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質問 # 285
A 2-day-old infant boy has been diagnosed with an atrial septal defect due to a persistent patent foramen ovale.
When explaining the diagnosis to the mother, the nurse includes in the discussion the function of the foramen ovale. In fetal circulation, the foramen ovale allows a portion of the blood to bypass the:
- A. Superior vena cava
- B. Left ventricle
- C. Pulmonary system
- D. Liver
正解：C
解説：
Explanation
(A) The foramen ovale permits a percentage of the blood to shunt from the right atrium to the left atrium. The blood then goes to the left ventricle, permitting systemic fetal circulation with blood containing a higher O2 saturation. (B) As the blood shunts from the right atrium to the left atrium, the pulmonary system is bypassed.
The fetus receives O2 from the maternal circulation, thereby permitting the partial bypass of the pulmonary system. (C) The foramen ovale is locatedin the atrial septum of the heart and does not affect the liver. (D) The superior vena cava returns blood to the heart, bringing blood to the location of the foramen ovale.
質問 # 286
Often children are monitored with pulse oximeter. The pulse oximeter measures the:
- A. O2 content of the blood
- B. Affinity of hemoglobin for O2
- C. PO2
- D. Oxygen saturation of arterial blood
正解：D
解説：
(A) The O2 content of whole blood is determined by the partial pressure of oxygen (PO2) and the oxygen saturation. The pulse oximeter does not measure the PO2. (B) The pulse oximeter is a noninvasive method of measuring the arterial oxygen saturation. (C) The PO2 is the amount of O2 dissolved in plasma, which the pulse oximeter does not measure. (D) The affinity of hemoglobin for O2 is the relationship between oxygen saturation and PO2 and is not measured by the pulse oximeter.
質問 # 287
A client's physician has prescribed theophylline (Theo- Dur) to help control the bronchospasm associated with the client's COPD. Instructions that should be given to the client include:
- A. "Call your physician if you develop palpitations, dizziness, or restlessness.''
- B. "Cigarette smoking may significantly increase the risk for theophylline toxicity.''
- C. "Take this medication on an empty stomach.''
- D. "Do not take your medicine if your pulse is less than 60 beats per minute.''
正解：A
解説：
Explanation/Reference:
Explanation:
(A) Indications of theophylline toxicity include palpitations, dizziness, restlessness, nausea, vomiting, shakiness, and anorexia. (B) Cigarette smoking significantly lowers theophylline plasma levels. (C) Theophylline should be taken with food to decrease stomach upset. (D) These instructions are appropriate for someone taking digoxin.
質問 # 288
A client has been in labor 10 hours and is becoming very tired. She has dilated to 7 cm and is at 0 station with the fetus in a right occipitoposterior position. She is complaining of severe backache with each contraction.
One comfort measure the nurse can employ is to:
- A. Have her push with each contraction
- B. Place her in knee-chest position during the contraction
- C. Apply strong sacral pressure during the contraction
- D. Use effleurage during the contraction
正解：C
解説：
Section: Questions Set F
Explanation:
(A) This measure is inappropriate. The knee-chest position is employed to take pressure off the cord. (B) Effleurage is a comfort measure but not the one that will contribute most to the relief of backache caused by a posterior position. (C) Sacral pressure will counteract the pressure created by the position of the fetal head. (D) The client is not completely dilated. Pushing is contraindicated until the second stage of labor.
質問 # 289
A 19-year-old primigravida is admitted to the labor and delivery suite of the hospital. Her husband is accompanying her. The couple tells the nurse that this is the first hospital admission for her. The client's vaginal exam indicates she is 3 cm dilated, 80% effaced, and at _0 station. Based on the vaginal exam, she is in:
- A. Stage 2, latent phase
- B. Stage 1, latent phase
- C. Stage 1, active phase
- D. Stage 3, transition phase
正解：B
解説：
Explanation/Reference:
Explanation:
(A) The second stage of labor is from full cervical dilation through birth of the baby. The three phases of this stage include latency or resting, descent, and final transition. The client is less than fully dilated so she is not in stage 2. (B) The first stage of labor begins with regular uterine contractions and continues until the woman is 10 cm dilated. The three phases of this stage include the early or latent phase (0-3 cm), the active phase (4-7 cm), and the transitional phase (7-10 cm). The client is <4 cm dilated so she is in the latent phase of the first stage of labor. (C) The third stage of labor is from the birth of the baby until the delivery of the placenta. The client is less than fully dilated. (D) The first stage of labor begins with regular uterine contractions and continues until the woman is 10 cm dilated. The three phases of this stage include the early orlatent phase (0-3 cm), the active phase (4-7 cm), and the transitional phase (7-10 cm). The client is <4 cm dilated so she is in the latent phase of the first stage of labor.
質問 # 290
A male client is admitted to the psychiatric unit after experiencing severe depression. He states that he intends to kill himself, but he asks the nurse not to repeat his intentions to
other staff members. Which response demonstrates understanding and appropriate action on the part of the nurse?
- A. "We need to discuss this further, but right now let's complete these forms."
- B. "This is very serious. I do not want any harm to come to you. I will have to report this to the rest of the staff."
- C. "Don't do that, you have so much to live for. You have a wonderful wife and children. The client in the next room has no one."
- D. "I understand you're depressed, but killing yourself is not a reasonable option."
正解：B
解説：
(A) To the client, suicide may be a reasonable action and the only one he can cope with at this time. (B) This response indicates to the client that his intention to commit suicide is not important to the nurse at this time. (C) The client is so depressed that he is not able to see the positive aspects of his life. At no time should the nurse discuss another client's problems in conversation. (D) This statement tells the client that the nurse recognizes his problem is of a serious nature and will take all steps necessary to help him.
質問 # 291
A primipara is assessed on arrival to the postpartum unit. The nurse finds her uterus to be boggy. The nurse's first action should be to:
- A. Massage her fundus
- B. Call the physician
- C. Give the prescribed oxytocic drug
- D. Assess her vital signs
正解：A
解説：
Explanation/Reference:
Explanation:
(A) The nurse should first implement independent and dependent measures to achieve uterine tone before calling the physician. (B) Assessment of vital signs will not help to restore uterine atony, which is the priority need. (C) Giving a prescribed oxytocic drug would be necessary ifthe uterus did not maintain tone with massage. (D) Fundal massage generally restores uterine tone within a few moments and should be attempted first.
質問 # 292
The postpartum nurse should include which of the following instructions to breast-feeding mothers?
- A. Limit feeding times for several days to avoid nipple soreness.
- B. Wash the nipples with soap and water before and after each feeding.
- C. Daily caloric intake should be increased by 500 cal.
- D. Breast milk is totally digestible by the baby because it contains lactose.
正解：C
解説：
(A) Limiting initial feeding times will only delay nipple soreness as well as the establishment of the letdown reflex, thus encouraging engorgement from clogged ducts and ductules. (B) Soap should be avoided because it may be excessively drying, predisposing nipples to cracking. (C) For optimal milk production, an additional 500 kcal over maintenance levels are needed daily. (D) Lipase, not lactose, emulsifies the fat in breast milk, making it almost totally digestible by infants.
質問 # 293
When assessing a female child for Turner's syndrome, the nurse observes for which of the following symptoms?
- A. Gynecomastia
- B. Tall stature
- C. Secondary sex characteristics
- D. Amenorrhea
正解：D
解説：
Explanation
(A) This syndrome is caused by absence of one of the X chromosomes. These children are short in stature. (B) Amenorrhea is a symptom of Turner's syndrome, which appears at puberty. (C) Sexual infantilism is characteristic of this syndrome. (D) Gynecomastia is a symptom in Klinefelter's syndrome.
質問 # 294
A client is having a vertical partial laryngectomy, and the nurse is planning his postoperative care. A priority postoperative nursing diagnosis for a client having a vertical partial laryngectomy would be:
- A. Altered oral mucous membrane
- B. Activity intolerance
- C. Ineffective airway clearance
- D. High risk for infection
正解：C
解説：
Section: Questions Set D
Explanation:
(A) The laryngectomy client should be able to gradually increase activities without difficulty. (B) The laryngectomy client may have copious amounts of secretions and require suctioning for the first 24-48 hours.
The cannula will require cleaning even after the first 24 hours because mucus collects in it. (C) The client does have a potential for infection, but it is not a more importantnursing priority than the ineffective airway clearance.
(D) This problem is not a more important nursing priority than ineffective airway clearance. The client's mouth may become dry, but good oral care should take care of the dryness.
質問 # 295
The nurse notes scattered crackles in both lungs and 1+ pitting edema when assessing a cardiac client. The physician is notified and orders furosemide (Lasix) 80 mg IV push stat. Which of the following diagnostic studies is monitored to assess for a major complication of this therapy?
- A. Serum electrolytes
- B. Complete blood count
- C. Arterial blood gases
- D. 12-Lead ECG
正解：A
解説：
(A) Furosemide, a potassium-depleting diuretic, inhibits the reabsorption of sodium and chloride from the loop of Henle and the distal renal tubules. Serum electrolytes are monitored for hypokalemia. (B) Severe acid-base imbalances influence the movement of potassium into and out of the cells, but arterial blood gases to not measure the serum potassium level. (C) Furosemide is a potassium-depleting diuretic. A complete blood count does not reflect potassium levels. (D) Abnormalities in potassium (both hyperkalemia and hypokalemia) are reflected in ECG changes, but these changes do not occur until the abnormality is severe.
質問 # 296
What is the appropriate nursing action for a child with increased intracranial pressure?
- A. Head turned to side
- B. Child lying flat
- C. Head of bed elevated 45 degrees with child's head maintained in a neutral position
- D. Frequent visitation for stimulation
正解：C
解説：
(A) Elevation of head of bed and neutral head position promote drainage of cerebrospinal fluid. (B) Flat position increases intracranial pressure and impedes cerebrospinal fluid drainage. (C) Head turned to either side impedes cerebrospinal fluid drainage. (D) Child should be in a calm, quiet environment with minimal stimulation.
質問 # 297
A client has been instructed in how to take her nitroglycerin tablets. The nurse giving her instructions knows the client understands the information when she tells her:
- A. "I should keep the tablets in the refrigerator."
- B. "I should take these with water but not with milk."
- C. "I should contact my physician if I have headaches after I take this medicine."
- D. "I should call the doctor if three doses of the medicine do not relieve my pain."
正解：D
解説：
Section: Questions Set E
Explanation:
(A) Headaches may occur after taking nitroglycerin because of vasodilation. (B) The tablets do not need to be refrigerated. The client should carry them with her. (C) The client should contact the physician if repeated doses of nitroglycerin do not relieve the discomfort. (D) Nitroglycerin tablets should be dissolved under the tongue, not swallowed.
質問 # 298
Degenerative disorders are attributed to many factors. As a nurse assigned to a convalescent home, one must often educate families about how such conditions occur. Which of the following statements might the nurse need to explore when a daughter tries to explain to her mother what caused her degenerative disorder?
- A. "It can be caused by lots of things, toxic agents and even alcohol, Mother."
- B. "I know some people who are having this problem and they were exposed to chemicals at work, Mother."
- C. "Perhaps, it's the way your parents used those double- bind messages, Mother."
- D. "Some folks believe that aging causes this, Mother."
正解：C
解説：
Explanation
(A) Aging is a factor in the cause of degenerative disorders. (B) Double-bind messages may be found in the histories of families of individuals who develop schizophrenia, but they are not related to degenerative disorders. (C) Chemicals (toxic agents) in work environments are predisposing factors to degenerative disorders. (D) Alcohol causes some degenerative disorders, such as Wernicke's syndrome.
質問 # 299
A 35-year-old client is receiving psychopharmacological treatment of his major depression with tranylcypromine sulfate (Parnate), a monoamine oxidase (MAO) inhibitor. The nurse teaches the client that while he is taking this type of antidepressant, he needs to restrict his dietary intake of:
- A. Potassium-rich foods
- B. Saturated fats
- C. Tyramine
- D. Tryptophan
正解：C
解説：
(A)
The client may need to avoid some potassium-rich foods (such as bananas, raisins, etc.). However, this is not because of the potassium content of these foods. (B) Tryptophan is an essential amino acid that is present in high concentrations in animal and fish protein.
(C)
The client will need to watch his dietary intake of tyramine. Tyramine is a by-product of the conversion of tyrosine to epinephrine. Tyramine is found in a variety of foods and beverages, ranging from aged cheese to caffeine drinks. Ingestion of tyramine-rich foods while taking a MAO inhibitor may lead to an increase in blood pressure and/or a life-threatening hypertensive crisis. (D) To maintain a healthy lifestyle, restriction of dietary saturated fats is advisable.
質問 # 300
The doctor has ordered a restricted fluid intake for a 2- year-old child with a head injury. Normal fluid intake for a child of 2 years is:
- A. 1600 mL/24 hr
- B. 2000 mL/24 hr
- C. 1300 mL/24 hr
- D. 900 mL/24 hr
正解：A
解説：
Explanation
(A, B, D) These values are incorrect. Normal intake for a child of 2 years is about 1600 mL in 24 hours. (C) This value is correct. Normal intake for a child of 2 years is about 1600 mL in 24 hours.
質問 # 301
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