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ISPN考试模拟试题(318)

Question:

A client who had transurethral resection of the prostate has dribbling urine after his Foley catheter is removed on the 2nd postoperative day. The nurse notes that the client had 200 mL of urine output in the last 8 hours with a 1,000 mL intake. Which of the following interventions is a priority for the nurse at this time? 

1. Apply a condom catheter. 

2. Assess for bladder distention. 

3. Obtain a urine specimen for culture. 

4. Teach the client Kegel exercises.

 


The imbalance between the client’s intake and output indicates that the client may be retaining urine since the removal of his Foley catheter. The nurse’s first action is to validate this assumption by assessing for bladder distention. 

Applying a condom catheter will not relieve urinary retention; condom catheters are meant to be used for incontinence. A urine specimen for a culture is obtained if a urinary infection is suspected, but this is not a priority at this point. Kegel exercises are helpful in controlling urinary dribbling but do nottreat retention. 

CN: Reduction of risk potential; CL: Synthesize

Answer:2

 

翻译

 

问题:

经尿道前列腺电切术后第二天尿路被移除的病人。护士注意到,在过去的8小时内,病人的尿液排出量为200毫升,摄入量为1000毫升。以下哪项干预措施是护士此时的首要任务?

1.使用避孕套导管。

2.评估膀胱扩张。

3.取尿样进行培养。

4.教授病人凯格尔练习。

 

答案:2

病人的吸入量和排出量之间的不平衡表明病人可能在取下导尿管后留着尿。护士的首要任务是通过评估膀胱扩张来验证这个假设。

使用安全套导管并不能缓解尿潴留;安全套导管是用来治疗尿失禁的。如果怀疑有尿路感染,就要取尿样进行培养,但这并不是重点。凯格尔运动有助于控制尿滴,但不能治疗尿潴留。

CN:降低风险可能性;CL:综合

小编寄语accept what was and what is, and you’ll have more positive energy to pursue what will be.接受过去和现在的模样,才会有能量去追寻自己的未来。

时间:2020/8/5 10:36:38
 
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