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ISPN考试模拟试题(480)

Question:

To protect a client who has received tissue plasminogen activator (t-PA) or alteplase recombinant (Activase) therapy, the nurse should: 

1. Use the radial artery to obtain blood gas samples. 

2. Maintain arterial pressure for 10 seconds. 

3. Administer IM injections. 

4. Encourage physical activity.

 

The nurse should use the radial artery to obtain blood gas samples because it is easier to maintain firm pressure there than on the femoral artery. Nursing interventions to protect the client who has received t-PA or alteplase recombinant (Activase) therapy include maintaining arterial pressure for 30 seconds because it takes longer for coagulation to occur with the thrombolytic agent on board. IM injections are contraindicated during thrombolytic therapy. The nurse should prevent physical manipulation of the client, which can cause bruising. 

CN: Reduction of risk potential; CL: Synthesize

Answer:1

 

翻译

问题:

为保护接受组织型纤溶酶原激活剂(t-PA)或重组阿替普酶(活化酶)治疗的患者,护士应:

1.用桡动脉采集血气样本。

2.保持动脉压10秒钟。

3.注射IM

4.鼓励体育活动。

 

答案:1

护士应使用桡动脉采集血气样本,因为桡动脉比股动脉更容易保持稳定的压力。为保护接受t-PAalteplase重组(Activase)治疗的病人而采取的护理干预措施包括维持动脉压30秒,因为在使用溶栓剂需要更长时间才能发生凝血。溶栓治疗期间禁止注射IM。护士应防止对病人进行可能导致瘀伤的物理操作。

CN:降低潜在风险;CL:综合

小编寄语:Life is like a pencil that is used all the time. It's sharp at first, but it's smooth gradually. However, if it's too smooth, it's almost time to be cut again.人生就像不停在用的铅笔,开始很尖,但慢慢的就磨的圆滑了。不过,太过圆滑了,就差不多又该挨削了。

时间:2021/3/22 10:39:40
 
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