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| Section | Weight | Objectives |
|---|---|---|
| Health Promotion and Maintenance | 6–12% | |
| Safe and Effective Care Environment | 17–33% | - Safety and Infection Control - Management of Care |
| Psychosocial Integrity | 6–12% | |
| Physiological Integrity | 43–67% | - Physiological Adaptation - Basic Care and Comfort - Pharmacological and Parenteral Therapies - Reduction of Risk Potential |
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質問 # 532
A female client at 36 weeks' gestation is experiencing preterm labor. Her physician has prescribed two doses of betamethasone 12 mg IM q24h. The nurse explains that she is receiving this drug to:
正解：D
解説：
Explanation
(A) Respiratory distress syndrome occurs in the newborn, not the fetus. It may be treated postnatally with surfactant therapy. (B) Betamethasone is a corticosteroid, not an anti-infective drug; therefore, its use would not prevent uterine infection. (C) Betamethasone binds with glucocorticoid receptors in alveolar cells to increase production of surfactant, thus increasing lung maturity in the preterm fetus. (D) Betamethasone does not affect uteroplacental circulatory exchange.
質問 # 533
A 72-year-old male client had the Foley catheter that was inserted during the transurethral resection of his prostate removed today. He is concerned about the urinary incontinence he is having since removal of the Foley catheter. The nurse explains that:
正解：B
解説：
Section: Questions Set D
Explanation:
(A) This problem is temporary, but it may take some time to resolve, especially in an older man. (B) This problem is usually temporary, but it may take some time to resolve. (C) Keeping the client dry will not relieve his anxiety about his incontinence. (D) The bladder spasms are not the cause of the client's incontinence.
質問 # 534
The 4th of July holiday comes while a client is in the hospital being treated for schizophrenia. She is taking chlorpromazine and has improved to the point of being allowed to go with a group to the park for a picnic. The side effect of chlorpromazine that the nurse needs to keep in mind during this outing is:
正解：C
解説：
Explanation
(A) A decrease in blood pressure sometimes occurs with chlorpromazine. It would not be a factor influenced by a picnic in the park. (B) Protection from the sun is important in clients taking phenothiazines because they burn easily and severely. (C) An appetite increase sometimes occurs with chlorpromazine. It would not be affected by a picnic. (D) Dryness of the mouth may occur at any time and is not affected by the picnic outing.
質問 # 535
When giving discharge instructions to a 24-year-old client who had a short-arm cast applied for a fractured right ulna, the nurse recognizes the importance of telling him that the drying time for a plaster of Paris cast is approximately:
正解：C
解説：
(A) Synthetic cast materials harden in 3-15 minutes. Weight bearing is permitted in 15-30 minutes. Drying time for plaster of Paris is about 24-72 hours. (B, C) Plaster of Paris cast materials are heavier than synthetic materials and require a drying time of 24-72 hours. Synthetic materials dry within 30 minutes. (D) Plaster of Paris cast materials are heavier thansynthetic materials and require a longer period to set and dry. Even though setting time (hardening) is only 3-15 minutes, the drying time for plaster of Paris is 24-72 hours. This depends on the size and thickness of the cast, exposure to air, and humidity in the air.
質問 # 536
A schizophrenic client who is experiencing thoughts of having special powers states that "I am a messenger from another planet and can rule the earth." The nurse assesses this behavior as:
正解：D
解説：
(A) Clients experiencing ideas of reference believe that information from the environment (e.g., the television) is referring to them. (B) Clients experiencing delusions of persecution believe that others in the environment are plotting against them. (C) Clients experiencing thought broadcasting perceive that others can hear their thoughts. (D) Clients experiencing delusions of grandeur think that they are omnipotent and have superhuman powers.
質問 # 537
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