During a routine visit to the physician's office
for monitoring of diabetes control, an older client
with diabetes mellitus complains to the nurse of
vision changes.
The client describes blurring of the vision with
difficulty in reading and with driving at night.
Given the client's history, the nurse interprets
that the client is probably developing:
1 Detached retina
2 Papilledema
3 Glaucoma
4 Cataracts
A home care nurse is assessing a client who has
begun using peritoneal dialysis.
The nurse determines that which manifestation
noted in the client would most likely indicate the
onset of peritonitis ?
1 Temperature of 99.0 F oral
2 History of gastrointestinal ( GI ) upset 1 week ago
3 Cloudy dialysate output
4 Presence of crystals in dailsate output
A nurse is priparing to administer an opioid
to a client via an epidural catheter.
Before administering the medication, the nurse
aspirates and obtains 5 ml of clear fulid.
The nurse takes which action ?
1 Injects the opioid slowly
2 Notifies the anesthesiologst
3 Injects the aspirate ( 6 ml of clear fluid )
back into the catheter and administers the opioid
4 Flushes the catheter with 6 ml of terile water
before injecting the opioid
A nurse has just inserted an indwelling Foley
catheter into the bladder of a postoperative
client who has not voided for 6 hours and has
a distended bladder.
After the tubing is secured and the collection
bag is hung on the bed frame, the nurse notices
that 800 ml urine had drained into the collection bag.
The appropriate nursing action for the safety of client
is to:
1 Clamp the tubing for 30 minutes and then release
2 Provide suprapubic pressure to maintain a steady
flow of urine
3 Check the specific gravity of the urine
4 Raise the collection bag high enough to slow the
rate of drainage
A client who undergoes a gastric resection is at
risk for developing dumping syndrome.
The nurse monitors the client for:
1 Extreme thirst
2 Bradycardia
3 Dizziness
4 Constipation
A nurse provides dietary measures to a client
with mild diverticulitis.
The nurse encourages the client to eat food
that are:
1 Low in fiber
2 high in fiber
3 High in fat
4 Low roughage
A nurse is caring for a client with a peptic ulcer.
In assessing the client for gastrointestinal
perforation (GI), the nurse monitors for:
1 Increase in bowel sounds
2 Sudden, severe abdominal pain
3 Positive guaiac stool tests
4 Slow, strong pulses
A nurse is teaching a client about the
modifiable risk factors that can reduce the
risk for colorectal cancer.
The nurse places highest priority on discussing
which wisk factor with this client ?
1 Personal history of ulceraive colotis or
gastrointestinal (GI) polyps
2 Distant relative with colorectal cancer
3 Age over 30 years
4 High fat, low faiber diet
A nurse has assisted the physician in placing
a central (subclavian) catheter.
Following the procedure, the nurse takes which
priority action ?
1 Obtains a temperature reading to monitor
for infection
2 Monitors the blood pressure (BP) to check
for fluid volume overload
3 Labels the dressing with the date and time
of catheter insertion
4 Ensures that a chest X-ray is done
The nurse is providing instructions to a client
and family regarding home care following left eye
cataract removal.
The nurse tells the clinet and family which of the
following about positioning in the postoperative
period ?
1 Lower the head between the knees three times
a day
2 Bend below the waist as frequently as able
3 Sleep on the right side or back
4 Sleep only on the left side
A nurse is planning preoperative care for a client
scheduled for insertion of an inferior vena cava
(IVC) filter.
The nurse questions the physician about
withholding which regularly scheduled medication
on the day before surgery ?
1 Furosemide (Lasix)
2 Potassium chloride (K-Dur)
3 Docusate (Colace)
4 Warfarin sodiume (Coumadin)
A client is to undergo pleural biopsy at the bedside.
Knowing the potential complications of the
procedure, the nurse plans to have which of the
following items available at the bedside ?
1 Chest tube and drainage system
2 Intubation tray
3 portable chest X-ray machine
4 Morphine sulfate injection
A postoperative client begins to drain small amounts
of bright red blood from the tracheostomy tube 24
hours after a laryngectomy.
The best nursing action is to:
1 Notify the surgeon
2 Increase the frequency of suctioning
3 Add moisture to the oxygen delivery system
4 Document the character and amount of drainage
A nurse prepares to assist a postoperative client
to progress from a lying to a sitting position to
prepare for ambulation.
Which nursing action is appropriate to maintain the
safety of the client ?
1 Assist the client to move quickly from the lying
position to the sitting position
2 Assess the client for signs of dizziness
and hypotension
3 Elevate the head of the bed quickly to assist the
client to a sitting position
4 Allow the client to rise from the bed to a standing
position unassisted
Which of the following would be the priority assessment for
an adolescent on return to the nursing unit after an appendectomy?
1. The dressing on the surgical site.
2. Intravenous fluid infusion site.
3. Nasogastric (NG) tube function.
4. Amount of pain.
A magnetic resonance imaging (MRI) test is
prescribed for a client with Bell's palsy.
Which nursing action is included in the client's
plan of care to prepare for this test?
1 Keep the client NPO for 6 hours before the test
2 Remove all metal-containing objects from the client
3 Shave the groin for insertion of a femoral catheter
4 Instruct the client in inhalation techniques for the administration of gas
The nurse teaches the client with an ileal conduit measures to prevent a urinary tract infection. Which of the following measures would be most effective?
1. Avoid people with respiratory tract infections.
2. Maintain a daily fluid intake of 2000 to 3000 mL.
3. Use sterile technique to change the appliance.
4. Irrigate the stoma daily.
<引用>
Lippincott's Review for NCLEX-RN by Diane M. Billings
Jan 15, 2002