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《Kaplan NCLEX-RN Question Trainer Test-1》(986-988)

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:
 
986. The nurse is caring for clients in the diabetic clinic. Which of the following clients should the nurse see FIRST?

1. A client with sunken eyeballs and a fruity breath odor.
2. A client who complains of pain in his calves when he exercises.
3. A client who states that she drinking liquids frequently and is always hungry.
4. A client says that she is having difficulty sleeping and cries frequently.

Strategy: Determine the least stable client.

(1) correct—indicates diabetic ketoacidosis; treat with normal saline and regular insulin
(2) suggestive of intermittent claudication, not an emergency situation
(3) suggestive of hyperglycemia, should assess blood sugar
(4) psychosocial issues, physical takes priority
  

987. A client is admitted with the following symptoms: dependent pitting edema, abdominal distention, and a recent 10-lb weight gain. The client has received 80 mg of furosemide (Lasix). Which of the following nursing observations is MOST important to report to the next shift? 

1. Complaints of nausea and vomiting.
2. Urine output of 200 cc in 2 hours.
3. Quiet and withdrawn behavior after lunch.
4. Blood pressure changes from 160/90 to 150/90.

Strategy: The topic of the question is unstated. Read the answers for clues.

(1) further signs and symptoms of right-sided heart failure; not a priority
(2) correct—furosemide is diuretic, which warrants close observation of the client’s urine output
(3) further signs and symptoms of right-sided heart failure; not a priority
(4) may occur as a result of volume loss, but is not a priority over answer choice #2

988. A three-year-old boy was shown to have delays on the Denver Development Screening Test (DDST). The mother asks the nurse, “Does this mean my child is going to be slow?” Which of the following responses by the nurse is BEST?

1. “Maybe he is just having a bad day. I’m sure he will do much better next time.”
2. “The test indicated a delay and we will have to investigate to learn more.”
3. “What are your thoughts about how your child performed on the test?”
4. “The results may not be accurate. Let’s set up a time to retest your child.”

Strategy: “BEST” indicates that fine discrimination is required. The topic of the questions is unstated. Determine topic by reading the answer choices.

(1) nontherapeutic, false reassurance
(2) factual but closed communication
(3) correct—open-ended, encourages discussion
(4) doesn’t encourage discussion of concerns
  

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