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ISPN考试模拟试题(二十二)

Questions

1. A nurse in the ambulatory preoperative unit identifies that a client is more anxious than most clients. What is the nurse’s best intervention?

A. Attempt to identify the client’s concerns.

B. Reassure the client that the surgery is routine.

C. Report the client’s anxiety to the health care provider.

D. Provide privacy by pulling the curtain around the client.


2. A client who was admitted to the hospital with metastatic cancer has a temperature of 100.4° F, a distended abdomen, and abdominal pain. The client asks the nurse, “Do you think that I’m going to have surgery?” How should the nurse respond?

A. “You seem concerned about having surgery.”

B. “Some people with your problem do have surgery.”

C. “I’ll find out for you. Your record will show if surgery is scheduled.”

D. “I don’t know about any surgery. You’ll have to ask your health care provider.”


3. What principle must a nurse consider when caring for a client with a closed wound drainage system?

A. Gravity causes fluids to flow down a pressure gradient.

B. Fluid flow rate is determined by the diameter of the lumen.

C. Siphoning causes fluids to flow from one level to a lower level.

D. Fluids flow from an area of higher pressure to one of lower pressure.


4. A client had extensive, prolonged surgery. Which electrolyte level should the nurse monitor most closely?

A. Sodium

B. Calcium

C. Chloride

D. Potassium


5. How should a nurse prepare an IV piggyback (IVPB) medication for administration to a client receiving an IV infusion? Select all that apply.

A. Wear clean gloves to check the IV site.

B. Rotate the bag after adding the medication.

C. Use 100 mL of fluid to mix the medication.

D. Change the needle before adding the medication.

E. Place the IVPB at a lower level than the existing IV.

F. Use a sterile technique when preparing the medication. 

Rationales

1.A 

The nurse should assess the situation before planning an intervention.

B,This minimizes concerns and cuts off communication.

C,This is premature; more information is needed.

D,The nurse needs more information; pulling the curtain may make the client feel isolated, which may increase anxiety.

Client Need: Psychosocial Integrity;

Cognitive Level: Application;

Integrated Process: Caring;

Nursing Process: Assessment/Analysis;

Reference: Ch 2, Nursing Process


2.A

This statement is open-ended and encourages the client to verbalize concerns.

B,D,This cuts off communication.

C,Nothing in the situation indicates that surgery is planned; this response may increase anxiety.

Client Need: Psychosocial Integrity;

Cognitive Level: Application;

Integrated Process: Caring; Communication/Documentation;

Nursing Process: Planning/Implementation;

Reference: Ch 2, The Nurse-Client Relationship


3.D 

A portable wound drainage system has negative pressure; a nurse must ensure that the collection chamber is compressed so that fluid flows down the pressure gradient from the client to the collection device.

A,This is Newton’s law of gravity, which is not the physical principle underlying the functioning of a portable wound drainage system.

B, C,Although true, this is not what causes the fluid to drain in a portable wound drainage system. 

Client Need: Reduction of Risk Potential;

Cognitive Level:Comprehension;

Nursing Process: Planning/Implementation;

Reference: Ch 3, General Nursing Care of Clients during the Postoperative Period


4.D 

Release of adrenocortical steroids (cortisol) by the stress of surgery causes renal retention of sodium and excretion of potassium.1 Although sodium may be depleted by nasogastric suction, retention by the kidneys generally balances this loss.

B, C, This is not depleted by surgery or urinary excretion.

Client Need: Physiological Adaptation;

Cognitive Level: Comprehension;

Nursing Process: Evaluation/Outcomes;

Reference: Ch 3, Acid-Base Balance


5. Answer: A, C, F.

A,Clean gloves should be worn to check the IV site because there is a risk of coming into contact with the client’s blood.

B, Ensuring that the medication is mixed is important. Rotating the bag is one way, although there are others.

C,The amount and type of solution depend on the medication.

D,The needle does not have to be changed if sterility is maintained.

E,The IVPB should be hung higher, not lower, than the existing bag.

F,Because IV solutions enter the body’s internal environment, all solutions and medications using this route must be sterile to prevent the introduction of microbes.

Client Need:Pharmacological and Parenteral Therapies;

Cognitive Level:Analysis;

Nursing Process: Planning/Implementation;

Reference: Ch 2, Nursing Responsibilities Related to Medication Administration

小编寄语:越努力,越幸运!Fighting!


时间:2019-06-04 16:12:11
 
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