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質問 # 432
A client who is gravida 1 para 1 vaginally delivered a 7- lb girl. She received a midline episiotomy at delivery. When assessing the level of her uterus immediately following delivery, the nurse would expect the fundus to be located:
- A. Midway between the umbilicus and the xiphoid process
- B. At the umbilicus
- C. Midway between the umbilicus and the symphysis pubis
- D. At the symphysis pubis
正解：C
解説：
(A) Within 12 hours of delivery, the fundus of the uterus rises to, or slightly above or below, the umbilicus. Fundal height generally decreases 1 fingerbreadth, or 1 cm/day. (B) The uterus descends into the pelvic cavity at approximately 10-12 postpartal days and can no longer be palpated abdominally. (C) Within 12 hours of delivery, the fundus of the uterus rises to, or slightly above or below, the umbilicus. Fundal height generally decreases 1 fingerbreadth, or 1 cm/day. An enlarged uterus may indicate subinvolution or postpartal hemorrhage. (D) Immediately following delivery, the uterus lies midline, about midway between the umbilicus and the symphysis pubis.
質問 # 433
The predominant purpose of the first Apgar scoring of a newborn is to:
- A. Obtain a baseline for comparison with the infant's future adaptation to the environment
- B. Determine gross abnormal motor function
- C. Evaluate the infant's vital functions
- D. Determine the extent of congenital malformations
正解：C
解説：
Explanation/Reference:
Explanation:
(A) Apgar scores are not related to the infant's care, but to the infant's physical condition. (B) Apgar scores assess the current physical condition of the infant and are not related to future environmental adaptation.
(C) The purpose of the Apgar system is to evaluate the physical condition of the newborn at birth and to determine if there is an immediate need for resuscitation. (D) Congenital malformations are not one of the areas assessed with Apgar scores.
質問 # 434
A client is having an amniocentesis. Prior to the procedure, an ultrasound is performed. In preparing the client, the nurse explains the reason for a sonogram in this situation to be:
- A. Determination of gross anomalies
- B. Determination of multiple gestations
- C. Determination of fetal age
- D. Determination of placental location
正解：D
解説：
(A)
Sonography can be used to determine the presence of multiple gestation. In this question, the sonogram is used as a preparatory step for a specific invasive procedure. (B) Sonography can be used to determine the presence of gross anomalies. In this question, the sonogram is used as a preparatory step for a specific invasive procedure. (C) Prior to amniocentesis, the abdomen is scanned by ultrasound to locate the placenta, thus reducing the possibility of penetrating it with the spinal needle used to obtain amniotic fluid.
(D)
Sonography can be used to determine fetal age. In this question, the sonogram is used
as a preparatory step for a specific invasive procedure.
質問 # 435
A 14-year-old boy has had diabetes for 7 years. He takes 30 U of NPH insulin and 10 U of regular insulin every morning at 7 AM. He eats breakfast at 7:30 AM and lunch at noon. What time should he expect the greatest risk for hypoglycemia?
- A. 1 PM
- B. 11 AM
- C. 9 AM
- D. 3 PM
正解：B
解説：
Explanation/Reference:
Explanation:
(A) This time is incorrect because regular insulin would peak after the teenager has eaten breakfast. (B) This time is incorrect because it is after lunch when the NPH peaks. (C) Regular insulin peaks in 2-3 hours and has a duration of 4-6 hours. NPH insulin's onset is 4-6 hours and peaks in 8-16 hours. Blood sugar would peak after meals and be lowest before meals and during the night. (D) This time is incorrect because it is before the NPH and after the regular insulin peak times.
質問 # 436
A client is diagnosed with diabetic ketoacidosis. The nurse should be prepared to administer which of the following IV solutions?
- A. D5in lactated Ringer's
- B. D5W
- C. 0.9 normal saline
- D. D5in normal saline
正解：C
解説：
(A) D5in normal saline would increase serum glucose. (B) D5W would increase serum glucose. (C) A concentration of 0.9 NS is used to correct extracellular fluid depletion. (D) D5in Ringer's lactate would increase serum glucose.
質問 # 437
A 32-year-old male client is a marketing representative. His job requires him to have a tremendous amount of energy during the day. He frequently uses cocaine to sustain his energy level. Lately he has increased his use of cocaine and even experimented with crack cocaine. Realizing he can no longer continue this destructive behavior, he is seeking treatment for cocaine addiction. In planning nursing care for the client's inpatient stay, which expected outcome is most appropriate?
- A. He will be able to deal with his feelings through participation in group therapy sessions.
- B. He will name activities that he would most likely be involved in posttreatment.
- C. He will meet with his family in counseling sessions and discuss his feelings.
- D. He will attend four consecutive group educational sessions on substance abuse.
正解：A
解説：
Explanation
(A) This expected outcome is specific as related to attendance, but not specific as related to outcome criteria.
(B) Stating activities does not guarantee involvement. (C) This goal may help the recovery process, but postcounseling behavior is not addressed. (D) This statement best describes the expected outcome. The client will be attending group therapy sessions and through them he will deal with his feelings.
質問 # 438
A 48-year-old client is being seen in her physician's office for complaints of indigestion, heartburn, right upper quadrant pain, and nausea of 4 days' duration, especially after meals. The nurse realizes that these symptoms may be associated with cholecystitis and therefore would check for which specific sign during the abdominal assessment?
- A. Rebound tenderness
- B. Cullen's sign
- C. Turner's sign
- D. Murphy's sign
正解：D
解説：
Explanation/Reference:
Explanation:
(A) This sign is a faint blue discoloration around the umbilicus found in clients who have hemorrhagic pancreatitis. (B) This sign indicates areas of inflammation within the peritoneum, such as with appendicitis.
It is a deep palpation technique used on a nontender area of the abdomen, and when the palpating hand is removed suddenly, the client experiences a sharp, stabbing pain at an area of peritoneal inflammation. (C) This sign is considered positive with acute cholecystitis when the client is unable to take a deep breath while the right upper quadrant is being deeply palpated. The client will elicit a sudden, sharp gasp, which means the gallbladder is acutely inflamed. (D) This is a sign of acute hemorrhagic pancreatitis and manifests as a green or purple discoloration in the flanks.
質問 # 439
A husband asks if he can visit with his wife on her ECT treatment days and what to expect after the initial treatment. The nurse's best response is:
- A. "Yes, you may visit. She may experience temporary drowsiness, confusion, or memory loss after each treatment."
- B. "Visitors are not allowed. We will telephone you to inform you of her progress."
- C. "You'll have to get permission from the physician to visit. Clients are pretty sick after the first treatment."
- D. "There's really no need to stay with her. She's going to sleep for several hours after the treatment."
正解：A
解説：
Explanation
(A) It is within the nurse's realm of practice to grant visiting privileges according to hospital policy. ECT treatments do not make clients sick. (B) Visitors are allowed and encouraged, particularly family members.
(C) Clients are usually awake within 1 hour posttreatment. Drowsiness wanes as the anesthetic wears off. (D) A family member is encouraged to stay with the client after return to the unit. The nurse has used an opportunity to do family teaching and allay fears by explaining temporary side effects of the treatment.
質問 # 440
The nurse is caring for a client who has had a tracheostomy for 7 years. The client is started on a fullstrength tube feeding at 75 mL/hr. Prior to starting the tube feeding, the nurse confirms placement of the tube in the stomach. The hospital policy states that all tube feeding must be dyed blue. On suctioning, the nurse notices the sputum to be a blue color. This is indicative of which of the following?
- A. The client aspirated tube feeding.
- B. This is a normal finding.
- C. The feeding is infusing into the trachea.
- D. The nurse has placed the suction catheter in the esophagus.
正解：A
解説：
(A)
Once the feeding tube placement is confirmed in the stomach, aspiration can occur if the client's stomach becomes too full. When suctioning the trachea, if secretions resemble tube feeding, the client has aspirated the feeding. (B) Because the trachea provides direct access to a client's airway, it would not be possible to place the catheter in the esophagus.
(C)
Blue-colored sputum is never considered a normal finding and should be reported and documented. (D) The nurse confirmed placement of the feeding tube in the stomach prior to initiating the tube feeding; therefore, it is highly unlikely that the feeding tube would be located in the trachea.
質問 # 441
A primigravida is at term. The nurse can recognize the second stage of labor by the client's desire to:
- A. Walk between contractions
- B. Relax during contractions
- C. Push during contractions
- D. Hyperventilate during contractions
正解：C
解説：
Explanation
(A) The second stage of labor is characterized by uterine contractions, which cause the client to bear down.
(B) Slow, deep, rhythmic breathing facilitates the laboring process. Hyperventilation is abnormal breathing resulting from loss of pain control. (C) The client should remain on bed rest during labor. (D) Contractions result in discomfort.
質問 # 442
The nurse is admitting a client with folic acid deficiency anemia. Which of the following questions is most important for the nurse to ask the client?
- A. "Do you take aspirin on a regular basis?"
- B. "Have your stools been normal?"
- C. "Do you drink alcohol on a regular basis?"
- D. "Do you eat red meat?"
正解：C
解説：
Explanation
(A) Aspirin does not affect folic acid absorption. (B) Folic acid deficiency is strongly associated with alcohol abuse. (C) Because folic acid is a coenzyme for single carbon transfer purines, calves liver or other purines are the meat sources. (D) Folic acid does not affect stool character.
質問 # 443
A 28-year-old client performs a long, involved ritual in getting up and preparing for the day. He became unable to get to his job before noon. His family, in desperation, has admitted him to the hospital's psychiatric unit. On the unit, he is always late for breakfast, which is served at 8 am. The nurse identifies that the best approach to this problem is to:
- A. Get him up early so that he can complete the ritual before breakfast
- B. Suggest that he do the rituals after breakfast
- C. Ask him to get all the other clients up so that he will forget about his ritual
- D. Allow him to eat late
正解：A
解説：
Explanation/Reference:
Explanation:
(A) Allowing him to eat late is not a solution to the problem because the ritual affects more than just this meal. (B) He is helpless to change this behavior because the rituals occur as a result of an irrational effort to control his anxiety. (C) To interfere with the ritual will increase anxiety. Until the basic problem is resolved, and in turn his need for the ritual relieved, arrange the schedule so that essential activities may be included (such as meals with the group). (D) This approach would be very disruptive to the other clients and would not serve to relieve the anxiety of the client.
質問 # 444
A female client plans to bottle-feed her newborn. Her physician has ordered bromocriptine (Parlodel) to suppress lactation. Which of the following instructions about bromocriptine should be given by the nurse?
- A. Bromocriptine is generally taken for 5 days.
- B. Bromocriptine stimulates the production of prolactin.
- C. Her blood pressure must be stable before starting bromocriptine.
- D. Hypertension is a primary side effect.
正解：C
解説：
Explanation/Reference:
Explanation:
(A) Bromocriptine inhibits the secretion of prolactin. (B) Hypotension is a side effect of this drug; hypertension is not. (C) Bromocriptine is generally taken for 14 days. (D) The administration of bromocriptine is delayed at least 4 hours postpartum and given only when the client's blood pressure is stable, because it can cause hypotension and syncope.
質問 # 445
A 6-year-old child is attending a pediatric clinic for a routine examination. What should the nurse assess for while conducting a vision screening?
- A. Gait
- B. Strabismus
- C. Papilledema
- D. Hearing test
正解：B
解説：
Explanation/Reference:
Explanation:
(A) Hearing should be assessed separately. (B) Gait should be assessed separately. Client usually remains in one place for vision screening. Gait is part of neurological assessment. (C) Strabismus is crossing of eyes or outward deviation, which may cause diplopia or ambylopia. It is easily assessed during vision screening. (D) Papilledema is assessed by an ophthalmoscopic examination, which follows vision screening. It is part of neurological assessment.
質問 # 446
A client was prescribed a major tranquilizer 2 months ago. One month ago she was placed on benztropine (Cogentin). What would indicate that benztropine therapy is effective?
- A. Muscle weakness
- B. Smooth, coordinated voluntary movement
- C. Rigidity
- D. Tremors
正解：B
解説：
Explanation/Reference:
Explanation:
(A) Benztropine is prescribed to decrease or alleviate extrapyramidal side effects of major tranquilizers.
Smooth, coordinated voluntary movement indicates minimal extrapyramidal side effects. (B) Tremors are an extrapyramidal side effect. (C) Rigidity is an extrapyramidal side effect. (D) Muscle weakness is an extrapyramidal side effect.
質問 # 447
During burn therapy, morphine is primarily administered IV for pain management because this route:
- A. Avoids causing additional pain from IM injections
- B. Facilitates absorption because absorption from muscles is not dependable
- C. Delays absorption to provide continuous pain relief
- D. Allows for discontinuance of the medication if respiratory depression develops
正解：B
解説：
(A) Absorption would be increased, not decreased. (B) IM injections should not be used until the client is hemodynamically stable and has adequate tissue perfusion. Medications will remain in the subcutaneous tissue with the fluid that is present in the interstitial spaces in the acute phase of the thermal injury. The client will have a poor response to the medication administered, and a "dumping" of the medication can occur when the medication and fluid are shifted back into the intravascular spaces in the next phase of healing. (C) IV administration of the medication would hasten respiratory compromise, if present. (D) The desire to avoid causing the client additional pain is not a primary reason for this route of administration.
質問 # 448
In evaluating the effectiveness of magnesium sulfate (MgSO4), which of the following might indicate that the client was developing MgSO4 toxicity?
- A. A 21 proteinuria value
- B. A 31 patellar tendon reflex
- C. Respirations of 12 breaths/min
- D. Urine output of 40 mL/hr
正解：C
解説：
Explanation
(A) Diminished (not accentuated) patellar tendon reflex is a sign of developing MgSO4 toxicity. A value of 21 is considered a normal tendon reflex; 3+ is considered brisker than normal. (B) MgSO4 is a central nervous system (CNS) depressant. It also relaxes smooth muscle. If the respiratory rate is <16 bpm magnesium toxicity may be developing. (C) Urine output of 40mL/hr is enough to allow elimination of toxic levels of magnesium.
Urinary output of <100 mL in a 4-hour period may result in toxic levels of magnesium. (D) Presence of protein in the urine is a symptom of pregnancy-induced hypertension (PIH), a clinical syndrome for which magnesium sulfate is frequently used in medical management. Protein in the urine is not induced by magnesium sulfate intake.
質問 # 449
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