发国际护士信息上国际护士网 找国际护士信息上国际护士网

护理名人堂

国际护士头条

头条:

中国护士网淘宝店铺

《Kaplan NCLEX-RN Question Trainer Test-1》(980-982)

发表日期:2016-12-19 | 来源 :国际护士网 | 作者 :www.the-nurses.com |点击数: 次 收听:
 
980. A client has a chest tube inserted for treatment of a hemothorax. Which of the following findings would indicate to the nurse that there is a problem with the effective functioning of the chest tube?

1. 15-cm of water is present in the suction control chamber.
2. Constant bubbling is observed in the water seal chamber.
3. 2-cm of water is present in the water seal chamber.
4. Clots of blood are observed in the collection chamber.

Strategy: Think about each answer choice.

(1) appropriate, regulates the amount of suction delivered to the patient
(2) correct—would indicate an air leak, would not allow negative pressure to be reestablished and would hinder complete resolution of the pneumothorax
(3) appropriate, provides for a water seal
(4) would be an expected finding

981. A nursing assessment of a disoriented male client reveals that the client has a self-care deficit (feeding). Which of the following would indicate to the nurse that the client has made a positive response to the plan of care?

1. Client explains the relationship between weight loss and change in mental status.
2. Client identifies the basic four food groups.
3. Client states he needs to drink more water.
4. Client feeds self when the nurse stays with him and cues him.

Strategy: Determine the outcome of each answer choice.

(1) would not be realistic in a client who is disoriented
(2) would not be realistic in a client who is disoriented
(3) would not be realistic in a client who is disoriented
(4) correct—disoriented client who is not able to be an independent self-care agent will need cuing from the nurse to accomplish self-feeding
  

982. A client is scheduled for a cardiac catheterization at 8 AM. The client’s laboratory work was completed five days ago. The results were: K+ 3.0 mEq/L, Na+ 148 mEq/L, glucose 178 mg/dL. He complains of muscle weakness and cramps. Which of the following nursing actions is BEST?

1. Administer the 7
AM dose of spironolactone (Aldactone).
2. Encourage eating bananas for breakfast.
3. Obtain stat K
+ level.
4. Call for twelve-lead EKG.

Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) Aldactone is potassium-sparing diuretic and is an oral medication, patient is NPO for procedure
(2) is not feasible prior to the cardiac cath because the client is NPO
(3) correct—signs and symptoms are indicative of hypokalemia; stat serum K
+ level is needed to confirm the K+ level prior to going for cardiac  atheterization
(4) is unnecessary at this time
  

国际护士网(www.the-nurses.com)

国际护士网微信公众号
数据统计中,请稍等!
标签:
国际护士网专题

大家都在看

国际护士风采

合作机构

友情链接

关于本站| 对外合作| 有偿投稿| 转载声明| 免责声明| 联系我们| 【网站地图】| 【百度地图】| 【谷歌地图】| 【Feed地图】

Copyrights © 2015 www.the-nurses.com, All rights reserved. 豫ICP备12001925号-2

  • 合作咨询
  • 官方微博
    国际护士网官方微博
  • 官方微信
    国际护士网微信公众号