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《Kaplan NCLEX-RN Question Trainer Test-1》(983-985)

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:
 
983. The nurse teaches a client with newly diagnosed diabetes mellitus proper foot care. Which of the following statements, if made by the client to the nurse, would indicate that further teaching is necessary?

1. “I should cut my toenails straight across.”
2. “I should not go barefoot.”
3. “I should inspect my feet once a week.”
4. “I should bathe my feet daily in warm water.”

Strategy: “Further teaching” indicates an incorrect response.

(1) prevents ingrown nails
(2) prevents possible injury to feet
(3) correct—should inspect feet daily for blisters, sores, ingrown nails, and cuts
(4) proper care 
NCLEX Question Trainer

 984. A client is admitted to the unit with pregnancy-induced hypertension (PIH). Which of the following actions is the priority nursing action?

1. Start an IV.
2. Obtain the vital signs.
3. Administer magnesium sulfate.
4. Notify the lab to draw blood.

Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes.

(1) implementation, not a priority action
(2) correct—assessment, important to do a baseline assessment in order to successfully evaluate the treatment
(3) implementation, not a priority action
(4) implementation, not a priority action

985. An elderly client is oriented during the day but becomes disoriented during the evening. Which of the following nursing actions is MOST appropriate?

1. Place a clock where the client can see it.
2. Restrain all four extremities.
3. Keep a light on in the client’s room.
4. Place the side rails in an upright position.

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

(1) will provide visual cues, safety is more important
(2) inappropriate
(3) may be appropriate, but is not priority over answer choice #4
(4) correct—side rails should always be in an upright position for a disoriented client
  

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