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ISPN考试模拟试题(二十六)


Questions

1.A nurse is concerned that a client is at risk for developing hyperkalemia. Which disease does the client have that has caused this concern?

A. Crohn

B. Cushing

C. End-stage renal

D. Gastroesophageal reflux


2.A client’s serum potassium level has increased to 5.8 mEq/L. What action should the nurse implement first?

A. Call the laboratory to repeat the test.

B. Take vital signs and notify the health care provider.

C. Inform the cardiac arrest team to place them on alert.

D. Take an electrocardiogram and have lidocaine available.


3.What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select all that apply.

A. Tetany

B. Seizures

C. Diarrhea

D. Weakness

E. Dysrhythmias


4.A nurse adds 20 mEq of potassium chloride to the IV solution of a client with diabetic ketoacidosis. What is the primary purpose for administering this drug?

A. Treat hyperpnea

B. Prevent flaccid paralysis

C. Replace excessive losses

D. Treat cardiac dysrhythmias


5.The intake and output of a client over an 8-hour period (8 AM to 4 PM) is: 8 AM: IV with D5W infusing and 900 mL left in bag 8:30 AM: 150 mL urine voided 9 AM to 3 PM: 200 mL gastric tube formula and 50 mL water at q3h intervals 1 PM: 220 mL voided 3:15 PM: 235 mL voided 4 PM: IV with 550 mL left in bag What is the difffference between the client’s intake and output? Record your answer using a whole number.

Answer: _________ m/L

Rationales

1.C 

One of the kidneys’ functions is to eliminate potassium from the body; diseases of the kidneys often interfere with this function, and hyperkalemia may develop, necessitating dialysis.

A,Clients with Crohn disease have diarrhea, resulting in potassium loss.

B,Clients with Cushing disease will retain sodium and excrete potassium.

D,Clients with gastroesophageal reflux disease are prone to vomiting that may lead to sodium and chloride loss with minimal loss of potassium.

Client Need: Physiological Adaptation;

Cognitive Level: Analysis;

Nursing Process: Assessment/Analysis;

Reference: Ch 3, Acid-Base Balance


2.B 

Vital signs monitor cardiorespiratory status; hyperkalemia causes cardiac dysrhythmias. The health care provider should be notified because medical intervention may be necessary.

A, A repeat laboratory test will take time and probably reaffirm the original results; the client needs immediate attention.

C,The cardiac arrest team is always on alert and will respond when called for a cardiac arrest.

D,These are insufficient interventions.

Client Need:Physiological Adaptation;

Cognitive Level:Analysis;

Nursing Process:Planning/Implementation;

Reference:Ch 3, Acid-Base Balance


3. Answer:C, D, E.

A,Tetany is caused by hypocalcemia.

B,Seizures caused by electrolyte imbalances are associated with low calcium or sodium levels.

C,Because of potassium’s role in the sodium/potassium pump, hyperkalemia will cause diarrhea.D,Because of potassium’s role in the sodium/potassium pump, hyperkalemia will cause weakness.

E,Because of potassium’s role in the sodium/potassium pump, hyperkalemia will cause cardiac dysrhythmias.

Client Need:Physiological Adaptation;

Cognitive Level:Analysis;

Nursing Process: Assessment/Analysis;

Reference: Ch 3, Acid-Base Balance


4.C 

Once treatment with insulin for diabetic ketoacidosis is begun, potassium ions reenter the cell, causing hypokalemia; therefore, potassium, along with the replacement fluids, is needed.

A, Potassium will not correct hyperpnea.

B, Flaccid paralysis does not occur in diabetic ketoacidosis.

D,Considering the relationship between insulin and potassium, treatment with KCl is prophylactic, preventing the development of dysrhythmias.

Client Need: Pharmacological and Parenteral Therapies;

Cognitive Level: Comprehension;

Nursing Process: Planning/Implementation;

Reference: Ch 3, General Nursing Care of Clients with Fluid and Electrolyte Problems


5. Answer: 495 mL.

Intake includes 350mL of IV fluid, 600 mL of NGT feeding, and 150mL of water via NGT, for a total intake of 1100mL; output includes voidings of 150, 220, and 235mL, for a total output of 605mL. Subtract 605mL from 1100mL for a difference of 495mL.

Client Need:Basic Care and Comfort;

Cognitive Level:Application;

NursingProcess:Planning/Implementation;

Reference:Ch 3, General Nursing Care of Clients with Fluid and Electrolyte Problems

小编寄语:一分耕耘,一分收获! Fighting!


时间:2019-06-11 17:29:22
 
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