The home care nurse has given instructions to a client who is beginnin

1.Capecitabine has been prescribed for a client with breast cancer, and the nurse provides instructions to the client about the medication . Which statement by the client indicates the need for further instruction?None 选项： A:"I need to monitor my temperature ." B:"I need to be sure to go to the clinic to receive my yearly flu vaccine ." C:"I may have some diarrhea, but if it becomes severe, I will call my primary health care provider ." D:"It's important for me to contact my primary health care provider if I have any fever or other signs of infection ."

2.A primary health care provider (PHCP) prescribes warfarin sodium for a client . The home care nurse visits the client at home and teaches the client about the medication and its administration . Which statement by the client indicates a need for further teaching?None 选项： A:"The urine normally changes to orange ." B:"This medicine will still be working 4 to 5 days after it is discontinued ." C:"This medication will require frequent blood work to monitor its effects ." D:"I cannot take aspirin or any aspirin-containing medications while I'm on this medication ."

3.The nurse provides home care instructions to a pregnant client with a history of cardiac disease . Which statement made by the client indicates a need for further teaching?None 选项： A:"It is best that I rest on my left side to promote blood return to the heart ." B:"I need to avoid excessive weight gain to prevent increased demands on my heart ." C:"I need to try to avoid stressful situations because stress increases the workload on the heart ." D:"During the pregnancy, I need to avoid contact with other individuals as much as possible to prevent infection ."

Document the client's statement in the electronic medical record

B:

Inform the nursing supervisor that the client needs additional teaching

C:

Notify the operating room scheduler of a possible delay in surgery

D:

Request that the health care provider clarify the client's concerns

">4.The health care provider gives the preoperative nurse a signed consent form and walks away. The client turns to the nurse and states, "I don't know what's going on. Why do I need surgery?" What action should the nurse perform first? 选项： A:

Document the client's statement in the electronic medical record

B:

Inform the nursing supervisor that the client needs additional teaching

C:

Notify the operating room scheduler of a possible delay in surgery

D:

Request that the health care provider clarify the client's concerns

5.A client scheduled to take a subcutaneous anticoagulant at home says to the nurse, "I'm not sure I will be able to take this medication at home ." Which statement by the nurse is appropriate?None 选项： A:"Maybe your spouse can give you your shots ." B:"You'll be fine once you get used to giving your own shots ." C:"What are your concerns about taking this medication at home?" D:"Don't worry . Your primary health care provider knows what's best for you ."

6.The nurse provides home care instructions to the parent of a child with acquired immunodeficiency syndrome (AIDS). Which statement by the parent indicates the need for further teaching?None 选项： A:"I will wash my hands frequently." B:"I will keep my child's immunizations up to date." C:"I will avoid direct unprotected contact with my child's body fluids." D:"I can send my child to day care with a fever as long as it is a low-grade fever."

7.The nurse in the ambulatory care unit is providing home care instructions to a client after cryotherapy for the treatment of malignant skin lesions. Which statement would be most appropriate for the nurse to include in the home care instructions for this client?None 选项： A:"Apply ice to the site to prevent swelling." B:"Clean the site with alcohol 3 times daily." C:"Apply a warm, damp washcloth if discomfort occurs." D:"Avoid showering or taking baths until seen by the primary health care provider in 1 week."

8.The nurse is providing instructions to a client regarding the use of a walker . Which statement by the client would indicate the need for further instruction?None 选项： A:"I need to inspect the rubber tips daily ." B:"I need to wear shoes when ambulating ." C:"I need to pick up the walker and move it forward, and then walk into the walker, one step at a time ." D:"The walker height needs to allow for about 45 degrees of flexion at my elbow so that the height of the walker will be safe ."

9.The nurse is providing instructions to a client being discharged from the hospital following removal of a chest tube that was inserted after thoracic surgery . Which statement made by the client indicates a need for further teaching?None 选项： A:"I would avoid heavy lifting for at least 4 to 6 weeks ." B:"If I have any difficulty breathing, I would call my doctor ." C:"If I note any signs of infection, I would contact my doctor ." D:"I would remove the chest tube site dressing as soon as I get home ."

10.The nurse is preparing discharge instructions for a client who sustained a skeletal muscle injury and is receiving baclofen . Which instruction would be included in the teaching plan?None 选项： A:Restrict fluid intake . B:Avoid the use of alcohol . C:Stop the medication if diarrhea occurs . D:Notify the primary health care provider (PHCP) if fatigue occurs .

11.A client is due to receive digoxin 0 .125 mg by mouth . The nurse prepares to administer the medication and notes that the label on the bottle of pills states that each tablet contains 0 .25 mg . The nurse would take which action?None 选项： A:Administer 2 tablets of the medication . B:Administer one-half tablet of the medication . C:Administer only 1 tablet of the medication and call the pharmacy . D:Withhold the medication and call the primary health care provider (PHCP) .

12.A client with Crohn's disease is experiencing acute pain, and the nurse provides information about measures to alleviate the pain. Which statement by the client indicates the need for further teaching?None 选项： A:"I know I can massage my abdomen." B:"I will continue using antispasmodic medication." C:"One of the best things I can do is use relaxation techniques." D:"The best position for me is to lie supine with my legs straight."

13.The nurse is caring for a client diagnosed with influenza who has had high fever, muscle aches, headache, and sore throat for 36 hours. The health care provider prescribes ibuprofen and oseltamivir. Which of the following actions by the nurse are appropriate? Select all that apply. 选项： A:

Clarify the prescription for oseltamivir with the health care provider

B:

Instruct the client to cover the mouth and nose while coughing or sneezing

C:

Place a mask on the client when transporting the client through the halls

D:

Plan discharge teaching about the importance of annual influenza vaccination

E:

Use contact precautions when providing care for the client

14.A client who has recently lost their spouse says, "No one cares about me anymore . All the people I loved are dead ." The nurse would make which therapeutic response when dealing with a grieving client?None 选项： A:"I certainly care about you ." B:"I don't believe that and neither should you ." C:"You must be feeling all alone at this point ." D:"It isn't unusual to feel alone when you are grieving ."

15.The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "I need to get out of this bad situation ." Which is the most helpful response by the nurse?None 选项： A:"Why don't you tell your spouse about this?" B:"What do you find difficult about this situation?" C:"This is not the best time to make that decision ." D:"I agree with you . You should get out of this situation ."

16.The nurse would interpret which comment by a client diagnosed with battered spouse syndrome as being consistent with the presence of low self-esteem?None 选项： A:"I'm lucky to be married to a spouse who really loves me so much ." B:"I stay because there's enough in it for me . I don't have to work full-time this way ." C:"I told my spouse that this is the last chance . I'm sure my spouse will do better believing that I will leave ." D:"Things would be fine at home if I just could do better . My spouse has a lot of pressure at work ."

17.At 8:00 a .m . , a client who has had a stroke (brain attack) was awake and alert with vital signs of temperature 98° F (37.2° C) orally, pulse 80 beats/min, respirations 18 breaths/min, and blood pressure 138/80 mm Hg. At noon, the client is confused and only responsive to tactile stimuli, and vital signs are temperature 99° F (36.7° C) orally, pulse 62 beats/min, respirations 20 breaths/min, and blood pressure 166/72 mm Hg. The nurse would take which action first?None 选项： A:Reorient the client. B:Retake the vital signs. C:Call the primary health care provider (PHCP). D:Administer an antihypertensive PRN (as needed).

18.The nurse working in a detoxification unit is admitting a client for alcohol withdrawal . The client's spouse states, "I don't know why I don't get out of this rotten situation ." Which response by the nurse addresses the spouse's concerns?None 选项： A:"This is not a good time to make that decision ." B:"What would your spouse think about your decision?" C:"What aspects of this situation are the most difficult for you?" D:"You seem to have a good grip on this situation . You probably need to get out ."

19.The nurse is caring for a client with a perforated duodenal ulcer. Which of the following imaging studies would the nurse anticipate the primary health care provider ordering to most accurately diagnose this condition?None 选项： A:Abdominal CT scan with no contrast B:Right upper quadrant ultrasound (US) C:Abdominal computed tomography (CT) scan with oral contrast D:Abdominal magnetic resonance imaging (MRI) with intravenous (IV) contrast

20.一Do you know Jim has broken up with his wife?—I don't know, ___. 选项： A: I don't care neither B: nor do I care C: nor don't I care D: I don't care also

21.231. The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats per minute. Which nursing action is most appropriate? 选项：A. Notify the primary health care provider (PHCP). B. Continue monitoring the fetal heart rate. C. Encourage the client to continue pushing with each contraction. D. Instruct the client’s coach to continue to encourage breathing techniques.

22.[填空题]must, should, need; because, as for, because ofWhen I was a boy, I ______to take care of my young sister, ______my parents were busy with their work all day long.

23.Health care providers helping patients learn to manage their diabetes include: (1) primary care physicians such as . (2) a specialist in diabetes care such as . (3) other health care providers such as and a nurse.

24.The nurse determines that the spouse of an alcoholic client is benefiting from attending an Al-Anon group if the nurse hears the spouse make which statement?None 选项： A:"I no longer feel that I deserve the beatings my spouse inflicts on me ." B:"My attendance at the meetings has helped me to see that I provoke my spouse's violence ." C:"I enjoy attending the meetings because they get me out of the house and away from my spouse ." D:"I can tolerate my spouse's destructive behaviors now that I know they are common among alcoholics ."

25.A client diagnosed with depression shares with the outpatient clinic nurse, "I lost my job this week and can't pay my rent . My one child is my only family, but I don't want to burden my child with my problems ." Which response by the nurse would best address the client's concern?None 选项： A:"Let's talk about the circumstances that caused you to lose your job ." B:"There are homeless shelters available for people who are experiencing this exact situation ." C:"Wouldn't you want to know if your child was having difficulties so that you could help if you could?" D:"Being homeless would allow us to admit you to the hospital so that you will have a place to eat and sleep ."