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ISPN考试模拟试题(二十七)

Questions

1.A nurse is caring for a client with ascites. What does the nurse consider to be the cause of the ascites?

A. Portal hypotension

B. Kidney malfunction

C. Diminished plasma protein level

D. Decreased production of potassium


2.A client is receiving an IV infusion of 5% dextrose in water. The client loses weight and develops a negative nitrogen balance. What nutritional problem prompts the nurse to notify the health care provider?

A. Excessive carbohydrate intake

B. Lack of protein supplementation

C. Insufficientintake of water-soluble vitamins

D. Increased concentration of electrolytes in cells


3.An IV solution of 1000 mL 5% dextrose in water is to be infused at 125 mL/hr to correct a client’s fluid imbalance. The infusion set delivers 15 drops/mL. To ensure that the solution will infuse over an 8-hour period, at how many drops per minute should the nurse set the rate of flow? Record your answer using a whole number.

Answer: ______ gtt/min


4.What complication is prevented when a nurse addresses the needs of a client who is hyperventilating?

A. Cardiac arrest

B. Carbonic acid deficit

C. Reduction in serum pH

D. Excess oxygen saturation

Rationales

1.C 

The liver manufactures albumin, the major plasma protein. A deficit of this protein lowers the osmotic (oncotic) pressure in the intravascular space, leading to a fluid shift.

A,An enlarged liver compresses the portal system, causing increased, rather than decreased, pressure.

B,The kidneys are not the primary source of the pathologic condition. It is the liver’s ability to manufacture albumin that maintains the colloid oncotic pressure.

D,Potassium is not produced by the body, nor is its major function the maintenance of fluid balance.

Client Need:Physiological Adaptation;

Cognitive Level:Comprehension;

Nursing Process:Assessment/Analysis;

Reference:Ch 3, Fluid and Electrolyte Balance


2.B 

An infusion of dextrose in water does not provide proteins required for tissue growth, repair, and maintenance; therefore, tissue breakdown occurs to supply the essential amino acids.

A,Each liter provides approximately 170 calories, which is insufficient to meet minimal energy requirements; tissue breakdown will result.

C,Weight loss is caused by insufficient nutrient intake; vitamins do not prevent weight loss.

D,An infusion of 5% dextrose in water may decrease electrolyte concentration.

Client Need:Physiological Adaptation;

Cognitive Level:Analysis;

Nursing Process:Evaluation/Outcomes;

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


3. Answer: 31 drops per minute. 

Use the following formula to solve the problem. 

Client Need:Pharmacological and Parenteral Therapies;

Cognitive Level:Application;

Nursing Process:Planning/Implementation;

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


4.B 

Hyperventilation causes excessive loss of carbon dioxide, leading to carbonic acid deficit and respiratory alkalosis.

A,Cardiac arrest is unlikely; the client may experience dysrhythmias but will loseconsciousness and begin breathing regularly.

C,Hyperventilation causes alkalosis; the pH is increased.

D,This cannot occur; the usual oxygen saturation of hemoglobin is 95% to 98%.

Client Need:Physiological Adaptation;

Cognitive Level:Application;

Nursing Process:Planning/Implementation;

Reference:Ch 3, Acid-Base Balance

小编寄语:滴水穿石,学习亦如此!Fighting!



时间:2019-06-12 17:10:20
 
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