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質問 193
A 44-year-old female client is receiving external radiation to her scapula for metastasis of breast cancer.
Teaching related to skin care for the client would include which of the following?
- A. Teach her to completely clean the skin to remove all ointments and markings after each treatment.
- B. Encourage her to wear a tight-fitting vest to support her scapula.
- C. Teach her to cover broken skin in the treated area with a medicated ointment.
- D. Encourage her to avoid direct sunlight on the area being treated.
正解: D
解説:
(A) The skin in a treatment area should be rinsed with water and patted dry. Markings should be left intact, and the skin should not be scrubbed. (B) Clients should avoid putting any creams or lotions on the treated area. This could interfere with treatment. (C) Radiation therapy clients should wear loose-fitting clothes and avoid tight, irritating fabrics. (D) The area of skin being treated is sensitive to sunlight, and the client should take care to prevent sun damage by avoiding direct sunlight and covering the area when she is in the sun.
質問 194
The physician has ordered that ampicillin 250 mg IV be given over 30 minutes. The medication is diluted as recommended in 10 mL in the volume control chamber of a set that has a tubing of 12 mL. Which nursing measure is most accurate considering these facts?
- A. Infuse volume at 44 mL/hr.
- B. Infuse volume at 30 mL/hr.
- C. Infuse volume at 22 mL/hr.
- D. Infuse volume at 10 mL/hr.
正解: A
解説:
(A) The volume to be infused should be diluted medication volume added to the volume control chamber (10 mL) plus the tubing volume (12 mL). The general formula for calculating IV medications for children is: Rate = Volume to Be Infused X Administration Set Drop Factor (microdrop: 60 gtts/min)Desired Time to Infuse in Minutes Rate = (10 + 12)22 X 60 30 = 44 mL/hr. (B, C, D) These values are incorrect.
質問 195
In assessing the nature of the stool of a client who has cystic fibrosis, what would the nurse expect to see?
- A. Blood-tinged stools
- B. Dark brown stools
- C. Clay-colored stools
- D. Steatorrhea stools
正解: D
解説:
Explanation/Reference:
Explanation:
(A) Clay-colored stools indicate dysfunction of the liver or biliary tract. (B) In the early stages of cystic fibrosis, fat absorption is primarily affected resulting in fat, foul, frothy, bulky stools. (C) Dark brown stools indicate normal passage through the colon. (D) Blood-tinged stools indicate dysfunction of the gastrointestinal (GI) tract.
質問 196
The nurse knows that children are more susceptible to respiratory tract infections owing to physiological differences. These childhood differences, when compared to an adult, include:
- A. Rounded shape of chest, smaller volume of air
- B. Diaphragmatic breathing, larger volume of air
- C. Fewer alveoli, slower respiratory rate
- D. Larger number of alveoli, diaphragmatic breathing
正解: A
解説:
Explanation
(A) Although a child has fewer alveoli than an adult, the child's respiratory rate is faster. (B) Although a child may use diaphragmatic breathing, the adult exchanges a larger volume of air. (C) The adult has a larger number of alveoli than a child. (D) The child's chest is rounded whereas the adult chest is more of an oval shape, and the child does exchange a smaller volume of air than an adult.
質問 197
A 3-year-old child has had symptoms of influenza including fever, productive cough, nausea, vomiting, and sore throat for the past several days. In caring for a young child with symptoms of influenza, the mother must be cautioned about:
- A. The possibility of pneumonia as a complication
- B. Giving clear liquids too soon
- C. Giving aspirin and bismuth subsalicylate (Pepto-Bismol) to treat the symptoms
- D. Allowing the child to come in contact with other children for 3 days
正解: C
解説:
(A) Aspirin should never be given to children with influenza because of the possibility of causing Reye's syndrome. Pepto- Bismol is also classified as a salicylate and should be avoided. (B) Depending on the severity of symptoms, the child may be receiving IV therapy or clear liquids. (C) The disease has a 1-3 day incubation period and affected children are most infectious 24 hours before and after the onset of symptoms. (D) Although viral
pneumonia can be a complication of influenza, this would not be an initial priority.
質問 198
A client had a hemicolectomy performed 2 days ago. Today, when the nurse assesses the incision, a small part of the abdominal viscera is seen protruding through the incision. This complication of wound healing is known as:
- A. Excoriation
- B. Decortication
- C. Dehiscence
- D. Evisceration
正解: D
解説:
Explanation
(A) Excoriation is abrasion of the epidermis or of the coating of any organ of the body by trauma, chemicals, burns, or other causes. (B) Dehiscence is a partial or complete separation of the wound edges with no protrusion of abdominal tissue. (C) Decortication is removal of the surface layer of an organ or structure. It is a type of surgery, such as removing the fibrinous peel from the visceral pleura in thoracic surgery. (D) Evisceration occurs when the incision separates and the contents of the cavity spill out.
質問 199
A client had abdominal surgery this morning. The nurse notices that there is a small amount of bloody drainage on his surgical dressing. The nurse would document this as what type of drainage?
- A. Sanguinous
- B. Catarrhal
- C. Serosanguinous
- D. Purulent
正解: A
解説:
(A)
Drainage from a surgical incision usually proceeds from sanguinous to serosanguinous.
(B)
Purulent drainage usually indicates infection and should not be seen initially from a surgical incision. (C) Drainage from a surgical incision is initially sanguinous, proceeding to serosanguinous, and then to serous. (D) Catarrhal is a type of exudate seen in upper respiratory infections, not in surgical incisions.
質問 200
After the fetal activity test (nonstress test) is completed, the RN is looking at the test results on the monitor strip. The RN observes that the fetal heart accelerated 5 beats/min with each fetal movement. The accelerations lasted 15 seconds and occurred 3 times during the 20- minute test. The RN knows that these test results will be interpreted as:
- A. A nonreactive test
- B. An unsatisfactory test
- C. A reactive test
- D. A negative test
正解: C
解説:
(A) A nonstress test that shows at least two accelerations of the fetal heart rate of 15 bpm with fetal activity, lasting 15 seconds over a 20-minute period. (B) Reactive criteria are not met. The accelerations of the fetal heart rate are not at least 15 bpm and do not last 15 seconds. This could mean fetal well-being is compromised. Usually a contraction stress test is ordered if the nonstress test results are negative. (C) An unsatisfactory test means the data cannot be interpreted, or there was inadequate fetal activity. If this happens, usually the test is ordered to be done at a later date. (D) A negative test is a term used to describe the results of a contraction stress test.
質問 201
A client takes warfarin (Coumadin) 15 mg po daily. To evaluate the medication's effectiveness, the nurse should monitor the:
- A. partial thromboplastin time (PTT)
- B. PTT-C
- C. prothrombin time (PT)
- D. Fibrin split products
正解: C
解説:
Explanation/Reference:
Explanation:
(A) PT evaluates adequacy of extrinsic clotting pathway. Adequacy of warfarin therapy is monitored by PT.
(B) PTT evaluates adequacy of intrinsic clotting pathway. Adequacy of heparin therapy is monitored by PTT. (C) There is no such laboratory test. (D) Fibrin split products indicate fibrinolysis. This is a screening test for disseminated intravascular coagulation. Heparin therapy may increase fibrin split products.
質問 202
An alcoholic client who is completing the inpatient segment of a substance abuse program was placed on disulfiram (Antabuse) drug therapy. What should the nurse include in the discharge instructions?
- A. Disulfiram is most effective when prescribed as late as possible in a recovery program.
- B. The effects of disulfiram can be triggered by alcohol 5 days to 2 weeks after the drug is discontinued.
- C. Disulfiram works on the desensitization principle.
- D. If disulfiram is taken and alcohol ingested, the client experiences nausea, vomiting and elevated blood pressure.
正解: B
解説:
Explanation/Reference:
Explanation:
(A) When alcohol is ingested with disulfiram therapy, the client experiences nausea, vomiting, and a potentially serious drop in blood pressure. (B) Disulfiram is most successful when used early in the recovery process while the individual makes major lifestyle changes necessary for long-term recovery. (C) Disulfiram works on the classical conditioning principle. (D) The effects of disulfiram can be felt when alcohol is ingested 1-2 weeks after disulfiram is discontinued.
質問 203
The nurse is caring for a 2-year-old girl with a subdural hematoma of the temporal area as a result of falling out of bed and notices that she has a runny nose. The nurse should:
- A. Test the discharge for sugar
- B. Turn her to her side
- C. Call the doctor immediately
- D. Help her to blow her nose carefully
正解: A
解説:
(A) The nasal discharge could be due to a cold. It is necessary to gather additional assessment data to identify a possible cerebrospinal fluid leak. (B) If the discharge is cerebrospinal fluid, it would not be safe to encourage the girl to blow her nose. (C) Cerebrospinal fluid is positive for sugar; mucus is not. (D) Turning her to her side will have no effect on her "runny nose." It is necessary to gather further assessment data.
質問 204
A 30-year-old client has just been treated in the ER for bruises and abrasions to her face and a broken arm from domestic violence, which has been increasing in frequency and intensity over the last few months.
The nurse assesses her as being very anxious, fearful, bewildered, and feeling helpless as she states, "I don't know what to do, I'm afraid to go home." The best response by the nurse to the client would be:
- A. "I'll call the police and they will take care of him, and you can go home and get some rest."
- B. "Let's talk about people and resources available to you so that you don't have to go home."
- C. "Did you do something that could have made him so angry?"
- D. "I wouldn't want to go home either; call a friend who could help you."
正解: B
解説:
Explanation/Reference:
Explanation:
(A) A person in crisis needs support, assistance, and direction from a caregiver rather than just an instruction. (B) A battered person may feel guilt and think that they cause the abuser's behavior; however, the abuser has the problem and goes through phases of violence. (C) The nurse should provide support and guidance to the client in crisis by offering alternatives and assist in referrals. (D) Focusing on help from law enforcement may be a very temporary solution, because the victim may be fearful of pressing charges.
This answer does not address the crisis of going home.
質問 205
The family member of a child scheduled for heart surgery states, "I just don't understand this open-heart or closed-heart business. I'm so confused! Can you help me understand it?" The nurse explains that patent ductus arteriosus repair is:
- A. A pediatric version of the coronary artery bypass graft surgery performed on adults. It is an open-heart surgery.
- B. Closed-heart surgery. It does not require that the child be placed on the heart-lung machine while the surgery is being performed.
- C. Open-heart surgery. The child will be placed on a heart-lung machine while the surgery is being performed.
- D. A pediatric version of percutaneous transluminal coronary angioplasty performed on adults. It is a closed-heart surgery.
正解: B
解説:
Explanation/Reference:
Explanation:
(A) Patent ductus arteriosus repair is a closed-heart procedure. The client is not placed on a heart-lung machine. (B) Patent ductus arteriosus is a ductus arteriosus that does not close shortlyafter birth but remains patent. Repair is a closed-heart procedure involving ligation of the patent ductus arteriosus. (C) Coronary artery bypass graft surgery is an open-heart surgical procedure in which blocked coronary arteries are bypassed using vessel grafts. (D) Percutaneous transluminal coronary angioplasty is a closedheart procedure that improves coronary blood flow by increasing the lumen size of narrowed vessels.
質問 206
A pregnant client is having a nonstress test (NST). It is noted that the fetal heart beat rises 20 bpm, lasting 20 seconds, every time the fetus moves. The nurse explains that:
- A. The test is normal and the fetus is reacting appropriately
- B. Further testing is needed
- C. The fetus is distressed
- D. The test is inconclusive and should be repeated
正解: A
解説:
Section: Questions Set G
Explanation:
(A) The test results were normal, so there would be no need to repeat to determine results. (B) There are no data to indicate further tests are needed, because the result of the NST was normal. (C) An NST is reported as reactive if there are two to three increases in the fetal heart rate of 15 bpm, lasting at least 15 seconds during a
15-minute period. (D) The NST results were normal, so there was no fetal distress.
質問 207
A physician's order reads: Administer KCl 10% oral solution 1.5 mL. The KCl bottle reads 20 mEq/15 mL.
What dosage should the nurse administer to the infant?
- A. 1 mEq
- B. Not enough information to calculate
- C. 2 mEq
- D. 1.13 mEq
正解: C
解説:
Explanation
(A) This answer is a miscalculation. (B) This answer is a miscalculation. (C) 1.33 mEq = 1 mL, then 1.5 mL X=1.99, or 2 mEq. (D) Information is adequate for calculation.
質問 208
A 25-year-old lawyer who is married with three young children works long hours in an effort to become a partner in the law firm. Following a recent hospitalization for a bleeding ulcer, he was referred for therapy to treat this psychophysiological disorder. On meeting with the therapist, he informed him or her that he was a busy man and did not have much time for this "psych stuff." When guiding the client to ventilate his feelings, the therapist can expect him to express feelings of:
- A. Shame
- B. Despair
- C. Anger
- D. Guilt
正解: C
解説:
Explanation/Reference:
Explanation:
(A) Guilt relates to depression. (B) Shame is not associated with psychophysiological disorders. (C) Despair relates to depression. (D) Repressed anger is associated with psychophysiological disorders.
質問 209
Stat serum electrolytes ordered for a client in acute renal failure revealed a serum potassium level of 6.4. The physician is immediately notified and orders 50 mL of dextrose and 10 U of regular insulin IV push. The nurse administering these drugs knows the Rationale for this therapy is to:
- A. Protect the myocardium from the effects of hypokalemia
- B. Drive potassium from the serum back into the cells
- C. Remove the potassium from the body by renin exchange
- D. Promote rapid protein catabolism
正解: B
解説:
(A) Sodium polystyrene sulfonate (Kayexalate), a cation exchange resin, exchanges sodium ions for potassium ions in the large intestine reducing the serum potassium. (B) Calcium is administered to protect the myocardium from the adverse effects of hyperkalemia. Serum levels reflect hyperkalemia. (C) Rapid catabolism releases potassium from the body tissue into the bloodstream. Infection and hyperthermia increase the process of catabolism. (D) The administration of dextrose and regular insulin IV forces potassium back into the cells decreasing the potassium in the serum.
質問 210
A 74-year-old obese man who has undergone open reduction and internal fixation of the right hip is 8 days postoperative. He has a history of arthritis and atrial fibrillation. He admits to right lower leg pain, described as "a cramp in my leg." An appropriate nursing action is to:
- A. Instruct him to rub the cramp out of his leg
- B. Elevate right lower extremity with pillows propped under the knee
- C. Assess for pain with plantiflexion
- D. Assess for edema and heat of the right leg
正解: D
解説:
Explanation/Reference:
Explanation:
(A) Calf pain with dorsiflexion of the foot (Homans' sign) can be a sign of a deep venous thrombosis; however, it is not diagnostic of the condition. (B) Swelling and warmth along the affected vein are commonly observed clinical manifestations of a deep venous thrombosis as a result of inflammation of the vessel wall. (C) Rubbing or massaging of the affected leg is contraindicated because of the risk of the clot breaking loose and becoming an embolus. (D) A pillow behind the knee can be constricting and further impair blood flow.
質問 211
A 17-year-old pregnant client who is gravida 1, para 0, is at 36 weeks' gestation. Based on the nurse's knowledge of the maternal physiological changes in pregnancy, which of these findings would be of concern?
- A. Complaints of dyspnea
- B. Edema of face and hands
- C. Hematocrit 39%
- D. Pulse of 65 bpm at 8 weeks, 73 bpm at 36 weeks
正解: B
解説:
(A) Dyspnea is a common complaint during the third trimester owing to the increasing size of the uterus and the resulting pressure against the diaphragm. (B) Edema of the face, hands, or pitting edema after 12 hours of bed rest may be indicative of preeclampsia and would be of great concern to the healthcare provider. (C) An increase in heart rate of 10-15 bpm is a normal physiological change in pregnancy due to the multiple hemodynamic changes. (D) A hematocrit value of 39% is within the normal range. A value <35% would indicate anemia.
質問 212
Nursing interventions designed to decrease the risk of infection in a client with an indwelling catheter include:
- A. Change the catheter tubing and bag every 48 hours
- B. Empty the catheter drainage bag at least daily
- C. Maintain fluid intake of 1200-1500 mL every day
- D. Cleanse area around the meatus twice a day
正解: D
解説:
Explanation/Reference:
Explanation:
(A) Catheter site care is to be done at least twice daily to prevent pathogen growth at the catheter insertion site. (B) Catheter drainage bags are usually emptied every 8 hours to prevent urine stasis and pathogen growth. (C) Tubing and collection bags are not changed this often, because research studies have not demonstrated the efficacy of this practice. (D) Fluid intake needs to be in the 2000-2500 mL range if possible to help irrigate the bladder and prevent infection.
質問 213
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