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《Kaplan NCLEX-RN Question Trainer Test-1》(1004-1006)

发表日期:2016-12-21 | 来源 :国际护士网 | 作者 :www.the-nurses.com |点击数: 次 收听:
 
1004. While doing a physical examination of a one-year-old child, which of the following assessments should be done by the nurse LAST?

1. Take a rectal temperature.
2. Auscultate the breath sounds.
3. Auscultate the apical heart rate.
4. Evaluate motor functions.

Strategy: Picture the situation.

(1) correct—all invasive procedures should be done last, so as not to alter cardiopulmonary assessment of the child
(2) should be done before a rectal temperature
(3) should be done before a rectal temperature
(4) should be done before a rectal temperature

1005. A patient is returned from surgery with a Jackson-Pratt drain in place. The nurse observes a student nurse perform a dressing change for the patient. Which of the following activities if performed by the student nurse would require an intervention by the nurse?

1. Documents the amount and character of the drainage in the patient’s chart.
2. Attaches the drain to the top sheet on the bed.
3. Empties the reservoir of the drain.
4. Records the amount of drainage on the output sheet.

Strategy: “Require an intervention” indicates an incorrect response.

(1) drains used to prevent wound infections and abscess formation
(2) correct—drain should be attached to patient’s gown or pajamas, never to the sheet or mattress
(3) Jackson-Pratt drain is a self-contained suction device that
  is emptied as needed
(4) important to monitor output
  

1006. An unaccompanied client who is six months pregnant is admitted to the nursing unit with vaginal bleeding. Which of the following comments, if made by the client, would indicate a need for the nurse to assess the adequacy of the client’s emotional support?

1. “My husband will be so angry with me if I lose this baby.”
2. “I'm afraid I am going to lose my baby.”
3. “I can't stay here. I don’t have any insurance.”
4. “I feel so guilty. I didn’t want to get pregnant.”

Strategy: Think about the what the words mean.

(1) correct—client’s concern about her husband’s feelings indicates that he may not be able to support her emotionally at this time
(2) reflects a reality-based concern
(3) indicates an economic concern
(4) indicates client needs to talk about her current feelings; does not give any indication of level of emotional support
  



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