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ISPN考试模拟试题(四十六)

Questions

1.A nurse inspects a two-day-old intravenous site and identifies erythema,warmth, and mild edema. The client reports tenderness when the area is palpated. What should the nurse do first?

A.Irrigate the IV tubing.

B.Discontinue the infusion.

C.Slow the rate of the infusion.

D.Obtain a prescription for an analgesic.


2.While convalescing from abdominal surgery a client develops thrombophlebitis. Which clinical indicators of this complication should the nurse expect to identify when assessing the client? Select all that apply.

A.Pain in the calf

B.Intermittent claudication

C.Redness in the affected area

D.Pitting edema of the lower leg

E.Ecchymotic areas around the ankle

F.Localized warmth in the lower extremity


3.A client who had surgery 24 hours ago reports pain in the calf. Assessment reveals redness and swelling at the site of discomfort. What should the nurse do?

A.Keep both legs dependent.

B.Notify the health care provider.

C.Apply a warm soak to the left calf.

D.Administer the prescribed analgesic.


4.A nurse is teaching a client about the use of antiembolism stockings.What instruction should the nurse include?

A.Keep the stockings on two hours and off two hours.

B.Wear the stockings only at bedtime when activity lessens.

C.Put the stockings on before getting out of bed in the morning.

D.Leave the stockings in place until the health care provider advises otherwise.


5.A health care provider orders thigh-high antiembolism stockings for a client with varicose veins. The client’s thighs are heavier than the lower legs, and the stockings fit on the lower leg but are causing discomfort and indentations on the upper thighs. What should the nurse do?

A.Replace the thigh-high stockings with knee-high stockings.

B.Leave the antiembolism stockings off to prevent tissue damage.

C.Roll the top of the stockings to below the knees to limit popliteal pressure.

D.Ask the health care provider if an elastic bandage can be used in place of the stockings.

Rationales

1.B 

The clinical findings indicate the presence of inflammation.The intravenous catheter should be removed to prevent the development of thrombophlebitis.

A, C,This is unsafe. It may further irritate the vein and precipitate a thrombophlebitis.

D,Although this may relieve the discomfort, it is not an intervention that will resolve the problem.

Client Need:Pharmacological and Parenteral Therapies;

Cognitive Level:Application;

Nursing Process:Planning/Implementation;

Reference:Ch6,Vascular Disease, Data Base


2.Answer: A, C,F.

A,Pain is related to the edema associated with the inflammatory response.

B,Intermittent claudication (pain when walking, resulting from tissue ischemia) may occur with peripheral arterial disease.

C,Redness is related to vasodilation and the inflammatory response.

D,Although some localized edema occurs, pitting edema does not occur in thrombophlebitis.

E,Ecchymosis is a sign of bleeding;thrombophlebitis is caused by a clot.

F,Thrombophlebitis is inflammation of a vein that occurs with the formation of a clot.Warmth is related to vasodilation.

Client Need:Physiological Adaptation;

Cognitive Level:Analysis;

Nursing Process:Assessment/Analysis;

Reference:Ch6,Vascular Disease, Data Base


3.B 

The clinical findings indicate a possible thrombophlebitis. Bed rest with the legs elevated should be maintained and the health care provider notified immediately.A thrombus may progress to a pulmonary embolus.

A,The legs should be kept elevated until the client is evaluated by the health care provider.

C,The application of warm soaks is a dependent function of the nurse that requires a health care provider’s order.

D,Administering an analgesic for pain in a site other than the one for which it was prescribed is not an independent nursing function; in addition,the medication may obscure the problem in the calf, place the client in jeopardy, or further delay treatment.

Client Need:Management of Care;

Cognitive Level:Application;

Nursing Process:Planning/Implementation;

Reference:Ch6,Vascular Disease, Nursing Care


4.C 

Support hose apply external pressure on the veins,preventing the retrograde pressure or flow that may occur in the standing or sitting positions;application before arising prevents the veins from having the opportunity to become engorged.

A,If this schedule is followed,at some point the feet will be dependent before the stockings are put on;venous pooling and edema may occur;application of elastic stockings at this time can cause tissue trauma.

B,They usually need not be worn while in bed with the feet elevated during sleep because gravity prevents venous pooling.

D,Stockings must be removed so that the legs can be washed and dried at least daily.

Client Need:Reduction of Risk Potential;

Cognitive Level:Application;

Integrated Process:Teaching/Learning;

Nursing Process:Planning/Implementation;

Reference:Ch6,Vascular Disease,Nursing Care


5.D 

An elastic bandage can be adjusted to the varying proportions of the client’s legs.

A,This action requires a health care provider’s order.

B,This is unsafe; this permits venous stasis.

C,This will increase the pressure in the popliteal space,which increases venous stasis and the risk of thrombophlebitis.

Client Need:Basic Care and Comfort;

Cognitive Level:Application;

Nursing Process:Planning/Implementation;

Reference:Ch6,Vascular Disease,Nursing Care

小编寄语: 没伞的孩子必须努力奔跑!Fighting!

时间:2019-07-11 16:40:51
 
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