Registered Nurse (RN) is an individual who has studied nursing for 2,3 or 4 years and who has passed a licensed examination (NCLEX).

　　"At the first level, the educational programme prepares the nurse, through study of behavioral, life and nursing science and clinical experience, for effective practice and the direction of nursing care, and for the leadership role. The first-level nurse is responsible for planning care in all settings for the promotion of health, prevention of illness, care of the sick, and rehabilitation; and functions as a member of the health team."　　—— ICN Constitution 1983

　　Simulated Tests

　　1. A patient on the psychiatric unit tells the nurse that people want to infect him with AIDS because he has the secret to preventing famine in the world. Which of these comments, if made by the nurse, would be therapeutic?

　　A.      "Tell me more about this."

　　B.      "When did you start believing this?"

　　C.      "I know that idea seems real to you, don't see it that way.

　　D.     “I can't imagine anyone mean enough to want to prevent you from improving food supply.”

　　2. Which of these goals would be most important for a female patient who has a borderline personality disorder while the patient is in group therapy?

　　A.      The patient will be able to explain the motivation for her behavior

　　B.      The patient will select her own activities

　　C.      The patient will interact with more people

　　D.     The patient will consider consequences before acting

　　3. A patient who is taking a monoamine oxidase inhibitor would demonstrate knowledge about the effectiveness of the medication by selecting foods that are

　　A. Low in cholesterol      B. Low in tyramine C. Free of gluten      D. Free of lactose

　　4. To discuss methods of stress reduction with a patient, the nurse should use which of these approaches first?

　　A.      Explain to the patient the physiological effects of stress

　　B.      Teach the patient relaxation techniques that reduce stress

　　C.      Determine if the patient is able to identify sources of stress

　　D.     Describe to the patient the benefits of active exercise in coping with stress

　　5. To detect for signs of bleeding following a thyroidectomy, it is most important for the nurse to include which of these measures in the patient's care plan?

　　A.      Palpating around the patient's incision site

　　B.      Lifting up the edge of the patient's dressing

　　C.      Turning the patient's head to the side

　　D.     Feeling the dressing at the sides and back the patient's neck

　　6. A patient who has had a thyroidectomy and is on thyroid extract says to the nurse, "The doctor says I should have thyroid test in a flew weeks. Why do I need tests when my thyroid has been removed?" which of these responses would give the patient accurate information?

　　A.      "It is important to evaluate the function of the parathyroid glands.'

　　B.      "It is important to determine when the pituitary gland begins to produce thyroid."

　　C.      "It is important to detect the presence of residual thyroid tissue."

　　D.     "It is important to know how your body is utilizing the medication."

　　7. Twelve hours after a thyroidectomy the patient develops carpal spasm. After notifying the physician, the nurse should be prepared to take which of these actions?

　　A.      Assist with a tracheostomy

　　B.      Administer calcium gluconate

　　C.      Prepare anticonvulsive medication for intravenous administration

　　D.     Schedule a carotid angiogram

　　Bill Brown, 25 years old, is brought to the emergency room complaining of fight flank pain. A renal calculus is suspected. He is given morphine sulfate and admitted to the hospital. He is scheduled for an intravenous pyelogram. His orders include morphine sulfate, q. 3. h, p.r.n, to relieve the pain of renal colic. He is to be out of bed as desired.

　　8. Mr. Brown is receiving morphine every 3 to 5 hours. He should be observed for side effects of morphine, which include:

　　A. Dizziness     B. Diplopia  C. Hypersalivation  D. Diarrhea

　　9. In preparing Mr. Brown for the IVP( intravenous pueloqnam), which of these statements should be included in the explanation given to him?

　　A.      "You will experience a warm sensation after the injection of the dye."

　　B.      "The X-ray table will be tilted while your x-rays are taken."

　　C.      "You will need to drink several glasses of fluid the morning of the procedure."

　　D.     "You will need to remain flat in bed for six hours after the procedure."

　　10.   An elderly patient is scheduled for radiographic tests, which require cleansing enemas and fasting for eight hours. During this period, which of these nursing diagnoses should be included in the patient's care plan?

　　A.      High risk for impaired skin integrity

　　B.      Alteration in bowel elimination

　　C.      High risk for fluid volume deficit

　　D.     Alteration in the nutrition

　　11.   A woman who is twelve weeks pregnant tells the nurse in the antepartal clinic that she swims in the town pool at least three times a week. The nurse should make which of these responses to this information?

　　A.      "Swimming in water that is less than body temperature may lower the temperature of the amniotic fluid."

　　B.      "Swimming may be too strenuous an activity after the second trimester of pregnancy."

　　C.      "Swimming in a public pool has a high probability of causing a uterine infection.

　　D.     "Swimming is an appropriate activity during pregnancy.

　　12.   A woman who is thirty weeks pregnant and who is attending the prenatal clinic has symptoms of pregnancy-induced hypertension. Which of these findings is indicative of this problem?

　　A.      She says, "I've been getting short of breath when I climb the second flight of stairs to my family' s apartment."

　　B.      She says, "I've had a craving for salty food lately."

　　C.      She has a blood pressure of 124/80mmHg compared with 90/60mmHg a month ago

　　D.     She has gained three pounds( 1.4kg) during the past month

　　13.   A pregnant woman who has abruptio placenta has an emergency cesarean birth under general anesthesia. Which of these measures should be included in the patient's care in the recovery room?

　　A.      Maintaining her in left lateral Sims' position

　　B.      Observing her for symptoms of infection

　　C.      Checking the characteristics of her lochia

　　D.     Assessing her for the presence of Homans' sign

　　14.   During the fourth stage of labor, the nurse notes that the patient's uterine fundus is boggy and in the midline. Which of these actions should the nurse take first?

　　A.      Massage the patient's uterine fundus

　　B.      Apply downward pressure to the patient's uterine fundus while she is voiding

　　C.      Discuss with the physician the patient's need for an oxytocic medication

　　D.     Check the characteristics of the patient's lochia

　　15.   A staff nurse is giving a shift report about a man with a psycho-physiologic illness. Which of these statements by the nurse would be consistent with the patient's therapy?

　　A.      "Encourage him to elaborate on his symptoms."

　　B.      "Assure him that there is no physical basis for his symptoms."

　　C.      "Tell him that the symptoms reflect his need for attention."

　　D.     "Direct his focus away from his symptoms."

　　16.   A patient has just been hospitalized for treatment of compulsive hand washing. The nurse should intervene if staff members are seen behaving in which of these ways?

　　A.      Whispering to one another within the patient's view

　　B.      Suddenly changing the patient's routine

　　C.      Turning away from the patient

　　D.     Touching the patient

　　17.   Which of these comments would a patient with an antisocial personality be most likely to make?

　　A.      "The police are always arresting me for nothing."

　　B.      "I'm feeling guilty because I've disappointed my family."

　　C.      "I'm becoming very anxious."

　　D.     "I've learned my lesson, and I'11 never do that again."

　　18.   A patient who has Alzheimer's disease is told by the nurse to brush his teeth. He shouts angrily, "Tomato soup!" Which of these actions by the nurse would be correct?

　　A.      Focus on the emotional reaction

　　B.      Clarify the meaning of his statement

　　C.      Give him step-by-step directions

　　D.     Do the procedure for him

　　19.   Which of these goals would be appropriate for a patient who has a diagnosis of Alzheimer' s disease?

　　A.      To develop social skills

　　B.      To increase motivation for serf-care

　　C.      To keep oriented to reality

　　D.     To protect from injury

　　20.   A patient has + + + + of albumin in his urine. The nurse should expect that he might have which of these symptoms'?

　　A.      Pulmonary rales

　　B.      Distended neck veins

　　C.      Muffled heart sounds

　　D.     Peripheral edema

　　A 54-year-old male patient has 15 years of history of cirrhosis from alcoholic abuse. He has had several hospital admissions for bleeding esophageal varices.

　　21.   When caring for him, you must consider that most important pathophysiologic factor contributing to the formation of esophageal varices is

　　A.      Decreased prothrombin formation

　　B.      Decreased albumin formation by the liver

　　C.      Portal hypertension

　　D.     Increased central venous pressure

　　22.   Assessing him, you will observe for

　　A.      Varicose veins and ulcers

　　B.      Ascites and hemorrhoids

　　C.      Intermittent claudication and cool extremities

　　D.     Decreased Peripheral pulses and jugular vein distention

　　23.   While he is on bed rest, he is in a semi-Fowler's position. The major objective for using this position is to

　　A.      Lower portal pressure

　　B.      Allow for effective breathing

　　C.      Decrease blood pressure

　　D.     Decrease risk of aspiration from vomiting

　　24.   The purpose of using a Sengslaken-Blakemore tube in clients with esophageal varices is to

　　A.      Apply direct pressure to bleeding ulcers

　　B.      Apply indirect pressure to bleeding ulcers via the esophageal

　　C.      Decrease the blood supply to the cardiac sphincter of the stomach

　　D.     Apply direct pressure to the esophageal and cardiac sphincter

　　25.   As the nurse assisting in the placement of a Sengslaken-Blakemore tube, prior to insertion you will

　　A.      Insert mercury into the gastric balloon

　　B.      Clamp the NG suction lumen

　　C.      Cheek both balloons for leaks

　　D.     Insert mercury into the esophageal balloon

　　26.   In addition, before the Sengstaken-Blakemore tube is inserted, you must he prepared to

　　A.      Administer an antacid

　　B.      Lavage the stomach with ice normal saline

　　C.      Administer atropine sulfate IM

　　D.     Start an IV of normal saline

　　27.   After the placement of the tube, you will evaluate him for

　　A.      Gastrointestinal hemorrhage

　　B.      Advancing of the tube

　　C.      Dislodging of the gastric balloon

　　D.     Esophagitis

　　28.   Evaluating him for the above complication, you will observe for an abrupt

　　A.      Drop in blood pressure

　　B.      Excruciating abdominal pain

　　C.      Difficulty in breathing

　　D.     Hematemesis

　　29.   If he exhibits the above sign, your initial nursing intervention is to

　　A.      Remove the tube

　　B.      Deflate the gastric balloon only

　　C.      Deflate the esophageal balloon only

　　D.     Cut the tube and remove it

　　30.   A patient is scheduled for an intravenous pyelogram (IVP). Which of these assessments of the patient would be most important to make prior to this scheduled IVP?

　　A.      Does he have a history of allergies?

　　B.      Does a member of his family have renal disease?

　　C.      Is his bladder distended?

　　D.     What was his recent food intake?

　　答案