has been taking lisinopril for 3 months. The client reports to the nurse a persistent dry cough that began about 1 month ago. The nurse interprets that the most likely reason for the client's complaint is what?
A Neutropenia as a result of therapyB An expected side effect of therapy الإجابة الصحيحةC Undiagnosed existence of heart failureD A concurrent upper respiratory infection Converting Enzyme (ACE) Inhibitors -
1205
A client diagnosed with active tuberculosis (TB) is to be admitted to a medical-surgical unit. Which action would the nurse take when planning a bed assignment?
A Place the client in a private, well-ventilated room. الإجابة الصحيحةB Plan to transfer the client to the intensive care unit.C Reserve the bed furthest away from the door in a double room.D Assign the client to share a double room with a noninfectious client. -
1206
A client develops an irregular heart rate. Which statement made by the client indicates to the nurse that the client is ready for learning?
A "I feel weak with an irregular pulse."B "What is it like to have a pacemaker?"C "All my medications will be changed now."D "How can this heart rate problem affect me?" الإجابة الصحيحة -
1207
A client diagnosed with valvular heart disease is at risk for developing heart failure. What would the nurse assess as the priority when monitoring for heart failure?
A Heart rateB Breath sounds الإجابة الصحيحةC Blood pressureD Activity tolerance -
1208
The nurse cares for a client receiving fludrocortisone acetate for the treatment of Addison's disease. When monitoring the client for improvement, what anticipated therapeutic effect of this medication would the nurse focus on?
A Promote electrolyte balance. الإجابة الصحيحةB Stimulate thyroid production.C Stimulate the immune response.D Stimulate thyrotropin production. -
1209
The nurse is assessing the leg pain of a client who has just undergone right femoral-popliteal artery bypass grafting. Which question would be most useful in determining whether the client is experiencing graft occlusion?
A "Can you describe what the pain feels like?"B "Can you rate the pain on a scale of 1 to 10?"C "Did you get any relief from the last dose of pain medication?"D "Can you compare this pain to the pain you felt before surgery?" الإجابة الصحيحة -
1210
A client has implemented dietary and other lifestyle changes to manage hypertension. The nurse determines that the client has been most successful when the client has which follow-up blood pressure reading?
A 164/90 mm HgB 156/89 mm HgC 140/94 mm HgD 128/84 mm Hg الإجابة الصحيحة -
1211
A client's medical record states a history of intermittent claudication. In collecting data about this symptom, the nurse would ask the client about which symptom?
A Chest pain that is dull and feels like heartburnB Leg pain that is sharp and occurs with exercise الإجابة الصحيحةC Chest pain that is sudden and occurs with exertionD Leg pain that is achy and gets worse as the day progresses -
1212
A client with heart failure is scheduled to have a serum digoxin level obtained. The nurse determines that the blood sample would be drawn at which time in relationship to the administration of digoxin?
A Just before a dose is given الإجابة الصحيحةB One hour after a dose is givenC Just after a dose has been givenD One-half hour after a dose is given -
1213
The nurse assesses the environmental safety of a client with chronic obstructive pulmonary disease receiving home oxygen therapy. Which observation by the nurse indicates that the client needs further teaching to ensure safety?
A Oxygen used 30 feet from a gas stoveB Oxygen tank stored in the tank holderC "No smoking" sign posted at the front doorD Oxygen concentrator propped against a wall Pulmonary Disease الإجابة الصحيحة -
1214
The nurse has finished suctioning the tracheostomy of a client. Which parameter would the nurse monitor to determine the effectiveness of the procedure?
A Breath sounds الإجابة الصحيحةB Capillary refillC Respiratory rateD Oxygen saturation level -
1215
The nurse has given the client with gastroesophageal reflux disease directions for the proper use of aluminum hydroxide tablets. The client indicates an understanding of the medication when which statement is made?
A "I should take the tablet at the same time as my other medications."B "I should swallow the tablet whole with a full glass of water."C "I should take each dose with a laxative to prevent constipation."D "I should chew the tablet thoroughly and then drink 4 ounces of water." Reflux Disease الإجابة الصحيحة -
1216
The nurse is assessing a client's chest drainage system at the beginning of the shift and notes continuous bubbling in the water-seal chamber. What would the nurse determine is the possible cause of the bubbling?
A The system is intact.B A pneumothorax is resolving.C The suction to the system is shut off.D There is an air leak somewhere in the system. الإجابة الصحيحة -
1217
A client is suspected of having a diagnosis of pulmonary tuberculosis. The nurse would assess the client for which signs/symptoms of tuberculosis?
A High fever and chest painB Increased appetite, dyspnea, and chillsC Weight gain, insomnia, and night sweatsD Low-grade fever, fatigue, and productive cough الإجابة الصحيحة -
1218
The nurse is preparing to implement emergency care measures for the client who has just demonstrated signs and symptoms of a pulmonary embolism. Which prescription would the nurse implement first?
A Apply oxygen. الإجابة الصحيحةB Administer morphine sulfate.C Start an intravenous (IV) line.D Obtain an electrocardiogram (ECG). -
1219
A client with a respiratory infection has been taking benzonatate as prescribed. The nurse would tell the client this medication performs which action?
A Increases comfort levelB Decreases anxiety levelC Calms the persistent cough الإجابة الصحيحةD Takes away nausea and vomiting Airway -
1220
The nurse is assessing a client suspected of having a rib fracture. Which typical signs/symptoms would the nurse observe for?
A Pain on expiration, deep rapid respirationsB Pain on inspiration, deep rapid respirationsC Pain on expiration, shallow guarded respirationsD Pain on inspiration, shallow guarded respirations الإجابة الصحيحة -
1221
A client is diagnosed with a flail chest. Which characteristics related to breathing would the nurse observe for in the client?
A Cyanosis and slow respirationsB Slight bradypnea with shallow breathsC Pallor and paradoxical chest movementD Severe dyspnea and paradoxical chest movement الإجابة الصحيحة -
1222
A client with the diagnosis of pneumonia experiences dyspnea when engaging activities. Which action would the nurse implement to help address client safety?
A Encourage deep, rapid breathing during activity.B Provide stimulation in the environment to maintain client alertness.C Observe vital signs and oxygen saturation periodically during activity. الإجابة الصحيحةD Schedule activities before giving respiratory medications or treatments. -
1223
The nurse provides discharge instructions to a client after implantation of a permanent pacemaker. The nurse would instruct the client to avoid exposure to which item?
A Hair dryersB Electric blanketsC Electric toothbrushesD Airport metal detectors الإجابة الصحيحة -
1224
A client experiencing low back pain asks the nurse which type of exercise will strengthen the lower back muscles. Which exercise would the nurse encourage the client to participate in to best strengthen the lower back muscles?
A TennisB DivingC CanoeingD Swimming الإجابة الصحيحة -
1225
The nurse has explained the reason that the primary health care provider has chosen laser surgery to treat a client's cervical cancer. Which statement by the client indicates an understanding of the explanation?
A "I want to be asleep during my procedure."B "I have too much cancer to be removed with surgery."C "I am young and the laser prevents cancer tissue from re- growing."D "My doctor is able to see all the edges of my cancer clearly." الإجابة الصحيحة -
1226
The nurse is monitoring a client diagnosed with hypercalcemia. Which assessment finding indicates a need for follow-up?
A Increased peristalsisB Decreased capillary refill الإجابة الصحيحةC Increased deep tendon reflexesD Decreased abdominal circumference -
1227
The nurse is monitoring the function of a client's chest tube that is attached to a chest drainage system. The nurse notes that the fluid in the water-seal chamber is below the 2-cm mark. What would the nurse determine based on this finding?
A There is a leak in the system.B Suction should be added to the system.C This is caused by client pneumothorax.D Water should be added to the chamber. الإجابة الصحيحة -
1228
A client has been prescribed transcutaneous electrical nerve stimulation (TENS) by the primary health care provider for the relief of chronic pain. Which statement by the client would indicate to the nurse a need for further teaching regarding this pain relief measure?
A "I understand that this will help relieve the pain."B "This unit will eliminate the need for taking so many pain medications."C "I am not real happy that I have to stay in the hospital for this treatment." الإجابة الصحيحةD "I am not sure that I am going to like those electrodes attached to my skin." -
1229
A client with acute myocardial infarction receives therapy with alteplase. Which finding indicates to the nurse that the client is experiencing a possible complication?
A Epistaxis الإجابة الصحيحةB VomitingC ECG changesD Absent pedal pulses -
1230
The nurse provides instructions to a client who is taking allopurinol for the treatment of gout. Which statement by the client indicates an understanding of the medication?
A "I should put ice on my lips if they swell."B "I need to take the medication 2 hours after I eat."C "I need to drink at least 8 glasses of liquids every day." الإجابة الصحيحةD "I can use an antihistamine lotion if I get a rash that is itchy." -
1231
The school nurse planning to give a class on testicular self- examination (TSE) at a local high school would include which instruction to the participants?
A Perform the self-examination every other month.B Perform the self-examination after a cold shower.C Expect the self-examination to be slightly painful.D Roll the testicle between the thumb and forefinger. الإجابة الصحيحة -
1232
A client has a history of fibrocystic disorder of the breasts. The nurse determines that the client understands the nature of the disorder when the client states that symptoms are most likely to occur at which time?
A After mensesB Before menses الإجابة الصحيحةC In the spring monthsD In the winter months -
1233
A client is preparing for discharge after a radical vulvectomy. The nurse determines that the client has the best understanding of the measures to prevent complications when the client expresses plans to engage in which activity after discharge?
A Walk الإجابة الصحيحةB HouseworkC Drive a carD Spend most of the day sitting -
1234
The nurse monitors a client diagnosed with silicosis for emotional reactions related to the chronic respiratory disease. Which emotional reaction, when expressed by the client, indicates a need for immediate intervention?
A AnxietyB DepressionC Suicidal ideation الإجابة الصحيحةD Ineffective coping Pulmonary Disease -
1235
A client returning from the postanesthesia care unit after transurethral resection of the prostate (TURP) has bladder irrigation running via a three-way Foley catheter. The nurse would notify the primary health care provider if which color of urine is noted in the urinary drainage bag?
A Pale pinkB Bright red الإجابة الصحيحةC Dark pinkD Tea-colored -
1236
The client prescribed phenelzine sulfate suddenly exhibits signs of hypertensive crisis. Which medication would the nurse plan to prepare?
A PhytonadioneB Phentolamine الإجابة الصحيحةC Protamine sulfateD Calcium gluconate Oxidase Inhibitors (MAOIs) -
1237
The nurse is caring for a 25-year-old client who will undergo bilateral orchiectomy for testicular cancer. Considering the nature of the illness, the nurse would make it a priority to explore which potential psychological concern with this client?
A Postoperative painB Postoperative swellingC Loss of reproductive ability الإجابة الصحيحةD Length of recuperative period -
1238
The nurse is conducting a prostate screening clinic. Which sign of prostatism would the nurse question each client about?
A Absence of postvoid dribblingB Ability to stop voiding quicklyC Excessive force in urinary streamD Hesitancy when initiating urinary stream الإجابة الصحيحة -
1239
A client has a history of syphilis infection. The nurse interprets that the client has been re-infected when which characteristic is noted on assessment of a penile lesion?
A Papular areas and erythemaB Cauliflower-like appearanceC Induration and client reporting absent pain الإجابة الصحيحةD Multiple vesicles, with some that have ruptured Problems -
1240
An adult client has been placed on a fluid restriction of 1200 mL/day. The nurse discusses the fluid restriction with the dietitian and then plans to allow the client to have how many milliliters of fluid from 7:00 am to 3:00 pm?
A 400 mLB 600 mL الإجابة الصحيحةC 800 mLD 1000 mL and Chronic Kidney Disease -
1241
A client diagnosed with chronic kidney disease (CKD) has learned about managing diet and fluid restriction between dialysis treatments. The nurse determines that the client is compliant with the therapeutic regimen when the assessment demonstrates a weight gain of no more than how many kilograms between hemodialysis treatments?
A 0.5 to 0.9 kgB 1 to 1.5 kg الإجابة الصحيحةC 2 to 4 kgD 5 to 6 kg and Chronic Kidney Disease -
1242
A client was admitted to the surgical unit after right total knee arthroscopy performed 2 hours earlier. Which surgeon's prescription requires clarification?
A Maintain right knee in a slightly flexed position. الإجابة الصحيحةB Implement patient-controlled analgesia (PCA) per protocol.C Place sequential compression devices on both legs while on bed rest.D Notify physical therapy to begin isometric quadriceps exercises on the day following surgery. Injury -
1243
A client is being discharged from the hospital after removal of chest tubes that were inserted following thoracic surgery. When providing home care instructions to the client, which client statement indicates a need for further teaching?
A "I need to avoid heavy lifting for the first 4 to 6 weeks."B "I need to take my temperature to detect a possible infection."C "I need to remove the chest tube site dressing as soon as I get home." الإجابة الصحيحةD "I need to report any difficulty with breathing to the surgeon." -
1244
The nurse is administering epoetin alfa to a client diagnosed with chronic kidney disease (CKD). For which adverse effect of this therapy would the nurse monitor the client for?
A AnemiaB Hypertension الإجابة الصحيحةC Iron intoxicationD Bleeding tendencies Hematopoietic Agents and Chronic Kidney Disease -
1245
A client is prescribed lansoprazole for the management of gastroesophageal reflux disease (GERD). The nurse determines that the client best understands this disorder and the medication regimen when the client reports taking which product for pain?
A NaprosynB IbuprofenC Acetaminophen الإجابة الصحيحةD Acetylsalicylic acid Reflux Disease (GERD) -
1246
The client scheduled for a transurethral resection prostatectomy (TURP) asks the nurse to explain how the prostate is going to be removed. The nurse would tell the client that the prostate will be removed through which pathway?
A The urethra الإجابة الصحيحةB A lower abdominal incisionC An upper abdominal incisionD An incision made in the perineal area -
1247
The nurse would tell a client who is scheduled for a bone marrow biopsy that the specimen can be withdrawn from which site?
A RibsB FemurC ScapulaD Sternum الإجابة الصحيحة -
1248
A client is admitted to the hospital with a diagnosis of infiltrating ductal carcinoma of the breast. Which expected manifestation would the nurse assess the client for?
A Bilateral palpable massesB Pain in the breast and edemaC A fixed, irregularly shaped mass الإجابة الصحيحةD A round-shaped mass that is moveable -
1249
The nurse performs an assessment on a client with cancer and notes that the client is receiving pain medication via this type of catheter. (Refer to the figure.) What would the nurse document that the client has?
A Epidural catheter الإجابة الصحيحةB Hickman catheterC Central venous catheter (CVC)D Patient-controlled analgesia (PCA) pump -
1250
A client has had a left mastectomy with axillary lymph node dissection. The nurse determines that the client understands postoperative restrictions and arm care when the client states the intention to engage in which activity?
A Using gloves when working in the garden الإجابة الصحيحةB Using a straight razor to shave under the armsC Carrying a handbag and heavy objects on the left armD Allowing blood pressures to be taken only on the left arm -
1251
The nurse is teaching a client about the modifiable risk factors that can reduce the risk for colorectal cancer. The nurse places priority on discussing which risk factor with this client?
A Age older than 30 yearsB High-fat and low-fiber diet الإجابة الصحيحةC Distant relative with colorectal cancerD Personal history of ulcerative colitis or gastrointestinal polyps -
1252
A client with gastroesophageal reflux disease (GERD) reports chest discomfort that feels like heartburn, especially following each meal. After teaching the client to take antacids as prescribed, the nurse suggests that the client lie in which position during sleep?
A Prone with the head of the bed flatB Supine with the head of the bed flatC On the left side with the head of the bed flatD With the head of the bed elevated 8 to 12 inches Reflux Disease الإجابة الصحيحة -
1253
The nurse is preparing to care for a client who has undergone esophagogastroduodenoscopy (EGD). After checking the vital signs, what would be the nurse's next priority?
A Monitor for sharp epigastric pain.B Give warm gargles for sore throat.C Check for a return of the gag reflex. الإجابة الصحيحةD Monitor for complaints of heartburn. -
1254
A client has been scheduled for a barium swallow (esophagography) to rule out esophageal stricture. The nurse determines that the client understands preprocedure instructions when the client states the intention to take which action before the test?
A Take all oral medications as scheduled.B Eat a regular breakfast on the day of the test.C Monitor own bowel movement pattern for constipation.D Remove metal objects and jewelry, especially from the neck and chest area. الإجابة الصحيحة -
1255
A client being discharged from the hospital with a diagnosis of gastric ulcer has a prescription for sucralfate 1 gram by mouth four times daily. The nurse determines that the client understands proper use of the medication when the client states the intention to take the medication at which time?
A With meals and at bedtimeB Every 6 hours around the clockC One hour after meals and at bedtimeD One hour before meals and at bedtime الإجابة الصحيحة -
1256
The nurse is assisting a primary health care provider with abdominal paracentesis on a client with cirrhosis and ascites. What position would the nurse assist the client into for this procedure?
A ProneB SupineC High-Fowler's الإجابة الصحيحةD Low Fowler's on the right side -
1257
A client was admitted to the hospital with a diagnosis of frequent symptomatic premature ventricular contractions (PVCs). After sitting up in a chair for a few minutes, the client reports feeling lightheaded. Which finding would the nurse anticipate on auscultation of the heartbeat?
A A regular apical pulseB An irregular apical pulse الإجابة الصحيحةC A very slow regular apical pulseD A very rapid regular apical pulse -
1258
A client with a history of duodenal ulcer is taking calcium carbonate chewable tablets. The nurse monitors the client for relief of which symptom?
A FlatusB Heartburn الإجابة الصحيحةC Rectal painD Muscle twitching -
1259
A client with the diagnosis of Bell's palsy is distressed about the change in facial appearance. Which characteristic of Bell's palsy would the nurse tell the client about to help the client cope with the disorder?
A It usually resolves when treated with vasodilator medications.B It is similar to stroke, but all symptoms will go away eventually.C It is not caused by stroke, and many clients recover in 3 to 5 weeks. الإجابة الصحيحةD The symptoms will completely go away once the tumor is removed. -
1260
A client has been given a prescription for propantheline as adjunctive treatment for peptic ulcer disease. How would the nurse tell the client to take this medication?
A With mealsB With antacidsC Just after mealsD Thirty minutes before meals الإجابة الصحيحة -
1261
Carbamazepine is prescribed for the management of generalized tonic-clonic seizures. The nurse instructs the client to inform the primary health care provider if which sign/symptom occurs?
A NauseaB DizzinessC Sore throat الإجابة الصحيحةD Drowsiness -
1262
A medication nurse is supervising a newly hired nurse who is administering pyridostigmine orally to a client diagnosed with myasthenia gravis. Which instruction provided to the client indicates safe practice by the newly hired nurse regarding the administration of this medication?
A Take the medication with sips of water. الإجابة الصحيحةB Lie on the right side after taking the medication.C Hyperextend the neck for 30 seconds before swallowing.D Void within at least 10 minutes before taking the medication. -
1263
A client diagnosed with chronic obstructive pulmonary disease (COPD) is on home oxygen at 2 L/min. The nurse assesses the client's respiratory rate at 22 breaths/min. When the client reports an increase in the dyspnea, what would the nurse do initially?
A Determine the need to increase the oxygen.B Call emergency services to come to the home.C Reassure the client that there is no need to worry.D Collect more information about the client's respiratory status. Pulmonary Disease الإجابة الصحيحة -
1264
A postmastectomy client has been found to have an estrogen receptor–positive tumor. The nurse interprets after reading this information in the pathology report that the client will most likely have which common follow-up treatment prescribed?
A Removal of the ovariesB Administration of estrogenC Administration of tamoxifen الإجابة الصحيحةD Administration of progesterone Modulators -
1265
The nurse reviews the client's health care record and notes that the client is taking donepezil hydrochloride. Understanding the purpose of this medication, the nurse suspects this client has which health problem?
A Dementia الإجابة الصحيحةB Seizure disorderC History of schizophreniaD Obsessive-compulsive disorder Alzheimer's Disease -
1266
The nurse reviewing a urinalysis report for a client with the diagnosis of acute kidney injury notes that the results are highly positive for proteinuria. The nurse determines that this client has which type of renal failure?
A Prerenal failureB Postrenal failureC Intrinsic renal failure الإجابة الصحيحةD Atypical renal failure and Chronic Kidney Disease -
1267
A client has a positive sputum culture for Mycobacterium tuberculosis and is prescribed streptomycin as part of the treatment. The nurse determines that the client is experiencing a toxic effect of the medication when which test result is abnormal?
A Vision testingB Hepatic enzymesC Hemoglobin and hematocritD Blood urea nitrogen (BUN) and creatinine الإجابة الصحيحة -
1268
A client diagnosed with multiple sclerosis is prescribed baclofen. Which assessment finding would indicate to the nurse that the client is experiencing a therapeutic response from the medication?
A Decreased nauseaB Decreased muscle spasms الإجابة الصحيحةC Increased muscle tone and strengthD Increased range of motion of all extremities -
1269
The nurse caring for a client immediately following transurethral resection of the prostate (TURP) notices that the client has suddenly become confused and disoriented. The nurse determines that this may be a result of which potential complication of this surgical procedure?
A Hyponatremia الإجابة الصحيحةB HypernatremiaC HypochloremiaD Hyperchloremia -
1270
A client with schizophrenia is prescribed risperidone. Which laboratory study would the nurse anticipate to be prescribed before the initiation of this medication therapy?
A Platelet countB Blood clotting testsC Liver function studies الإجابة الصحيحةD Complete blood count Antidepressants -
1271
The nurse is evaluating a weight-reduction plan designed for an obese client. Which statement by the client indicates the need for further teaching?
A "It is so difficult to find food exchanges that taste good and fill me up."B "This diet doesn't let me go out for lunch with my friends at work anymore." الإجابة الصحيحةC "I wish my mother could have seen me lose the 60 pounds in the last 9 months."D "My wife was kidding me the other night about my being a whole new husband." Nutrition/Malabsorption Problems -
1272
A client with the diagnosis of chronic kidney disease (CKD) has received dietary counseling about potassium restriction in the diet. The nurse determines that the client has learned the information correctly when the client states that he or she will do what when preparing vegetables?
A Eat only fresh vegetables.B Boil them and discard the water. الإجابة الصحيحةC Use only salt substitutes to season.D Buy frozen vegetables whenever possible. and Chronic Kidney Disease -
1273
A client diagnosed with chronic kidney disease has been prescribed epoetin alfa. The nurse reminds the client about the importance of taking which prescribed medication to enhance the effects of this therapy?
A Ferrous gluconate الإجابة الصحيحةB Calcium carbonateC Aluminum carbonateD Aluminum hydroxide gel Hematopoietic Agents and Chronic Kidney Disease -
1274
The nurse cares for a client who is pale and frequently reports fatigue, weakness, and dizziness. Which serum laboratory test result is the nurse's priority for planning care?
A Hematocrit 43% (0.43)B Sodium 130 mEq/L (130 mmol/L)C Potassium 4.8 mEq/L (4.8 mmol/L)D Hemoglobin of 7 g/dL (70 g/L) الإجابة الصحيحة -
1275
The nurse is assessing a client with a diagnosis of polycythemia vera. Which clinical manifestation would the nurse expect to note in this client?
A PallorB Hypertension الإجابة الصحيحةC A low hematocrit levelD Pale mucous membranes -
1276
A client with the diagnosis of leukemia is receiving chemotherapy. When the registered nurse (RN) notes that the white blood cell (WBC) count is 4000 mm3 (4 x 109/L), the new nurse caring for the client is informed about the results. Which intervention identified by the new nurse indicates a need for further teaching?
A Restricting visitors with colds or respiratory infectionsB Removing all live plants, flowers, and stuffed animals in the client's roomC Placing the client on a low-bacteria diet that excludes raw foods and vegetablesD Padding the side rails and removing all hazardous and sharp objects from the room الإجابة الصحيحة -
1277
The nurse is delivering care to a client who is diagnosed with toxic shock syndrome (TSS). Which complication of this syndrome would the nurse monitor the client for?
A Pulmonary embolismB Vitamin K deficiencyC Factor VIII deficiencyD Hypotension الإجابة الصحيحة -
1278
The nurse caring for a client with an acute head injury would carefully assess which function as the primary indicator of neurological status?
A Vital signsB Motor functionC Sensory functionD Level of consciousness الإجابة الصحيحة -
1279
A client is admitted to the hospital with the diagnosis of Cushing's disease. The nurse would monitor the client's laboratory studies for which associated finding?
A HypokalemiaB Hyperglycemia الإجابة الصحيحةC Decreased plasma cortisol levelsD Low white blood cell (WBC) count -
1280
Which sign/symptom is an indication that the client experiencing postoperative blood loss is anemic?
A Fatigue الإجابة الصحيحةB BradypneaC BradycardiaD Muscle cramps -
1281
The nurse observes a client during a seizure and notes that the client's entire body became rigid, and the muscles in all four extremities alternated between relaxation and contraction. Which type of seizure would the nurse document that the client had experienced?
A Partial seizureB Absence seizureC Tonic-clonic seizure الإجابة الصحيحةD Complex partial seizure -
1282
The nurse is reviewing the care plan of a client diagnosed with having the deficits associated with a right-sided stroke. The nurse notes documentation that the client has unilateral neglect with left- sided deficits. The nurse plans care with the understanding that which action would be least helpful?
A Place bedside articles on the left side.B Approach the client from the right side. الإجابة الصحيحةC Teach the client to scan the environment.D Move the commode and chair to the left side. -
1283
The nurse is evaluating the status of a client with the diagnosis of myasthenia gravis. The nurse interprets that the client's medication regimen may not be optimal if the client continues to experience fatigue occurring at which time?
A Early in the morning and before lunchB Before meals and at the end of the dayC Early in the morning and late in the dayD Following exertion and at the end of the day الإجابة الصحيحة -
1284
A client is diagnosed with pernicious anemia. The nurse reviews the client's health history for disorders involving which organ responsible for vitamin B12 absorption?
A LiverB Ileum الإجابة الصحيحةC KidneyD Hepatobiliary -
1285
A client had a positive Papanicolaou smear and underwent cryosurgery with laser therapy. What information would the nurse provide the client as a part of discharge teaching?
A Pain can be relieved with opioid analgesics.B Sitz baths are soothing to the irritated tissues.C Vaginal discharge should be clear and watery. الإجابة الصحيحةD There should be absolutely no odor or vaginal discharge. -
1286
The nurse is planning preoperative teaching with a client scheduled for a transurethral resection of the prostate (TURP). Which most frequent cause of postoperative pain should the nurse plan to include in the discussion?
A Bladder spasms الإجابة الصحيحةB Bleeding within the bladderC Tension on the Foley catheterD The lower abdominal incision -
1287
A client with a diagnosis of gastroesophageal reflux disease (GERD) has just received a breakfast tray. The nurse notices that which is the only food that will increase the lower esophageal sphincter (LES) pressure and thus lessen the client's symptoms?
A CoffeeB Nonfat milk الإجابة الصحيحةC Fresh scrambled eggsD Whole wheat toast with butter Reflux Disease -
1288
The nurse is reviewing the serum laboratory test results for a client with a diagnosis of sickle cell anemia. Which parameter would the nurse anticipate will be elevated?
A SodiumB Hemoglobin-S الإجابة الصحيحةC Hemoglobin A1cD Prothrombin time -
1289
A client is being discharged after undergoing a transurethral resection of the prostate (TURP). The nurse teaches the client to expect which variation in normal urine color for several days after the procedure?
A Dark redB Pink-tinged الإجابة الصحيحةC Clear yellowD Cloudy amber -
1290
A client is admitted to the hospital in sickle cell crisis. For which clinical indicator would the nurse monitor the client?
A Pain الإجابة الصحيحةB DiarrheaC BradycardiaD Blurred vision -
1291
When quinidine gluconate is prescribed for a client the nurse reviews the client's medical record. Which condition is a contraindication in the use of this medication?
A AsthmaB InfectionC Muscle weaknessD Complete atrioventricular (AV) block الإجابة الصحيحة -
1292
The nurse would question which medication if prescribed for a client diagnosed with an inoperable ruptured intracranial aneurysm?
A NicardipineB Heparin sodium الإجابة الصحيحةC Docusate sodiumD Aminocaproic acid -
1293
A client who has a history of chronic ulcerative colitis is diagnosed with anemia. The nurse interprets that which factor is most likely responsible for the anemia?
A Blood loss الإجابة الصحيحةB Intestinal hookwormC Intestinal malabsorptionD Decreased intake of dietary iron Disease -
1294
A client has been given a prescription to begin using nitroglycerin transdermal patches. The nurse instructs the client about this medication administration system and tells the client to expect which side effect?
A SweatingB Headache الإجابة الصحيحةC Dry mouthD Constipation -
1295
The nurse is visiting a client who has been prescribed topical clotrimazole. The nurse would educate the client to the fact that this medication will alleviate which condition?
A PainB Rash الإجابة الصحيحةC FeverD Sneezing -
1296
The nurse is providing care to the diagnosed with stroke who has received medication therapy with tissue plasminogen activator. Which item would the nurse have available for use as part of standard nursing care for this client?
A FlashlightB Pulse oximeterC Suction equipmentD Occult blood test strips الإجابة الصحيحة -
1297
A client newly diagnosed with angina pectoris has taken two sublingual nitroglycerin tablets for chest pain. The chest pain is relieved, but the client now reports a headache. The nurse interprets that this most likely represents which response?
A An early sign of medication toleranceB An allergic reaction to the nitroglycerinC An expected side effect of the medication الإجابة الصحيحةD A warning that the medication should not be used again -
1298
The nurse is evaluating a diabetic client's understanding of the signs of hyperglycemia. Which statement by the client reflects an understanding?
A "I may become diaphoretic and faint."B "I may notice signs of fatigue, dry skin, and increased urination." الإجابة الصحيحةC "I need to take an extra diabetic pill if my blood glucose is greater than 300."D "I should restrict my fluid intake if my blood glucose is greater than 250." -
1299
A client prescribed albuterol sulfate by inhalation cannot cough up secretions. The nurse would teach the client which action to best help clear the bronchial secretions?
A Get more exercise each day.B Use a dehumidifier in the home.C Administer an extra dose before bedtime.D Increase the amount of fluids consumed every day. الإجابة الصحيحة -
1300
The nurse reviews the serum laboratory results for a client prescribed hydrochlorothiazide. Which most frequent side effect of this medication should the nurse specifically monitor for?
A Hypokalemia الإجابة الصحيحةB HypocalcemiaC HypernatremiaD Hyperphosphatemia -
1301
The nurse has administered a dose of diazepam to the client with a skeletal injury experiencing muscle spasms. Which most important action should the nurse take before leaving the client's room?
A Draw the shades closed.B Provide the client access to a bedpan.C Turn the volume on the television down.D Instruct the client not to get out of bed without assistance. Sedative-Hypnotics الإجابة الصحيحة -
1302
The nurse provides home care instructions to a client who is taking lithium carbonate. Which statement by the client indicates a need for further teaching?
A "I need to take the lithium with meals."B "My blood levels must be monitored very closely."C "I need to decrease my salt and fluid intake while taking the lithium." الإجابة الصحيحةD "I need to withhold the medication if I have excessive diarrhea or vomiting." -
1303
A client who is brought to the emergency department has experienced a burn covering greater than 25% of his total body surface area (TBSA). When reviewing the laboratory results drawn on the client, which value would the nurse most likely expect to note?
A Hematocrit 65% (0.65) الإجابة الصحيحةB Albumin 4.0 g/dL (40 g/L)C Sodium 140 mEq/L (140 mmol/L)D White blood cell (WBC) count 6000 mm3 (6 x 109/L) -
1304
The nurse is caring for a client with a diagnosis of Parkinson's disease who is taking benztropine mesylate daily. When assessing the client, what would the nurse specifically monitor for to determine if the client is experiencing a side effect of this medication?
A Pupil responseB Prothrombin timeC Skin temperatureD Intake and output الإجابة الصحيحة -
1305
A client has received electroconvulsive therapy (ECT). What intervention would the nurse perform first in the posttreatment area and upon the client's awakening?
A Assist the client from the stretcher to a wheelchair.B Orient the client and monitor his or her vital signs. الإجابة الصحيحةC Assess for a gag reflex so that the client can eat and drink with safety.D Offer the client frequent reassurance and repeat orientation statements. -
1306
A client with a diagnosis of acquired immunodeficiency syndrome and cytomegalovirus retinitis is receiving ganciclovir. Which action would the nurse plan to take while the client is taking this medication?
A Monitor blood glucose levels for elevation.B Administer the medication on an empty stomach only.C Apply pressure to venipuncture sites for at least 2 minutes.D Provide the client with a soft toothbrush and an electric razor. الإجابة الصحيحة -
1307
A client being discharged from the hospital with a prescription for quinidine to control ventricular ectopy is provided medication instructions by the nurse. Which statement by the client would indicate the need for further teaching?
A "The best time to schedule this medication is with my meals."B "I need to take this medication regularly, even if my heart feels strong."C "I should avoid alcohol, caffeine, and cigarettes while on this medication."D "If I get diarrhea, nausea, or vomiting, I need to stop the medication immediately." الإجابة الصحيحة -
1308
A client experiencing a mild panic attack has the following arterial blood gas (ABG) results: pH 7.49, Pco2 31 mm Hg, Pao2 97 mm Hg, HCO3 22 mEq/L. The nurse reviews the results and determines that the client has which acid-base disturbance?
A Metabolic acidosisB Metabolic alkalosisC Respiratory acidosisD Respiratory alkalosis الإجابة الصحيحة -
1309
A client with a diagnosis of diabetes insipidus asks the nurse about the purpose of the vasopressin she has been prescribed. The nurse responds, knowing that this medication promotes which action?
A VasodilationB Decrease in peristalsisC Decrease in urinary output الإجابة الصحيحةD Inhibit smooth muscle contraction -
1310
A client previously well controlled with glyburide has recently begun reporting fasting blood glucose to be 180 to 200 mg/dL (10.28 to 11.42 mmol/L). Which medication, noted in the client's record, may be contributing to the elevated blood glucose level?
A Prednisone الإجابة الصحيحةB RanitidineC CimetidineD Ciprofloxacin hydrochloride -
1311
Buspirone hydrochloride is prescribed for a client diagnosed with an anxiety disorder. The nurse providing instructions would inform the client about which characteristic of this medication?
A There is risk of addiction.B Dizziness and nausea may occur. الإجابة الصحيحةC Tolerance can occur with the medication.D The medication can produce a sedating effect. Antianxiety/Anxiolytics -
1312
The nurse is teaching a client who is taking cyclosporine after renal transplant about medication information. The nurse would tell the client to be especially alert for which problem?
A Hair lossB Weight lossC HypotensionD Signs of infection الإجابة الصحيحة -
1313
Neuroleptic malignant syndrome is suspected in a client with schizophrenia who is prescribed an atypical antipsychotic medication. Which medication would the nurse prepare in anticipation of being prescribed to treat this adverse effect related to the use of this medication?
A Bromocriptine الإجابة الصحيحةB Protamine sulfateC Enalapril maleateD Phytonadione (vitamin K) -
1314
A client who sustained a fractured leg has learned how to use crutches. The nurse would determine that the client has a need for further teaching if the client makes which statement about using crutches?
A "I will keep spare crutch tips available."B "I will keep crutch tips dry so they don't slip."C "I will inspect the crutch tips for wear from time to time."D "I will keep the set of crutches my son used as a spare pair." الإجابة الصحيحة -
1315
The nurse collecting data from the client is providing instructions regarding a new prescription for disulfiram. Which datum is important for the nurse to obtain before beginning the administration of this medication?
A When the last full meal was consumedB When the last alcoholic drink was consumed الإجابة الصحيحةC If the client has a history of hyperthyroidismD If the client has a history of diabetes insipidus -
1316
A client with a diagnosis of nephrotic syndrome states to the nurse, "Why should I even bother trying to control my diet and the swelling? It doesn't really matter what I do if I can never get rid of this kidney problem anyway!" Which potential client problem would the nurse address based on the client's statement?
A AnxietyB Difficulty copingC Feeling powerless الإجابة الصحيحةD Negative body image Inflammation/Infection/Trauma -
1317
When a daily dose of fluoxetine hydrochloride is prescribed for a client with depression, the nurse provides instructions regarding its administration. Which statement by the client indicates an understanding regarding the administration of the medication?
A "I should take the medication with food only."B "It is best to take the medication in the morning." الإجابة الصحيحةC "I should take the medication at bedtime with a snack."D "I should take the medication at noontime with an antacid." Reuptake Inhibitors (SSRIs) -
1318
A client with a diagnosis of Tourette's syndrome is receiving haloperidol decanoate. The nurse prepares to administer this medication understanding that this medication has which action?
A Is a serotonin reuptake blockerB Inhibits the breakdown of released acetylcholineC Blocks the uptake of norepinephrine and serotoninD Blocks the binding of dopamine to the postsynaptic dopamine receptors in the brain الإجابة الصحيحة -
1319
A client has undergone a mastectomy. The nurse determines that the client is having the most difficulty adjusting to the loss of the breast when which behavior is observed?
A Refuses to look at the dressing الإجابة الصحيحةB Requires help with sponge bathingC Asks that the nurse limit visitors to only familyD Dresses in a loose nightgown the client brought from home -
1320
A client has been prescribed lansoprazole for 4 weeks. The nurse should monitor the client for relief from which problem?
A DiarrheaB Heartburn الإجابة الصحيحةC FlatulenceD Constipation Receptor Antagonists -
1321
A client who had a total knee replacement with a metal prosthesis is being prepared for discharge to home. Which statement by the client indicates to the nurse a need for further teaching?
A "I can expect that changes in the shape of the knee will occur." الإجابة الصحيحةB "I need to tell any future caregivers about the metal prosthesis."C "I need to report bleeding gums or tarry stools to the primary health care provider."D "I need to report fever, redness, or increased pain to the primary health care provider." -
1322
The nurse is providing medication instructions to a client who is prescribed imipramine daily. Which statement by the client indicates a need for further teaching?
A "I need to avoid alcohol while taking the medication."B "I need to take the medication in the morning before breakfast." الإجابة الصحيحةC "The effects of the medication may not be noticed for at least 2 weeks."D "A missed dose should be taken as soon as possible unless it is almost time for the next dose." Antidepressants -
1323
The nurse is preparing to assess a client admitted with a diagnosis of trigeminal neuralgia (tic douloureux). On review of the client's record, which symptom would the nurse expect the client is experiencing?
A Bilateral pain in the area of the sixth cranial nerveB Unilateral pain in the area of the sixth cranial nerveC Abrupt onset of pain in the area of the fifth cranial nerve الإجابة الصحيحةD Chronic, intermittent pain in the area of the seventh cranial nerve -
1324
The nurse would instruct the client prescribed docusate to monitor for which intended effect of the medication?
A Abdominal painB Decreased heartburnC Decrease in fatty stoolsD Regular bowel movements الإجابة الصحيحة -
1325
A client's laboratory test results reveal a decrease in both serum transferrin and total iron-binding capacity (TIBC). Which disorder is the most likely cause of the client's anemia?
A InfectionB Malnutrition الإجابة الصحيحةC Iron deficiencyD Sickle cell disease Nutrition/malabsorption problems -
1326
Which type of anemia is diagnosed with a Schilling test?
A AplasticB Pernicious الإجابة الصحيحةC MegaloblasticD Iron deficiency Nutrition/malabsorption problems -
1327
A primary health care provider has written a prescription for a client diagnosed with diabetic gastroparesis to receive metoclopramide four times a day. The nurse schedules this medication to be given at which times?
A With each meal and at bedtimeB One hour after each meal and at bedtimeC Thirty minutes before meals and at bedtime الإجابة الصحيحةD Every 6 hours spaced evenly around the clock Nutrition/Malabsorption Problems -
1328
The nurse is caring for a client who has just had a mastectomy. Which exercise would the nurse assist the client in doing during the first 24 hours after surgery?
A Hand wall climbingB Pendulum arm swingsC Elbow flexion and extension الإجابة الصحيحةD Shoulder abduction and external rotation -
1329
The nurse teaches a client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure for cholecystitis. The nurse determines that the client has a need for further teaching if the client makes which statement?
A "An anesthetic throat spray will be used."B "A signed informed consent is necessary."C "Medication will be given orally for sedation." الإجابة الصحيحةD "It is important to lie still during the procedure." -
1330
A client has a prescription to take magnesium citrate to prevent constipation after upper and lower gastrointestinal (GI) barium studies. The nurse tells the client that which is the best way to take this medication?
A With fruit juice onlyB At room temperatureC With a tepid glass of waterD Chilled with a full glass of water الإجابة الصحيحة -
1331
A client has begun medication therapy with pancrelipase. The nurse would educate the client to expect which occurrence from this medication?
A Relieve of heartburnB Eliminate of abdominal painC Help regulating blood glucoseD Decrease in the amount of fat in the stools الإجابة الصحيحة -
1332
A client reports gas pains after surgery and requests medication. The nurse reviews the medication prescription sheet to see if which medication is prescribed for the relief of gas pains?
A DroperidolB Simethicone الإجابة الصحيحةC AcetaminophenD Magnesium hydroxide -
1333
The home care nurse notes that an older client is prescribed cimetidine. On assessment of the client, the nurse would check for which side effect of this medication?
A FatigueB Confusion الإجابة الصحيحةC ConstipationD Blurred vision Receptor Antagonists Reflux Disease -
1334
A client is admitted to the hospital after sustaining a fall from a roof. The client has multiple lacerations and a right leg fracture, which has been treated with a plaster cast. How would the nurse position the client's leg to promote optimal circulation?
A Flat or a level positionB Flat for 3 hours and elevated for 1 hourC Elevated for 3 hours, and then flat for 1 hourD Elevated on pillows continuously for 24 to 48 hours الإجابة الصحيحة -
1335
A physical assessment is performed on a suicidal client upon admission to the inpatient unit. The nurse understands its importance because it provides information regarding which priority assessment data?
A The presence of abnormalitiesB Evidence of physical self-harm الإجابة الصحيحةC Both subjective and objective baseline dataD Existing medical problems and complaints -
1336
A client being mechanically ventilated after experiencing an embolus is visibly anxious. Which action would the nurse take?
A Remain with the client and provide reassurance. الإجابة الصحيحةB Ask a family member to stay with the client at all times.C Encourage the client to sleep until arterial blood gas results improve.D Ask the primary health care provider to write a prescription for an antianxiety medication. -
1337
The nurse understands that the client is responding favorably to a prescription for colchicine when there is a decrease in which sign/symptom?
A HeadachesB Joint inflammation الإجابة الصحيحةC Blood glucose levelD Serum triglyceride level -
1338
A client has a prescription to begin short-term therapy with enoxaparin. The nurse explains to the client that this medication is being prescribed for which action?
A Dissolve urinary calculiB Relieve migraine headachesC Stop progression of multiple sclerosisD Reduce the risk of deep vein thrombosis الإجابة الصحيحة -
1339
A client takes aluminum hydroxide tablets as needed for heartburn. The nurse teaches the client that which is the most common side effect of this medication?
A DizzinessB ExcitabilityC Muscle painD Constipation Reflux Disease الإجابة الصحيحة -
1340
The nurse is caring for a young adult client diagnosed with sarcoidosis. The client is angry and tells the nurse that there is no point in learning disease management because there is no possibility of ever being cured. Based on the client's statement, the nurse determines that the client is experiencing which potential problem?
A ApprehensionB Powerlessness الإجابة الصحيحةC IntellectualizationD Ineffective thought process -
1341
The nurse is caring for a client taking memantine. Which data would the nurse monitor for this client?
A Liver function studiesB Complete blood countC Renal function studies الإجابة الصحيحةD Pulmonary function studies Alzheimer's Disease -
1342
An older client has been prescribed casanthranol on a long-term basis to treat constipation. The nurse determines that which laboratory finding is a result of the side/adverse effects of this medication?
A Sodium 135 mEq/L (135 mmol/L)B Sodium 145 mEq/L (145 mmol/L)C Potassium 3.1 mEq/L (3.1 mmol/L) الإجابة الصحيحةD Potassium 5.0 mEq/L (5.0 mmol/L) -
1343
A client has been prescribed cyclobenzaprine for the management of muscle spasms. The nurse would observe the client for which most frequent side effect?
A FatigueB IrritabilityC ExcitabilityD Drowsiness Injury الإجابة الصحيحة -
1344
The nurse caring for a client after shoulder arthroplasty for rheumatoid arthritis monitors the client for brachial plexus compromise. To assess the status of the median nerve, which action would the nurse perform?
A Have the client spread all of the fingers wide and resist pressure.B Monitor for flexion of the biceps by having the client raise the forearm.C Have the client move the thumb toward the palm and back to the neutral position.D While grasping the nurse's hand, note the strength of the client's first and second fingers. and Osteoarthritis الإجابة الصحيحة -
1345
The nurse is preparing to provide preoperative teaching with a client scheduled for neck dissection. Which topic would the nurse initially focus on?
A The client's usual coping behaviorsB The client's dependable support systemsC Postoperative communication techniquesD The information already supplied by the surgeon الإجابة الصحيحة -
1346
A client diagnosed with refractory myasthenia gravis is told by the primary health care provider that plasmapheresis therapy is indicated. When the client asks the nurse to repeat the primary health care provider's reason for prescribing this treatment, the nurse would tell the client that this therapy will most likely improve which problem?
A Double visionB Difficulty breathing الإجابة الصحيحةC Urinary incontinenceD Prickling sensation in the legs -
1347
A client is admitted to the hospital in myasthenic crisis. The nurse would ask the client about which precipitating factor for this event?
A Getting more sleep than usualB Not taking prescribed medication الإجابة الصحيحةC A decrease in food intake recentlyD Taking excess prescribed medication -
1348
A client diagnosed with trigeminal neuralgia asks the nurse what can be done to minimize the episodes of pain. The nurse's response is based on an understanding that what can trigger the pain?
A Infection or stressB Hypoglycemia and fatigueC Facial pressure or extreme temperature الإجابة الصحيحةD Excessive watering of the eyes or nasal stuffiness -
1349
A client has been diagnosed with Bell's palsy. The nurse assesses the client to determine if which signs/symptoms are present?
A Eye paralysis and ptosis of the eyelidsB Chewing difficulties and one-sided facial droop الإجابة الصحيحةC Fixed pupil and an elevated eyelid on one sideD Twitching of one side of the face and ruddy cheeks -
1350
The nurse is admitting a client with a diagnosis of Guillain-Barré syndrome. During the history taking, the nurse would ask if the client has recently experienced which physical problem?
A MeningitisB Seizures or head traumaC A back injury or spinal cord traumaD A respiratory or gastrointestinal (GI) infection الإجابة الصحيحة -
1351
A client is prescribed diphenhydramine 1% as a topical agent for allergic dermatosis. The nurse evaluates that the medication is having the intended effect when the client reports relief of what complaint?
A PainB Urticaria الإجابة الصحيحةC HeadacheD Skin redness Antiinflammatory/Antiinfective -
1352
A client being treated for a comminuted tibia fracture asks the nurse to explain what a comminuted fracture means. The nurse would give which response?
A "It means the fracture is incomplete."B "It means the bone is partially fractured."C "It means the bone fractured with splintering of the bone into fragments." الإجابة الصحيحةD "It means the skin or mucous membrane was broken when the fracture occurred." -
1353
The nurse is monitoring a client with a fracture to the left arm. Which sign observed by the nurse is consistent with impaired venous return in the area?
A Increasing edema الإجابة الصحيحةB Weakened distal pulseC Pallor or blotchy cyanosisD Continued pain despite medication -
1354
A client diagnosed with glomerulonephritis and at risk of developing acute kidney injury should be monitored for which sign associated with a complication?
A BradycardiaB Hypertension الإجابة الصحيحةC Decreased cardiac outputD Decreased central venous pressure and Chronic Kidney Disease -
1355
A client has been prescribed metoprolol for hypertension. The nurse monitors client compliance carefully because of which common side effect of the medication?
A Impotence الإجابة الصحيحةB Mood swingsC Increased appetiteD Complete atrioventricular (AV) block -
1356
A client receiving chemotherapy has a platelet count of 15,000 mm3 (15 x 109/L). Based on this laboratory result, which form of precautions would the nurse implement?
A ContactB Bleeding الإجابة الصحيحةC RespiratoryD Neutropenic Disorders -
1357
A family member asks to take the client, who is on aneurysm precautions, to the unit lounge for "just a few minutes." Which concepts would the nurse plan to use when explaining why the client must remain in the room?
A A quiet environment promotes more rapid healing of the aneurysm.B Clients with aneurysms need isolation to cope with photosensitivity.C Reduced environmental stimuli are needed to prevent aneurysm rupture. الإجابة الصحيحةD The client has disorganization of thoughts and feelings and needs reduced activity. -
1358
A client has been prescribed metoclopramide on a long-term basis. A home care nurse calls the primary health care provider immediately if which side effect is noted in this client?
A ExcitabilityB Anxiety or irritabilityC Uncontrolled rhythmic movements of the face or limbs الإجابة الصحيحةD Dry mouth not minimized by the use of sugar-free hard candy Reflux Disease -
1359
The nurse caring for a client prescribed clozapine reviews the client's laboratory studies. Which laboratory study is the priority to monitor for an adverse effect associated with the use of this medication?
A Platelet countB Cholesterol levelC Blood urea nitrogenD White blood cell count الإجابة الصحيحة -
1360
The nurse is performing a physical assessment on a client with rheumatoid arthritis. The nurse assesses the client's hands and notes which characteristic deformities? Refer to the figure. (From Lewis S, Dirksen S, Heitkemper M, Bucher L: Medical-surgical nursing: assessment and management of clinical problems, ed 9, St. Louis, 2014, Elsevier.)
A Ulnar drift الإجابة الصحيحةB Rheumatoid nodulesC Swan neck deformityD Boutonniére deformity and Osteoarthritis -
1361
The nurse is assessing the left lower extremity of a client with type 2 insulin-requiring diabetes and cellulitis. The nurse should do which of the following?
A Instruct the client to elevate the left leg when sitting in the chair. الإجابة الصحيحةB Encourage the client to ambulate in the halls on the unit.C Massage the left leg with alcohol to stimulate circulation.D Cleanse the left lower leg with perfumed liquid soap. -
1362
The client with glaucoma is scheduled for a hip replacement. Which of the following prescriptions would require clarification before the nurse carries it out?
A Administer morphine sulfate.B Administer atropine sulfate. الإجابة الصحيحةC Teach deep-breathing exercises.D Teach leg lifts and muscle-setting exercises. -
1363
Jail staff asked for a mental health evaluation of a 21-year-old female arrested on charges of prostitution after she stabbed herself with a fork and woke from nightmares in fits of rage. The evaluation revealed that she was kidnapped and held from ages 8 to 16 by a convicted child pornographer. She said she never contacted her family after her release from captivity. The nurse should do the following in what order of priority from first to last?
A Initiate suicide precautions and a no harm contract.B Ask the client if she wishes to contact her family while hospitalized.C Offer empathy and support and be nonjudgmental and honest with her. الإجابة الصحيحةD Encourage safe verbalizations of her emotions, especially anger. -
1364
A client with a history of hypertension and peripheral vascular disease underwent an aortobifemoral bypass graft. Preoperative medications included pentoxifylline (Trental), metoprolol (Toprol XL), and furosemide (Lasix). On postoperative day 1, the 12 noon vital signs are: Temperature 37.2°C; heart rate 132 bpm; respiratory rate 20; blood pressure 126/78. Urine output is 50 to 70 mL/h. The hemoglobin and the hematocrit are stable. Using the SBAR (Situation- Background-Assessment-Recommendation) technique for communication, the nurse recommends that the primary care provider:
A Continues the pentoxifylline.B Increases the IV fluids.C Restarts the metoprolol.D Resumes the furosemide. الإجابة الصحيحة -
1365
A client has acute arterial occlusion. The health care provider (HCP) has prescribed IV heparin. Before starting the medication, the nurse should:
A Review the blood coagulation laboratory values. الإجابة الصحيحةB Test the client's stools for occult blood.C Count the client's apical pulse for 1 minute.D Check the 24-hour urine output record. -
1366
A client is scheduled for an intravenous pyelogram (IVP). The evening before the procedure, the nurse learns that the client has a sensitivity to shellfish. The nurse should:
A Administer a cathartic to the client to empty the colon.B Administer an antiflatulent to the client to relieve gas.C Keep the client on nothing-by-mouth (NPO) status.D Cancel the IVP and notify the physician. الإجابة الصحيحة -
1367
The nurse notices that a client with Parkinson's disease is coughing frequently when eating. Which one of the following interventions should the nurse consider?
A Have the client hyperextend the neck when swallowing.B Tell the client to place the chin firmly against the chest when eating.C Thicken all liquids before offering to the client. الإجابة الصحيحةD Place the client on a clear liquid diet. -
1368
A client is brought to the emergency department (ED) by a friend who states that the client recently ran out of his lorazepam (Ativan) and has been having a grand mal seizure for the last 10 minutes. The nurse observes that the client is still seizing. What is the nurse’s priority action?
A Monitor the client's safety and place seizure pads on the cart rails. الإجابة الصحيحةB Record the time, duration, and nature of the seizures.C Page the ED primary health care provider and prepare to give diazepam (Valium) intravenously.D Ask the friend about the client's medical history and current medications. -
1369
A patient diagnosed with systemic erythematosus lupus ment. She is prescribed cyclosporine and indomethacin. sess first?
A “My feet are swollen.”B “I have a paper cut on my index finger and it’s red and الإجابة الصحيحةC “It seems like I’m always so tired.”D “I’m using a vitamin C cream to minimize the rash -
1370
The patient with respiratory failure is receiving me- chanical ventilation and continues to produce arte- rial blood gas results indicating respiratory acidosis. Which change in ventilator setting should the nurse expect to correct this problem?
A Increase in ventilator rate from 6 to 10 breaths/min الإجابة الصحيحةB Decrease in ventilator rate from 10 to 6 breaths/minC Increase in oxygen concentration from 30% to 40%D Decrease in oxygen concentration from 40% to 30% -
1371
The nurse is admitting an older adult patient to the acute care medical unit. Which assessment factor alerts the nurse that this patient has a risk for acid- base imbalances?
A History of myocardial infarction (MI) 1 year agoB Antacid use for occasional indigestionC Shortness of breath with extreme exertionD Chronic renal insufficiency الإجابة الصحيحة -
1372
A patient with lung cancer has received oxycodone 10 mg orally for pain. When the student nurse assesses the patient, which finding would the nurse instruct the student nurse to report immediately?
A Respiratory rate of 8 to 10 breaths/min الإجابة الصحيحةB Decrease in pain level from 6 to 2 (on a scale of 1 to 10)C Request by the patient that the room door be closedD Heart rate of 90 to 100 beats/min -
1373
The patient has a nasogastric (NG) tube connected to intermittent wall suction. The student nurse asks why the patient’s respiratory rate and depth has decreased. What is the nurse’s best response?
A “It’s common for patients with uncomfortable equipment such as NG tubes to have a lower rate of breathing.”B “The patient may have a metabolic alkalosis because of the NG suctioning, and the decreased respira- tory rate is a compensatory mechanism.” الإجابة الصحيحةC “Whenever a patient develops a respiratory acid- base problem, decreasing the respiratory rate helps correct the problem.”D “The patient is hypoventilating because of anxiety, and we will have to stay alert for the development of respiratory acidosis.” -
1374
The student nurse, under the supervision of an RN, is reviewing a patient’s arterial blood gas results and notes an acute increase in arterial partial pressure of carbon dioxide (Paco ) to 51 mm Hg compared with the previous results. Which statement by the student nurse indicates an accurate understanding of the acid- base balance for this patient?
A “When the Paco is acutely elevated, the blood pH should be lower than normal.” الإجابة الصحيحةB “This patient should be taught to breathe and re- breathe in a paper bag.”C “An elevated Paco always means that a patient has an acidosis.”D “When a patient’s Paco is increased, the respira- tory rate should decrease to compensate.” -
1375
The nurse is providing care for several patients who are at risk for acid-b ase imbalance. Which patient is most at risk for respiratory acidosis?
A A 68- year- old patient with chronic emphysema الإجابة الصحيحةB A 58- year- old patient who uses antacids every dayC A 48- year- old patient with an anxiety disorderD A 28- year- old patient with salicylate intoxication -
1376
The nurse is caring for a patient who experiences fre- quent generalized tonic-c lonic seizures associated with periods of apnea. The nurse must be alert for which acid- base imbalance?
A Respiratory alkalosisB Respiratory acidosis الإجابة الصحيحةC Metabolic alkalosisD Metabolic acidosis -
1377
A patient with atrial fibrillation is ambulating in the hallway on the coronary step- down unit and suddenly tells the nurse, “I feel really dizzy.” Which action should the nurse take first?
A Help the patient to sit down. الإجابة الصحيحةB Check the patient’s apical pulse.C Take the patient’s blood pressure.D Have the patient breathe deeply. -
1378
An 88- year- old patient who has not yet had the in- fluenza vaccine is admitted after reporting symptoms of generalized muscle aching, cough, and runny nose starting about 24 hours previously. Which of these prescribed medications is most important for the nurse to administer at this time?
A Oseltamivir 75 mg PO الإجابة الصحيحةB Guaifenesin 600 mg POC Acetaminophen 650 mg POD Influenza vaccine 180 mcg IM -
1379
A patient who has been infected with the Ebola virus has an emesis of 750 mL of bloody fluid and com- plains of headache, nausea, and severe lightheaded- ness. Which action included in the treatment protocol should the nurse take first?
A Give acetaminophen 650 mg PO.B Administer ondansetron 4 mg IV.C Infuse normal saline at 500 mL/hr. الإجابة الصحيحةD Increase oxygen flow rate to 6 L/min. column who will be assigned to the nursing actions RN LPN/LVN AP sacral wound osteoporosis and positive patient the nostrils of a RN assessment. order to safely don the personal protective equipment Order order to safely remove the personal protective Order -
1380
The nurse is making a home visit to a 50- year- old patient who was recently hospitalized with a right leg deep vein thrombosis and a pulmonary embolism (venous thromboembolism). The patient’s only medica- tion is enoxaparin subcutaneously. Which assessment information will the nurse need to communicate to the health care provider (HCP)?
A The patient says that her right leg aches all night.B The right calf is warm to the touch and is larger than the left calf.C The patient is unable to remember her husband’s first name. الإجابة الصحيحةD There are multiple ecchymotic areas on the patient’s abdomen. -
1381
The high-p ressure alarm on a patient’s ventilator goes off. When the nurse enters the room to assess the patient, who has acute respiratory distress syndrome, the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should the nurse take first?
A Reassure the patient that the ventilator will do the work of breathing for him.B Manually ventilate the patient while assessing pos- sible reasons for the high- pressure alarm. الإجابة الصحيحةC Increase the fraction of inspired oxygen (Fio ) on the ventilator to 100% in preparation for endotra- cheal suctioning.D Insert an oral airway to prevent the patient from biting on the endotracheal tube. -
1382
When assessing a 22-y ear- old patient who required emergency surgery and multiple transfusions 3 days ago, the nurse finds that the patient looks anxious and has labored respirations at a rate of 38 breaths/min. The oxy- gen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate?
A Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes.B Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs.C Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation.D Switch the patient to a nonrebreather mask at 95% to 100% fraction of inspired oxygen (Fio ) and call the health care provider (HCP) to discuss the patient’s status. الإجابة الصحيحة -
1383
The nurse has just finished assisting the health care provider (HCP) with a thoracentesis for a patient with recurrent left pleural effusion caused by lung cancer. The thoracentesis removed 1800 mL of fluid. Which patient assessment information is most important to report to the HCP?
A The patient starts crying and says she can’t go on with treatment much longer.B The patient reports sharp, stabbing chest pain with every deep breath.C The blood pressure is 100/48 mm Hg, and the heart rate is 102 beats/min. الإجابة الصحيحةD The dressing at the thoracentesis site has 1 cm of bloody drainage. -
1384
After extubation of a patient, which finding would the nurse report to the health care provider immediately?
A Respiratory rate of 25 breaths/minB Patient has difficulty speakingC Oxygen saturation of 93%D Crowing noise during inspiration الإجابة الصحيحة -
1385
The student nurse applies suction for at least 20 seconds. the case study on the left then refer to the findings be- question. Underline or highlight the factors that increase HHS. of 40 pack-y ears smoking cigarettes. Patient states he smoking. Patient was exposed to secondhand smoke dur- and teen years. Patient started smoking at age 13. Patient which were not successful. Most members of the patient’s Patient’s daughter does not want to be around smokers Instructions: Read the case study on the left and circle the numbers that best answer the question.
A I get short of breath when I walk more than 2 blocks. الإجابة الصحيحةB M y father died a year ago and I still grieve for having lost him.C I ’m afraid that I’ll need home oxygen soon and I still smoke 5 to 6 cigarettes a day.D I ’ve had a cough for about 4 weeks now. -
1386
A patient with acute myelogenous leukemia is receiv- ing induction-p hase chemotherapy. Which assess- ment finding requires the most rapid action?
A Serum potassium level of 7.8 mEq/L (7.8 mmol/L) الإجابة الصحيحةB Urine output less than intake by 400 mLC Inflammation and redness of the oral mucosaD Ecchymoses present on the anterior trunk -
1387
A patient who has been receiving cyclosporine after an organ transplantation is experiencing these symp- toms. Which one is of most concern?
A Bleeding of the gums while brushing the teethB Nontender lump in the right groin الإجابة الصحيحةC Occasional nausea after taking the medicationD Numbness and tingling of the feet -
1388
A patient with a right above-the-knee amputation asks the nurse why he has phantom limb pain. What is the nurse’s best response?
A “Phantom limb pain is not explained or predicted by any one theory.” الإجابة الصحيحةB “Phantom limb pain occurs because your body thinks your leg is still present.”C “Phantom limb pain will not interfere with your activities of daily living.”D “Phantom limb pain is not real pain but is remem- bered pain.” -
1389
During the assessment of a patient with fractures of the medial ulna and radius, the nurse finds all of these data. Which assessment finding should the nurse report to the health care provider immediately?
A The patient reports pressure and pain. الإجابة الصحيحةB The cast is in place and is dry and intact.C The skin is pink and warm to the touch.D The patient can move all the fingers and the thumb. -
1390
The nurse is teaching an older patient about risks for fractures and osteoporosis. Which diagnostic test should the nurse teach about when the goal is to establish the patient’s bone strength and determine if osteoporosis is present?
A Computed tomography scanB Magnetic resonance imaging scanC Dual- energy x-r ay absorptiometry (DXA or DEXA) scan الإجابة الصحيحةD Joint x- rays -
1391
The nurse is assessing a newly admitted older adult with diabetes. Assessment reveals an abnormal ap- pearance of the feet (see the figure below). The nurse recognizes this as which deformity?
A Claw toe deformityB Hammer toe deformityC Charcot foot deformity الإجابة الصحيحةD Hypertrophic ungula labium deformity -
1392
Propylthiouracil (PTU) is prescribed for a cli- ent with Graves’ disease. The nurse should teach the client to immediately report which of the following?
A Sore throat.B Painful, excessive menstruation. الإجابة الصحيحةC Constipation.D Increased urine output. BBiilllliinnggss__PPaarrtt 22__CChhaapp 33__TTeesstt 0088..iinndddd 447777 -
1393
A client with thyrotoxicosis says to the nurse, “I am so irritable. I am having problems at work because I lose my temper very easily.” Which of the following responses by the nurse would give the cli- ent the most accurate explanation of her behavior?
A “Your behavior is caused by temporary confu- sion brought on by your illness.”B “Your behavior is caused by the excess thy- roid hormone in your system.” الإجابة الصحيحةC “Your behavior is caused by your worrying about the seriousness of your illness.”D “Your behavior is caused by the stress of try- ing to manage a career and cope with illness.” -
1394
Serum concentrations of thyroid hormones and thyroid-stimulating hormone (TSH) are tests ordered for the client with thyrotoxicosis. Which of the following laboratory values are indicative of thyrotoxicosis?
A Elevated thyroid hormone concentrations and normal TSH.B Elevated TSH and normal thyroid hormone concentrations.C Decreased thyroid hormone concentrations and elevated TSH. الإجابة الصحيحةD Elevated thyroid hormone concentrations and decreased TSH. -
1395
After a period of unsuccessful treatment with Elavil (amitriptyline), a woman diagnosed with depression is switched to Parnate (tranylcyprom- ine). Which statement by the client indicates the client understands the side effects of Parnate?
A “I need to increase my intake of sodium.”B “I must refrain from strenuous exercise.”C “I must refrain from eating aged cheese or yeast products.” الإجابة الصحيحةD “I should decrease my intake of foods containing sugar.” 698 BBiilllliinnggss__PPaarrtt 22__CChhaapp 44__TTeesstt 11..iinndddd 669988 -
1396
The nursing assistant tells the nurse that the client is sick and is not coming to the dining room for lunch. The nurse should direct the nursing assis- tant to do which of the following?
A Take the client a lunch tray and let him eat in his room.B Tell the client he’ll need to wait until supper to eat if he misses lunch.C Invite the client to lunch and accompany him to the dining room. الإجابة الصحيحةD Inform the client that he has 10 minutes to get to the dining room for lunch. -
1397
The client diagnosed with conversion dis- order has a paralyzed arm. A staff member states, “I would just tell the client her arm is paralyzed because she had an affair and neglected her baby’s care to the point where the baby had to be hospi- talized for dehydration.” Which of the following responses by the nurse is best?
A “Ignore the client’s behaviors and treat her with respect.”B “Pushing insight will increase the client’s anxiety and the need for physical symptoms.” الإجابة الصحيحةC “Pushing awareness will be helpful and fur- ther the client’s recovery.”D “We’ll meet with the client and confront her with her behavior.” -
1398
The physician refers a client diagnosed with somatization disorder to the outpatient clinic because of problems with nausea. The client’s past symptoms involved back pain, chest pain, and problems with urination. The client tells the nurse that the nausea began when his wife asked him for a divorce. Which of the following is most appropriate?
A Asking the client to describe his problem with nausea.B Directing the client to describe his feelings about his impending divorce. الإجابة الصحيحةC Allowing the client to talk about the physi- cians he has seen and the medications he has taken.D Informing the client about a different medica- tion for his nausea. -
1399
A client diagnosed with pain disorder is talk- ing with the nurse about fishing when he suddenly reverts to talking about the pain in his arm. Which of the following should the nurse do next?
A Allow the client to talk about his pain.B Ask the client if he needs more pain medica- tion.C Get up and leave the client.D Redirect the interaction back to fishing. الإجابة الصحيحة -
1400
The home health nurse is interviewing an older patient with a history of rheumatoid arthritis who reports “feeling pretty good, except for the pain and stiffness in my joints when I first get out of bed.” Which member of the health care team would be notified to aid in the patient’s pain?
A Health care provider to review the dosage and frequency of pain medicationB Physical therapist for evaluation of function and possible exercise therapy الإجابة الصحيحةC Social worker to locate community resources for complementary therapyD Home health aide to help patient with a warm shower in the morning -
1401
Which postoperative patient is manifesting the most serious negative effect of inadequate pain management?
A Demonstrates continuous use of call bell related to unsatisfied needs and discomfortB Develops venous thromboembolism because of im-mobility caused by pain and discomfort الإجابة الصحيحةC Refuses to participate in physical therapy because of fear of pain caused by exercisesD Feels depressed about loss of function and hopeless about getting relief from pain -
1402
For which of these patients is IV morphine the first-line choice for pain management?
A A 33-year-old intrapartum patient needs pain relief for labor contractions.B A 24-year-old patient reports severe headache related to being hit in the head.C A 56-year-old patient reports breakthrough bone pain related to multiple myeloma. الإجابة الصحيحةD A 73-year-old patient reports chronic pain associated with hip replacement surgery. -
1403
The nurse is caring for a patient with esophageal cancer. Which task could be delegated to assistive personnel (AP)?
A Assisting with oral hygiene الإجابة الصحيحةB Observing response to feedingsC Evaluating risk for aspirationD Initiating weight measurements, as needed -
1404
A cheerful older widow comes to the community clinic for her annual checkup. She is in reasonably good health, but she has a hearing loss of 40 dB. She confides, “I don’t get out much. I used to be really active, but the older I get, the more trouble I have hearing. It can be really embarrassing.” What is the priority nursing concept to consider in planning care for this patient?
A SafetyB Sensory perception الإجابة الصحيحةC Mood and affectD Functional ability -
1405
The nurse is planning a treatment and prevention program for chronic bowel incontinence for an older patient. Which intervention should the nurse try first?
A Administer a glycerin suppository 15 minutes before evacuation time.B Insert a rectal tube at specified intervals each day.C Assist the patient to the commode or toilet 30 minutes after meals. الإجابة الصحيحةD Use incontinence briefs or adult-sized diapers. -
1406
The nurse is planning hospital discharge teaching for four patients. For which patient is it most important to instruct about the need to use sunscreen?
A A 32-year-old patient with pneumonia who has a new prescription for doxycyclineB A fair-skinned 55-year-old patient with psoriasis who works outside for 8 hours daily الإجابة الصحيحةC A dark-skinned 62-year-old patient who has had keloids injected with hydrocortisoneD A 78-year-old patient with a red, pruritic rash caused by an allergic reaction to penicillin -
1407
When assessing a patient with cervical cancer who had a total abdominal hysterectomy yesterday, the nurse obtains the following data. Which information has the most immediate implications for planning of the patient’s care?
A Fine crackles are audible at the lung bases.B The patient’s right calf is swollen, and she reports mild calf tenderness. الإجابة الصحيحةC The patient uses the patient-controlled analgesia device every 30 minutes.D Urine in the collection bag is amber and clear.
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