【点名时间】——国际护士模拟试题11
2016/7/15 宏景USRN
今天是【点名时间】与你第11次见面。
邻居家的小朋友又闹腾了？那个XX明星又有绯闻了？你喜欢的歌手的演唱会错过了？没关系的亲们!至少，你正在进行的另一个人生征程还在继续。坚持下去，就能演绎自己的主角。
51. A nurse is teaching a patient about blood pressure measurement in pregnancy. The nurse teaching should be based on which of the following statements?
A. Blood pressure can be expected to rise slightly in the second trimester.
B. Arterial blood pressure is highest when a woman is sitting.
C. Arterial blood pressure is highest when a woman is supine.
D. Orthostatic blood pressure readings should be taken at each prenatal visit.
52. The parents of a child diagnosed with a schizoid personality disorder ask the nurse how this diagnosis was made. The nurse should explain that the child exhibited which of the following manifestations?
A. Inability to experience pleasure.
B. Jealousy and a quickness to react to anger.
C. Insensitivity to the welfare of others.
D. Lack of guilt or social conscience.
53. An order on a 3 kg critically ill neonate's chart reads as follows: Give digoxin(Lanoxin)0.25mg NG daily. Which of the following nursing actions is appropriate in relation to the prescribed order?
A. Carry out the order as written.
B. Give the digoxin after checking the apical pulse and potassium level.
C. Hold the drug until a serum digoxin level is obtained.
D. Question the doctor about this order.
54. In teaching a mother of an 18 month-old about prevention and safety in the home, the nurse should include which of the following measures in response to accidental ingestion?
A. Induce vomiting with one dose of ipecac syrup.
B. Call the local Poison Control Center for advice prior to treatment.
C. Give the child several glasses of water to flush the substance.
D. Have the child eat the inner portion of a piece of bread.
55. The patient receiving rofecoxib(Vloxx) should be monitored for which of the following side effects?
A. Tiredness and somnolence.
B. Hypotension and tachycardia.
C. Dyspnea and chest pain.
D. Irritability and agitation.
昨天答案解析
46. Key: A
Client Need, Reduction of Risk Potential
A. Hyperextension facilitates insertion of the catheter into the trachea.
B. This position is used for insertion of a nasogastric tube. This position would inhibit insertion.
C. Turning the patient's head to the right may help the nurse suction the patient's left main stem hronchus. However, this is after the catheter has been inserted and refers to suctioning. not insertion.
D. Positioning in some instances, (e. g. turning the patient's head to the left) helps the nurse to suction the patient's right main stem bronchus. However, this would be after the catheter has been inserted and refers to suctioning, not insertion.
47. Key: D
Client Need: Management of Care
D. Dysfunctional grieving related to loss is the priority nursing diagnosis. This diagnosis includes the presenting symptoms of isolation, self-neglect and social withdrawal.
A. There is no evidence in this scenario that the patient is anxious about her own death.
B. Self-care deficit is present. but it is one feature of dysfunctional grieving and is therefore incomplete in itself.
C. Anticipatory grieving usually refers to the process that begins when a terminal diagnosis is made for either a patient or family member. This is not present in this scenario.
48. Key: A
Client Need: Basic Care and Comfort
A. One way to promote defecation is to have the patient assume a squatting position. With a bedside commode. the patient will be able to assume the squatting position and this is most like their normal elimination pattern. The nurse should incorporate the patient's elimination routine or habits as much as possible and reinforce those that promote health. The epidural drip can be easily moved and transported. The chest tubes have to remain close to the suction device so as to prevent a pneumothorax.
B. If the patient is able to get out of bed. he should be permitted to use a commode. This is most like the patient's normal routine and pattern. This patient is unable to go far because he is connected to suction.
C. With the chest tube, the patient will have to remain connected to suction and there is a limitation in the amount or degree of movement. The nurse does not want to clamp or disconnect the chest tube. It may result in a pneumothorax. Use of the commode is the most realistic option.
D. Clamping or disconnecting chest tubes is contraindicated. Such actions may result in a tension pneumothorax, which is life threatening.
49. Key: B
Client Need: Physiological Adaptation
B. The nurse should assess the pain experience from the patient's perspective. Believe the patient in their reports of pain. The patient is the source for evaluating outcomes of pain management. A numerical rating scale requires a patient to rate pain from 0 to 10. 0 being no pain. IO being severe pain. The patient rates her pain at 2, which is a low pain level.
A. Sleep or sedation may be mistakenly equated with lack of pain, but even patients with severe pain may sleep. A nurse who is unfamriliar with physiologic and behavioral pain responses may question if a patient has pain if he/she is asleep. If the patient is asleep. the nurse should not conclude that the pain is absent.
C. A numerical rating scale requires clients to rate pain on a scale of 0 to 10, 0 being no pain, 10 being severe pain.
D. A behavioral indication of the effects of pain may be immobilization.
50. Key: A
Client Need: Management of Care
A. Documentation is defined as anything written or printed that is relied on as a record of proof for authorized persons. Effective documentation reflects the quality of care and provides evidence of each healthcare team member’s accountibility in giving care. Accountability means that the nurse is responsible professionally and legally for the type and quality of nursing care provided.
B. Even though accurate documentation is one of the best defenses against legal claims associated with nursing care, the nurse must function under the Code of Ethics. The nurse is responsible for carrying out nursing responsibilities that provide quality nursing care.
C. Insurance reimbursement requires accurate documentation. However, nurses must remember that they are professionals and must be aware of their professional nursing role.
D. Many regulatory bodies require proper documentation. However. the primary reason for accurate documentation relates to evidence of accountability.
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