The nurse is monitoring a client who is in active labor with a cervica

Constricted pupils

Heart rate of 120/min

2.The nurse is caring for a client after percutaneous placement of a coronary stent for a myocardial infarction. The client rates lower back pain as 5 on a scale of 0-10 and has blood pressure of 140/92 mm Hg. The cardiac monitor shows normal sinus rhythm with occasional premature ventricular contractions. Which prescription should the nurse administer first? Click on the exhibit button for additional information. 选项： A:

Respirations of 24/min

Captopril PO every 8 hours

Morphine IV PRN for pain

Potassium chloride IVPB once

3.231. 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.

Regular insulin subcutaneous with meals

4.The second heart sound occurs at the onset of which phase of the cardiac cycle? 选项： A:

Isovolumetric contraction

Rapid ejection

Systole

5.The nurse is caring for a client who reports severe abdominal pain and vaginal spotting. The client had a positive urine pregnancy test at home, and her last menstrual period was 8 weeks ago. Which client report to the nurse is most concerning? 选项： A:

Isovolumetric relaxation

E:Rapid ventricular filling

Abdominal pain rated as 8 out of 10

History of pelvic inflammatory disease

Intermittent nausea and vomiting for the past 7 days

6.The unit secretary notifies the nurse that 4 clients called the nurses' station reporting pain. Which client should the nurse assess first? 选项： A:

Right shoulder pain and dizziness

Client who had a foot amputation today reporting left shoulder pain radiating down the arm

Client who has acute pancreatitis reporting severe, continuous, penetrating abdominal pain

Client who has multiple myeloma reporting deep pelvic pain after walking down the hall

7.A nurse cares for a client on life support who has been declared brain dead. Which intervention is appropriate at this time? 选项： A:

Client who has sickle cell disease reporting severe pain in the arms and upper back

Ask the family members about their plans for the funeral service

Call the local organ procurement services representative

Discontinue nursing care and provide postmortem care

8.Cardiac muscle occurs only in the wall of the heart and cardiac muscle contraction accounts for the ( ) , which creates blood pressure, the force that propels blood in the arteries and arterioles. 选项： A:

Remove life support as requested by the spouse and family

stability

urination

heartbeat

9.The nurse receives report on the assigned team of clients on the oncology unit. All are receiving chemotherapy. Which client should the nurse check on first? 选项： A:

concentration

Alopecia and oral mucositis noted on assessment

Morning hemoglobin result is 8 g/dL (80 g/L)

New-onset back pain and weakness in legs

Persistent vomiting and potassium result is 3.4 mEq/L (3.4 mmol/L)

10.下列各种形态的汞化物，毒性最大的是(　　)。选项： A:

Hg(CH3)2

HgO

Hg

Hg2Cl2

11.下列各种形态的汞化物,毒性最大的是（) 选项： A:

Hg（CH3）2

HgO

Hg

12.Which one of the following is correct about uncoordinated uterine？（）选项： A:Uncoordinated contraction of uterine muscles, resulting in low intrauterine pressure B:Ineffective contraction C:The gravida is quiet during the intermittent period of contraction, and the abdominal pain disappears D:The uterus contraction polarity is reversed but the dilatation of cervical os is not affected E:There will be no intrauterine distress generally

Hg2CL2

13.What are the main forces of deliver after the onset of labor?选项： A:Abdominal muscle contraction force; B:Uterine contraction force; C:Anal raphe contraction force; D:Round ligament contraction force; E:Diaphragm contraction force

14.舌杆应至少离开下颌前牙舌侧龈缘选项： A:

1-2mm

3-4mm

5-6mm

16.A Native American client is hospitalized for depression and attempted suicide. Family members have requested that they be allowed to bring in a medicine healer to perform a ritual on the client. Which of the following is the best action by the nurse? 选项： A:

7-8mm

E:9-10mm

15.正常成人在正常状态下瞳孔直径约为选项： A:

4～6mm

2.5～4mm

8～10mm

1～2mm

6～8mm

Explain that the client's depression is being treated with medications

Explain that the client's depression will not be relieved by a ritual

Plan a meeting with the health care provider (HCP), family, nurse, and medicine healer to make arrangements for the ceremony

18.The health care provider (HCP) explains the risks and benefits of a procedure to the client through an interpreter. The HCP leaves after asking the nurse to witness the client's signature on the consent. The interpreter and client now have a lengthy discussion in the foreign language. The nurse should take which action at this time? 选项： A:

Tell the family that such practices are not allowed in the hospital

17.侧隐窝前后径小于何值为狭窄选项： A:

4mm

6mm

3mm

7mm

5mm

Ask the interpreter to explain the discussion

Confirm the client's consent with the interpreter, using gestures

Have the interpreter witness the signature

Indicate that the interpreter was used when witnessing the client's signature

19.‎消火栓的栓口直径应为（）选项： A:

35mm

45mm

65mm

55mm

20.侧腭杆与龈缘的关系是选项： A:

与龈缘接触

离开1-3mm

离开4-5mm

离开6-10mm

E:离开11-15mm

Document the client's statement in the electronic medical record

Inform the nursing supervisor that the client needs additional teaching

Notify the operating room scheduler of a possible delay in surgery

">21.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:

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

Document the client's statement in the electronic medical record

Inform the nursing supervisor that the client needs additional teaching

Notify the operating room scheduler of a possible delay in surgery