A client admitted to the nursing unit from
the emergency department has a C-4 spinal
cord injury.
Which assessment should the nurse perform
first when admitting the client to the nursing
unit ?
1 Take the client's temperature
2 Assess extremity muscle strength
3 Observe for dyskinesias
4 Listen to breath sound
A nurse develops a plan of care for a client
admitted to the hospital with a diagnosis of
an acute myocardial infarction.
The priority nursing diagnosis in the acute phase
would be:
1 Anxiety
2 Interrupted Family Processes
3 Impaired Comfort
4 Powerlessness
A client began receiving a unit of blood 30
minutes ago.
The client rings the call bell and complains
of difficulty breathing, itching, and a tight
sensation in the chest.
Which of the following is the first action of
the nurse ?
1 Recheck the unit of blood for compatibility
2 Check the client's temperature
3 Stop the transfusion
4 Call the physician
A client in labor has a concurrent diagnosis of
sickle cell anemia.
Because the client is at high risk for sickling crisis,
which action is the priority to assesit in preventing
a crisis from occurring during labor ?
1 Reassure the client
2 Administer oxygen throughout labor
3 Maintain strict asepsis
4 Prevent bearing down
A nurse is providing diet teaching to a client
with congestive heart failure(CHF).
The nurse tells the client to avoid:
1 Leafy green vegetables
2 Steak sauce
3 Apple juice
4 Sherbet
A client is admitted to the hospital with
Cushing's syndrome.
The nurse reviews the results of the client's
laboratory studies for which manifestation of
this disorder ?
1 Hypokalemia
2 Hyperglycemia
3 Low white blood cell (WBC) count
4 Decreased plasma cortisol levels
A nurse is prepareing to implement emergency
care measures for the client who has just
experienced pulmonary embolism.
The nurse implement which of the following
physician orders first ?
1 Administer morphine sulfate
2 Apply oxygen
3 Start an intravenous line
4 Obtain an electrocardiogram (ECG)
A nurse assesses a client admitted to the hospital
with rib fractures in order to identify the risk for
potential complications.
The nurse notes that the client has a history of
emphysema.
Following the assessment, the nurse ensures that
which priority intervention is documented in the
plan of care ?
1 Have the client cough and breath deeply 20 minutes
after pain medication is given
2 Administer low-flow oxygen at 2 liters per minute as
prescribed
3 Assist the client to a position of comfort
4 Administer small, frequent meals with plenty of fluids
A client is admitted to the emergency department
with complaints of severe, radiating chest pain.
The client is extremely restless, frightened, and
dyspneic.
Immediate admission orders include oxygen by nasal
cannula at 4 liters per minute, troponin, creatinine
phosphokinase (CPK), a chest X ray, and a 12-lead ECG.
Which action woud the nurse take first ?
1 Obtain the 12-lead ECG
2 Draw the blood specimens
3 Call radiology to order the chest X-ray
4 Apply the oxygen to the client
A nurse assesses the client with a diagnosis
of thyroid storm.
Which classic signs and symptoms associated
with thyroid storm would indicate the need for
immediate nursing intervention ?
1 Polyuria , nausea , and severe headaches
2 Fever , tachycardia , and systolic hypertension
3 Profuse diaphoresis , flushing , and constipation
4 Hypotension , translucent skin , and obesity
A home care nurse visits a client with chronic
obstructive pulmonary disease (COPD) who is
on home oxygen at 2 liters per minute.
The client's resporatory rate is 22 breath per
minute, and the client is complaining of increased
dyspnea.
The nurse would initially :
1 Determine the need to increase the oxygen
2 Collect additional information regarding the
client's respiratory status
3 Call emergency services to come the home
4 Reassure the client that there is no need to
worry
A nurse notes that the client has an order
to have a Schilling test performed.
The nurse reads the client's progress notes,
looking for a tentative diagnosis of which of
the following types of anemias ?
1 Pernicious
2 Megaloblastic
3 Iron-deficiency
4 Aplastic
A 33 years old female is admitted to the hospital
with a suspected diagnosis of Graves' disease.
Which symptom related to the client's menstrual
cycle would the client most likely report?
1 Dysmenorrhea
2 Metrorrhagia
3 Amenorrhea
4 Menorrhagia
Which of the following initial physical findings would indicate
the development of carditis in a child with rheumatic fever?
1. Heart murmur.
2. Low blood pressure.
3. Irregular pulse.
4. Anterior chest wall pain.
Which of the following nursing assessment
findings indicates hypovolemic shock in a client
who has had a 15% blood loss?
1. Pulse rate less than 60 bpm.
2. Respiratory rate of 4 breaths/minute.
3. Pupils unequally dilated.
4. Systolic blood pressure less than 90 mm Hg.
The nurse receives emergency laboratory results for a client with chest pain and immediately
informs the physician. An increased myoglobin level suggests which of the following?
1. Cancer.
2. Hypertension.
3. Liver disease.
4. Myocardial damage.
If the client who was admitted for MI develops cardiogenic shock, which characteristic sign should the nurse expect to observe?
1. Oliguria.
2. Bradycardia.
3. Elevated blood pressure.
4. Fever.
今日の問題はこれ！！
When an unconscious client with multiple injuries arrives in the emergency room, which nursing intervention receives the highest priority?
1. Establishing an airway.
2. Replacing blood loss.
3. Stopping bleeding from open wounds.
4. Checking for a neck fracture.
<引用>
Lippincott's Review for NCLEX-RN by Diane M. Billings
Jan 15, 2002
A postmenopausal woman is worried about pain in the upper outer quadrant of her left breast. The nurse's first course of action is to
1. do a breast examination and report the results to the physician.
2. explain that pain is caused by hormonal fluctuations.
3. reassure the client that pain is not a symptom of breast cancer.
4. teach the client the correct procedure for breast self-examination (BSE).
<引用>
Lippincott's Review for NCLEX-RN by Diane M. Billings
Jan 15, 2002