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好好学习，天天向上

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好好学习，天天向上 CG和TOEFL资料的备用版 一起学习吧~ 2005-10-09 电解质紊乱 TAG： cgfns 试题 电解质紊乱

  1. A nurse is reading a physician's progress notes in the client's record and reads that the physician has documented "insensible fluid loss of approximately 800 mL daily." The nurse understands that this type of fluid loss can occur through:
  2. The gastrointestinal (GI) tract
  3. Urinary output
  4. Wound drainage
  5. The skin progress notes 病情记录 document 记录 insensible fluid loss 非显性失水 gastrointestinal 胃肠的 urinary 泌尿的 drainage 引流 gastro- 胃 gastroenteritis 肠胃炎 gastrology 胃病学 gastritis 胃炎 answer:4 Rationale: Sensible losses are those of which the person is aware, such as through wound drainage, Gl tract losses, and urination. Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs.
  6. A nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume deficit?
  7. A client with a colostomy
  8. A client receiving frequent wound irrigations
  9. A client with congestive heart failure (CHF)
  10. A client with decreased kidney function assign 指派 deficit 缺乏 colostomy 结肠造瘘术 irrigation 冲洗 , 冲洗法 congestive 充血的 congestive heart failure (CHF) 充血性心力衰竭 colo- 结肠 colitis 结肠炎 colectomy 结肠切除术 colostomy 结肠造瘘术 answer: 1 Rationale: Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient IV fluid replacement, draining fistulas, and the presence of an ileostomy( 回肠造口术 ) or colostomy. A client with CHF or decreased kidney function or a client receiving frequent wound irrigations is at risk for fluid volume excess.
  11. A nurse is caring for a client who has been taking diuretics on a long-term basis. A fluid volume deficit is suspected. Which assessment finding would be noted in a client with this condition?
  12. Rales
  13. Increased blood pressure
  14. Decreased hematocrit
  15. Decreased central venous pressure (CVP) diuretic 利尿的 , 利尿剂 rale 罗音 , 水泡音 hematocrit 血细胞比容 central venous pressure (CVP) 中心静脉压 hemato- 血 hematology 血液 hematopoiesis 造血作用 hematoma 血肿 answer: 4 Rationale: Assessment findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased CVP, weight loss, poor skin turgor( 充盈 ), dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. The normal CVP is between 4 and 11 mm H 2 O. A client with dehydration has a low CVP. The assessment findings in options 1, 2, and 3 are seen in a client with fluid volume excess.
  16. A nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is at risk for a fluid volume excess?
  17. The client with renal failure
  18. The client with an ileostomy
  19. The client on diuretics
  20. The client on gastrointestinal (Gl) suctioning excess 过剩 , 过量 renal failure 肾衰 ileostomy 回肠造口术 suction 吸引 diuretic 利尿剂 ileo- 回肠 ileocolitis 回肠结肠炎 ileocecostomy 回肠盲肠吻合术 ileotomy 回肠切开术 answer: 1 Rationale: The causes of fluid volume excess include decreased kidney function, congestive heart failure (CHF), the use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client with an ileostomy, the client on diuretics, and the client on Gl suctioning are at risk for fluid volume deficit.
  21. The nurse is caring for a client with congestive heart failure (CHF). On assessment, the nurse notes that the client is dyspneic and that rales are heard on auscultation. The nurse suspects fluid volume excess. What additional signs would the nurse expect to note in this client if fluid volume excess is present?
  22. A decreased central venous pressure
  23. Flat neck and hand veins
  24. An increase in blood pressure
  25. Weight loss dyspneic 呼吸困难的 (dyspnea 呼吸困难 ) auscultation 听诊 flat 平坦的 , 扁平的 -pnea 呼吸 apnea 呼吸暂停 hyperpnea 呼吸过度 , 喘息 hypopnea 呼吸不足 , 呼吸浅慢 answer: 3 Rationale: Assessment findings associated with fluid volume excess indude cough, dyspnea, rales, tachypnea, tachycardia, an elevated BP and a bounding pulse, an elevated central venous pressure (CVP), weight gain, edema, neck and hand vein distention, altered level of consciousness, and a decreased hematocrit Options 1, 2, and 4 identify signs noted in fluid volume deficit.
  26. A nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because the client:
  27. Is on nasogastric (NG) suction
  28. Has a history of renal disease
  29. Has a history of Addison's disease
  30. Is taking a potassium-sparing diuretic potassium 钾 nasogastric 鼻饲的鼻胃的 Addison's disease 阿狄森氏病 , 慢性肾上腺皮质机能减退症 sparing 节俭的 , 保守的 potassium-sparing diuretic 保钾利尿药 naso- 鼻 nasopharyngeal 鼻咽的 nasoscope 鼻镜 nasopharyngitis 鼻咽炎 answer: 1 Rationale: Potassium-rich GI fluids are lost through Gl suction, placing the client at risk for hypokalemia. The client with renal disease or Addison's disease and the client taking a potassium-sparing diuretic are at risk for hyperkalemia.
  31. A nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 3.2mEq/L. Which of the following would the nurse note on the ECG as a result of the laboratory value?
  32. Elevated T waves
  33. Absent P waves
  34. Elevated ST segment
  35. U waves electrolyte 电解质 ECG 心电图 T waves T 波 ST segment ST 段 U waves U 波 electro- 电 electrobiology 生物电学 electrocardiogram 心电图 electrocoagulation 电凝法 answer: 4 Rationale: A serum potassium level below 3.5 mEq/L is indicative of hypokalemia. Potassium deficit is a relatively common electrolyte imbalance and is potentially life threatening. ECG changes include inverted T waves, ST segment depression, heart block, and prominent U waves.
  36. A nurse prepares to administer IV potassium chloride as prescribed to a client with hypokalemia. Which of the following would not be a part of the nurse's plan in regard to the preparation and administration of the potassium?
  37. Prepare the medication for bolus administration
  38. Obtain a controlled IV infusion pump
  39. Dilute in appropriate amount of normal saline
  40. Monitor urine output during administration chloride 氯化物 hypokalemia 低血钾 infusion 输注 dilute 稀释 urine output 尿量 administration 服法 , 给药 -kalemia 钾血症 hyperkalemia 高钾血症 hypokalemia 低钾血症 answer: 1 Rationale: Potassium chloride administered by IV must always be diluted in IV fluid and infused via a pump or controller. The usual concentration of IV potassium chloride is 20 to 40 mEq/L. Potassium chloride is never given by bolus (W push). Giving potassium chloride by IV push can result in cardiac arrest. Dilution in normal saline is recommended, and dextrose solution is avoided because this type of solution increases intracellular potassium shifting. The IV bag containing the potassium chloride is always agitated before hanging. The IV site is monitored dosety because potassium chloride is very irritating to the veins and the risk of phlebitis exists. Urinary output is monitored during administration, and the physician is contacted ifthe urinary, output is less than 30 mL/hr.
  41. A nurse instructs a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse determines that the client understands the food sources of potassium if the client states that the food item lowest in potassium is:
  42. Spinach
  43. Carrots
  44. Avocado
  45. Apples potassium 钾 source 来源 hypo-hypoalimentation 营养不良 hypochondrium 季肋 hypodermia 皮下组织 food high in potassium: avocado 鳄梨 ; raisins 葡萄干 ; pork, veal 小牛肉 , beef; cantaloupe 甜瓜 ; spinach; banans; fish; oranges; strawberries; mushrooms; carrot; potatoes; tomatoes hypo-h ypoacidity 胃酸过少 hypoactive 活动减退的 hypoaldosteronism 醛固酮减少症 answer: 4 Rationale: A medium apple provides approximately 159 mg of potassium. Spinach (31/2 oz) provides 470 rog. A large carrot provides 34I mg and a medium avocado provides 1097 mg of potassium.
  46. A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a potassium level of 5.5 mEq/L on one client's laboratory reports. The nurse understands that which client is at most risk for the development of a potassium value at this level?
  47. The client who has sustained a traumatic burn
  48. The client with Cushing's syndrome
  49. The client with colitis
  50. The client who has been overusing laxatives sustained 持续的 , 持久的 traumatic 外伤性的 Cushing's syndrome 柯兴综合征 colitis 结肠炎 overuse 滥用 , 使用过度 laxative 缓泻药 over- 过度 , 超 over-react 反应过度强烈 over-sensitive 过于敏感的 overload 超负荷 answer: 1 Rationale: A serum potassium level greater than 5.1 mEq/L is indicative of hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive celldestruction, such as in trauma, bums, or sepsis or with metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing's' syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.
  51. A nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.4mEq/L. Which of the following would the nurse expect to note on the ECG as a result of the laboratory value?
  52. Tall T waves
  53. Prominent U wave
  54. ST depression
  55. Inverted T wave ECG 心电图 prominent 卓越的 , 显著的 , 突出的 depression 降低 , 抑郁症 -lyte 可分解物 , 溶解质 anolyte 阳极 ( 电解 ) 液 ,catholyte 阴极电解液 hydrolyte 水解质 answer: 1 Rationale: A serum potassium level above 5.4 mEq/L is indicative of hyperkalemia. ECG changes include flat P waves, prolonged PR intervals, widened QRS complexes, and tall T waves.
  56. A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of 130 mEq/L on one client's laboratory reports. The nurse understands that which client is at most risk for the development of a sodium value at this level?
  57. The client who is taking diuretics
  58. The client who is taking corticosteroids
  59. The client with renal failure
  60. The client with hyperaldosteronism sodium 钠 corticosteroid 皮质类固醇 hyperaldosteronism 醛 固 酮过多症 cortico- 皮 , 皮质 corticosterone 皮质脂酮 corticotropin 促肾上腺皮质激素 decorticate 去皮质 answer: 1 Rationale: Hyponatremia is evidenced by a serum sodium level of less than 135 mEq/L. Hyponatremia can occur in the client taking high-ceiling diuretics. The client taking corticosteroids and the client with renal failure or hyperaldosteronism are at risk for hypematremia.
  61. A nurse is caring for a client with acute congestive heart failure who is receiving high doses of a high-ceiling diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia is present?
  62. Dry, flaky skin
  63. Decreased urinary output
  64. Increased specific gravity of the urine
  65. Hyperactive bowel sounds high-ceiling diuretic (loop diuretic) 髓袢利尿药 tendon 腱 hyponatremia 低血钠 specific gravity 比重 urine hhxcttxs 发表于 11:20:51 | 阅读全文 | 评论 (0) | 引用 (Trackback 0) | 编辑 2005-10-09 酸碱平衡 TAG： cgfns 试题 酸碱平衡
  66. A nurse plans care for a client with chronic obstructive pulmonary disease (COPD) knowing that the client is most likely to experience what type of acid-base imbalance?
  67. Respiratory acidosis
  68. Respiratory alkalosis
  69. Metabolic acidosis
  70. Metabolic alkalosis COPDchronic obstructive pulmonary disease 慢性阻塞性肺部疾病 acid 酸 base 碱 acid-base imbalance 酸碱平衡失调 respiratory acidosis 呼吸性酸中毒 metabolic alkalosis 代谢性碱中毒 acido- 酸 acidometer 酸度计 acidophil 嗜酸细胞acidogenic生酸的 answer: 1 Rationale: Respiratory acidosis is most often due to hypoventilation. Chronic respiratory acidosis is most commonly caused by COPD. In end-stage disease, pathological changes lead to airway collapse, air trapping, and disturbance of ventilation-perfusion {V/Q} relationships. Options 2, 3, and 4 are incorrect options.
  71. A nurse reviews the blood gas results of a client with Guillain-Barr è syndrome. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which of the following validates the nurse's findings?
  72. pH 7.50, Pco2 52 mm Hg
  73. pH 7.35, Pco2 40 mm Hg
  74. pH 7.25, Pco2 50 mm Hg
  75. pH 7.50, Pco2 30 mm Hg Guillain-Barr è syndrome 格－巴二氏综合征 ( 急性感染性多神经炎 ) validate 证实 alkalo- 碱 alkaloid 生物碱 alkalosis 碱毒症 alkalemia 碱血 [ 症 ] alkalinuria 碱性尿 alkaline 碱性的 2.3 Rationale: The normal pH is 7.35 to 7,45. The normal Pco 2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is down and the Pco 2 is up. Option 1 identifies an alkalotic condition. Option 2 identifies normal values. Option 4 identifies respiratory alkalosis.
  76. A nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Pco 2 of 30 mm Hg. The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition?
  77. Sodium level of 145 mEq/L
  78. Potassium level of 3.0 mEq/L
  79. Magnesium level of 2.0 mg/dL
  80. Phosphorus level of 4.0 mg/dL ventilator 呼吸机 blood gas 血气 magnesium 镁 -osis 异常状态 thrombosis 血栓形成 varicosis 静脉曲张 toxicosis 中毒 thyrotoxicosis 甲状腺毒症 oncosis 癌症病 3.2 Rationale: Clinical manifestations of respiratory alkalosis include headache, tachypnea, paresthesias, tetany, vertigo, convulsions, hypokalemia, and hypocalcemia. Options 1, 3, and 4 identify normal laboratory values. Option 2 identifies the presence of hypokalemia.
  81. A nurse reviews the arterial blood gas results or a client and notes the following: pH of 7.45, Pco 2 of 30 mm Hg, and HCO 3 of 22 mEq/L. The nurse analyzes these results as indicating:
  82. Metabolic acidosis, compensated
  83. Metabolic alkalosis, uncompensated
  84. Respiratory alkalosis, compensated
  85. Respiratory acidosis, uncompensated arterial 动脉的 compensated 代偿 uncompensated 失代偿 arterio- 动脉 arteriectomy 动脉切除术 arteriole 微动脉 ; 小动脉 arteriosclerosis 动脉硬化 arteriovenous 动静脉的 4.:5 Rationale: The normal pH is 7.35 to 7.45. In respiratory condition, an opposite effect will be seen between the pH and the Pco2. In this situation, the pH is at the high end of the normal value and the Pco2 is low. In an alkalotic condition, the pH is up. Therefore, the values identified in the question indicate a respiratory alkalosis. Compensation occurs when the pH returns to a normal value. Since the pH is in the normal range at the high end, compensation has occurred.
  86. A client is scheduled for blood to be drawn from the radial artery for an arterial blood gas (ABG) determination. Before the blood is drawn, an Allen test is performed to determine the adequacy of the:
  87. Popliteal circulation
  88. Ulnar circulation
  89. Femoral circulation
  90. Carotid circulation radial artery 桡动脉 ABGs (arterial blood gases) 动脉血气 Allen test 艾伦试验 adequacy 通畅性 popliteal 腘动脉的 ulnar 尺骨的 femoral 股骨的 carotid 颈动脉 ; 颈总动脉的 circulo- 循环 circular 环状的；循环的 circulating nurse 巡回护士 circulation 循环 circulatory 循环的 circulus 环 circulate 循环 5.2 Rationale: Before radial puncture for obtaining an arterial specimen for ABGs, an Allen test should be performed to determine adequate ulnar circulation. Failure to determine the presence of adequate collateral circulation could result is severe ischemic injury to the hand, if damage to the radial artery occurs with arterial puncture. Options 1, 3, and 4 are incorrect options.
  91. A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client, knowing that the client is at risk for which acid-base disorder?
  92. Respiratory acidosis
  93. Respiratory alkalosis
  94. Metabolic acidosis
  95. Metabolic alkalosis suction 吸引 disorder 病症 ; 障碍 vomiting 呕吐 hydrochloric acid 盐酸 hydro- 氢化 ; 氢 ; 水 hydrobromide 氢溴化物 hydrocele 阴囊水囊肿 ; 鞘膜积液 hydrocephalus 脑积水 hydroflumethiazide 氢氟噻嗪 6.4 Rationale: Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid. Options 1, 2, and 3 are incorrect.
  96. A nurse caring for a client with an ileostomy understands that the client is at most risk for developing which acid-base disorder?
  97. Respiratory acidosis
  98. Respiratory alkalosis
  99. Metabolic acidosis
  100. Metabolic alkalosis intestinal 肠的 ileostomy 回肠造口术 diarrhea 腹泻 -ostomy 造口术 , 吻合术 cecostomy 盲肠造口术 colocecostomy 结肠盲肠吻合术 sigmoidostomy 乙状结肠造口术 ileosigmoidostomy 回肠乙状结肠吻合术 tracheostomy 气管造口术 pyelostomy 肾盂造瘘术 7.3 Rationale: Intestinal secretions high in bicarbonate may be lost through enteric drainage tubes or an ileostomy or with diarrhea. These conditions result in metabolic acidosis. Options 1, 2, and 4 are incorrect because they do not occur in the client with an ileostomy.
  101. A nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Based on this documentation, which of the following did the nurse observe?
  102. Respirations that are abnormally deep, regular, and increased in rate
  103. Respirations that are regular but abnormally slow
  104. Respirations that are labored and increased in depth and rate
  105. Respirations that cease for several seconds diabetic 糖尿病的 ketoacidosis 酮症酸中毒 Kussmaul's respiration 库斯毛尔呼吸，库

金呼吸 documentation 记录 labored 困难的 ( 吃力的 ) cease 停止 bradypnea 呼吸过慢 hyperpnea 呼吸急促 keto- 酮 ketoaciduria 酮酸尿 ketoestradiol 酮雌 [ 甾 ] 二醇 ketogenesis 生酮作用 ketonemia 酮血症 ketone 酮 8.1 Rationale: Kussmaul's respirations are abnormally deep, regular, and increased in rate. In bradypnea, respirations are regular but abnormally slow. In hyperpnea, respirations are labored and increased in depth and rate. Apnea is described as respirations that cease for several seconds. 9. A nurse understands that the excessive use of oral antacids containing bicarbonate can result in which acid-base disturbance?

  1. Respiratory alkalosis
  2. Respiratory acidosis
  3. Metabolic acidosis
  4. Metabolic alkalosis excessive 过度的 ( 极度的 , 非常的 antacid 制酸剂 bicarbonate 碳酸氢盐 parenteral 不经肠的 , 肠道外的 acetate 醋酸盐 citrate 柠檬酸盐 lactate 乳酸盐 -ate 盐 silicate 硅盐酸 phosphate 磷酸盐 9.4 Rationale: Increases in base components occur as a result of oral or parenteral intake of bicarbonates, carbonates, acetates, citrates, or lactates. Excessive use of oral antacids containing bicarbonate can cause a metabolic alkalosis. Options 1, 2, and 3 are incorrect.
  5. A nurse is caring for a client with renal failure. Blood gas results indicate a pH of 7.30, a Pco 2 of 32mm Hg, and an HCO 3 of 20 mEq/L. The nurse has determined that the client is experiencing metabolic acidosis. Which of the following laboratory values would the nurse expect to note?
  6. Sodium level of 145 mEq/L
  7. Magnesium level of 2.0 mg/dL
  8. Potassium level of 5.2 mEq/L
  9. Phosphorus level of 4.0 mg/dL renal failure 肾 [ 功能 ] 衰竭 central nervous system 中枢神经系统
  10. :3 Rationale: Clinical manifestations of metabolic acidosis include hyperpnea with Kussmaul's respirations; headache; nausea, vomiting, diarrhea; fruity-smelling breath resulting from improper fat metabolism; central nervous system depression, including mental dullness, drowsiness, stupor, and coma; twitching; and convulsions. Hyperkalemia will occur. hhxcttxs 发表于 11:15:21 | 阅读全文 | 评论 (0) | 引用 (Trackback 0) | 编辑 2005-10-09 化验检查 TAG： cgfns 试题 化验检查
  11. A nurse is assigned to a 40 year-old client who has a diagnosis of chronic pancreatitis. The nurse reviews the laboratory result, anticipating a laboratory report that indicates a serum amylase level of:
  12. 45 U/L
  13. 100 U/L
  14. 300 U/L
  15. 500 U/L chronic 慢性的 acute 急性的 pancreatitis 胰腺炎 serum 血清 amylase 淀粉酶 pancreato- 胰 pancreatic 胰的 , 胰腺的 pancreatin 胰酶 ; 胰泌素 pancreatoduodenectomy 胰头十二指肠切除术 pancreatotomy 胰切开术 amylo- 淀粉 amyloid 淀粉样的 amyloidosis 淀粉样变性 amylolysis 淀粉分解 answer:3 Rationale: The normal serum amylase level is 25 to 151 IU/L. With chronic cases of pancreatitis, the rise in serum amylase levels usually does not exceed three times the normal value. In acute pancreatitis, the value may exceed five times the normal value. Option 1 indicates a low value. Option 2 is within normal limits. Option 4 is an extremely elevated level seen in acute pancreatitis.
  16. A client is suspected of having a myocardial infarction. A nurse assesses for elevations in which of the following isoenzyme values reported with the creatinine phosphokinase (CPK) level?
  17. MM
  18. MB
  19. BB
  20. MK myocardial 心肌的 infarction 梗塞 , 梗死 isoenzyme 同功酶 creatinine 肌酐 ; 肌酸酐 phosphokinase 磷酸激酶 CPK( creatinine phosphokinase) 肌酸磷酸激酶 -ase 酶 ( 酶类药 ) collagenase 胶原酶 hydrogenase 氢化酶 lactalase 乳酸酶 answer:2 Rationale: CPK is a cellular enzyme that can be fractionated into three isoenzymes. The MB band reflects CPK from cardiac muscle. This is the level that elevates with myocardial infarction. The MM band reflects CPK from skeletal muscle. The BB band reflects CPK from the brain. There is no MK band.
  21. An adult client has had laboratory work done as part of a routine physical examination. A nurse interprets that the client may have a mild degree of renal insufficiency if which of the following serum creatinine levels is found?
  22. 0.2 mg/dL
  23. 0.5 mg/dL
  24. 1.9 mg/dL
  25. 3.5 mg/dL renal 肾的 insufficiency 功能不全 ； 闭锁不全 in- 表示否定 inaccuracy 不准确度 inactivation 失效 ; 灭活 inadequacy 功能不全 answer:3 Rationale: The normal serum creatinine level for adults is 0.6 to 1.3 mg/dL. The client with a mild degree of renal insufficiency would have a slightly elevated level. A creatinine level of 0.2 mg/dL is low, and a level of 0.5 mg/dL is just below normal. A creatinine level of 3.5 mg/dL may be associated with acute or chronic renal failure.
  26. A client with a history of a seizure disorder who has been compliant with medication therapy is admitted to the hospital with seizure activity. Phenytoin (Dilantin) is administered to the client by the IV push route, and subsequently a serum phenytoin level is drawn. A nurse evaluates that the medication therapy has been most effective if the laboratory result is:
  27. 3 μ g/mL
  28. 8 μ g/mL
  29. 16 μ g/mL
  30. 24 μ g/mL seizure 发作 ; 癫痫发作 phenytoin 苯妥英 ; 美芬妥英〔抗癫痫药〕 Dilantin 苯妥英 ; 大仑丁 subsequently 后来 , 随后 evaluate 评价 effective 有效的 answer:3 Rationale: The therapeutic range for serum phenytoin (Dilantin) level is 10 to 20 μ g/mL. If the level is below the therapeutic range, the client may continue to experience seizure activity. If the level is too high, the client could experience phenytoin toxicity.
  31. A client who takes theophylline (Theo-Dur) for chronic obstructive pulmonary disease (COPD) is seen in the urgent care center for respiratory distress. Just before therapy is initiated, a baseline theophylline level is drawn. Once the client is stabilized, a nurse begins discharge teaching. The nurse would be especially vigilant to include information about complying with medication therapy if the client's baseline result was:
  32. 10 μ g/mL
  33. 12 μ g/mL
  34. 15 μ g/mL
  35. 18 μ g/mL theophylline 茶碱 aminophylline 氨茶碱 respiratory distress 呼吸窘迫 baseline 基线 stabilize 稳定 discharge 放电 ; 出院 vigilant 警惕着的 comply with 顺从 answer:1 Rationale: The therapeutic range for the serum theophylline (or aminophylline) level is 10 to 20 μ g/ml. If the level is below the therapeutic range, the client may experience frequent exacerbations of the disorder. Although all of the options identify, values within the therapeutic range, option 1 is the option that reflects a need for compliance with medication.
  36. A nurse checks the laboratory result for a serum digoxin level that was drawn for a client earlier in the day and notes that the result is 2.4 ng/mL. Which of the following is the most important action on the part of the nurse?
  37. Record the normal value on the client's flowsheet
  38. Administer the next dose of the medication as scheduled
  39. Check the client's last pulse rate
  40. Notify the physician digoxin 地高辛 flowsheet 流程图 , 流程单 elapse ( 时间 ) 过去 ， 消逝 ， 经过 answer:4 Rationale: The normal therapeutic range for digoxin is 0.5 to 2.0 ng/mL. A value of 2.4 exceeds the therapeutic range and could be toxic to the client. The most important action is to notify, the physician, who may give further orders about holding further doses of digoxin. Option 1 is incorrect because the value is not normal. The next dose should not be administered automatically. Checking the client's last pulse rate is not incorrect, but may have limited value in this situation. Depending on the time that has elapsed since the last assessment, it may be more useful to do a current assessment of the client's status.
  41. A client is receiving a continuous IV infusion of heparin in the treatment of deep vein thrombosis. The client's activated partial thromboplastin time (aPPT) level is 65 seconds. The client's baseline before the initiation of therapy was 30 seconds. A nurse anticipates that which action is needed?
  42. Shutting off the heparin infusion
  43. Decreasing the rate of the heparin infusion
  44. Leaving the rate of the heparin infusion as is
  45. Increasing the rate of the heparin infusion heparin 肝素 thrombosis 血栓形成 hromboplastin 促凝血酶原激酶 ; 凝血活酶 ; 凝血激酶 infusion 输液 ; 输注 baseline 基线 ， 基准 answer:3 Rationale: The normal aPTT varies between 20 and 36 seconds, depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 and 2.5 times normal. Thus, the client's aPTT is within the therapeutic range, and the dose should remain unchanged.
  46. A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium (Coumadin) has a prothrombin time (PT) of 30 seconds. On the basis of the PT level, a nurse anticipates which of the following orders?
  47. Holding the next dose of warfarin sodium
  48. Administering the next dose of warfarin sodium
  49. Increasing the next dose of warfarin sodium
  50. Adding a dose of heparin atrial 房的 ; 心房的 fibrillation 纤维性颤动 maintenance therapy 维持治疗 warfarin 华法林 ; 苄丙酮香豆素 ; 华法令 Coumadin 苄丙酮香豆素钠 prothrombin time 凝血酶原时间 heparin 肝素 answer:1 Rationale: The normal PT is 9.6 to 11.8 seconds (adult male) or 9.5 to 11.3 seconds (adult female). A therapeutic PT level is 1.5 to 2.0 times greater than the client's control level. Since the value stated is high (and perhaps near the critical range), the nurse should anticipate that the client would not receive further doses at this time.
  51. An adult client who has had pre-admission testing before surgery has had serum electrolytes drawn. A nurse would report which of the following abnormal values to the surgeon's office preoperatively? l. Sodium, 148 mEq/L
  52. Potassium, 3.8 mEq/L
  53. Chloride, 101 mEq/L
  54. Bicarbonate, 26 mEq/L pre-admission 住院前 electrolytes 电解质 preoperative 术前 bicarbonate 碳酸氢盐 , 碳酸氢根 answer:1 Rationale: The normal serum electrolyte ranges for adults are as follows: sodium, 135 to 145 mEq/L; potassium. 3.5 to 5.1 mEq/L; chloride, 98 to 107 mEaJL; bicarbonate (venous), 22-29 mEq/L. The only abnormal value identified above is the serum sodium. The nurse reports any abnormal preoperative laboratory value to the surgeon's office.
  55. A client with a history of cardiac disease is due for a morning dose of furosemide (Lasix). A nurse plans to report which serum potassium level before administering the dose of furosemide?
  56. 3.8 mEq/L
  57. 3.2 mEq/L
  58. 4.8 mEq/L
  59. 4.2 mEq/L dose 剂量 ; 一剂药 furosemide (Lasix) 呋塞米 ; 呋喃苯氨酸 ; 速尿 dysrhythmia 节律障碍 answer: 2 Rationale: The normal serum potassium level in the adult is 3.5 to 5.1 mEq/L. Option 2 is the only value that falls below the therapeutic range. Administering furosemide to a client with a low potassium level and a cardiac history could precipitate ventricular dysrhythmias. Options 1, 3, and 4 are within the normal range.
  60. An adult client with a history of gastrointestinal (GI) bleeding has a platelet count of 300,000 cells/ μ L. Which action by a nurse is most appropriate upon reading this report?
  61. Report the abnormally low count
  62. Report the abnormally high count
  63. Place the client on bleeding precautions
  64. Place the normal report in the client's medical record gastrointestinal 胃肠的 platelet count 血小板计数 precautions 警惕 answer:4 Rationale: A normal platelet count ranges from 150,000 to 400,000cells/ μ L. The nurse should place the report containing the normal laboratory value in the client's medical record. A platelet count of 300,000 cells/ μ L is not an elevated count. It is also not a low count; therefore, it is not necessary to place the client on bleeding precautions.
  65. An adult client with hepatic cirrhosis has been following a diet with optimal amounts of protein, since neither an excess nor a deficiency of protein has been helpful. The nurse evaluates the client's status as being most satisfactory if the total protein level is which of the following values, in the normal range?
  66. 0.4 g/dL
  67. 3.7 g/dL
  68. 6.4 g/dL
  69. 9.8 g/dL cirrhosis 硬化 excess 超过 ; 过剩 ; 过量 deficiency 缺乏 ; 不足 ; 故障 answer: 3 Rationale: The normal range for total serum protein level in the adult client is 6.0 to 8.0 g /dL. The dient with cirrhosis often has low total protein levels as a result of inadequate nutrition. Excess protein is not helpful, though, since a function of the liver is to metabolize protein. Protein metabolism may not be done well by a diseased liver. Options 1 and 2 identify low values, and option 4 identifies a high protein value.
  70. A client is seen in the urgent care center for complaints of chest pain that began three days ago. Since that time, the client has not been feeling well and fatigues easily. A nurse would suspect myocardial infarction at the time of chest pain if which of the following isoenzymes for lactic dehydrogenase (LDH) came back positive?
  71. LDH1
  72. LDH3
  73. LDH4
  74. LDH5 fatigue hhxcttxs 发表于 11:13:18 | 阅读全文 | 评论 (0) | 引用 (Trackback 0) | 编辑 2005-10-09 TPN完全肠道外营养 TAG： 试题 cgfns TPN完全肠道外营养
  75. A client has been discharged to home on total parenteral nutrition (TPN). With each visit, a home care nurse assesses which of the following parameters most closely in monitoring this therapy?
  76. Temperature and weight
  77. Temperature and blood pressure
  78. Pulse and weight
  79. Pulse and blood pressure TPN(Total parenteral nutrition) 全肠道外营养 [ 支持 ]; 静脉高营养 parenteral 不经肠的 , 肠道外的 parameter 参数 1.1 Rationale: The client receiving TPN at home should have the temperature monitored as a means of detecting infection, which is a potential complication of this therapy. An infection could also result in sepsis, since the catheter is in a blood vessel. The client's weight is monitored as a measure of the effectiveness of this nutritional therapy and to detect fluid overload. The pulse and blood pressure are important parameters to assess, but they do not relate specifically to the effects of TPN.
  80. A nurse is caring for a group of adult clients on an acute care medical-surgical nursing unit. The nurse understands that which of the following clients would be the least likely candidate for total parenteral nutrition (TPN)?
  81. A 66-year-old client with extensive burns
  82. A 42-year-old client who had an open cholecystectomy
  83. A 35-year-client with persistent nausea and vomiting from chemotherapy
  84. A 27-year-old client with severe exacerbation of regional enteritis (Crohn's disease) candidate 候选者 burn 烧伤 cholecystectomy 胆囊切除术 nausea 恶心 vomiting 呕吐 chemotherapy 化学疗法 exacerbation 恶化 regional enteritis 局限性肠炎 ; 节段性肠炎 (segmental enteritis) Crohn's disease 克隆氏病 cholecysto- 胆囊 cholecystoduodenostomy 胆囊十二指肠吻合术 cholecystitis 胆囊炎 cholecystojejunostmy 胆囊空肠吻合术 2.2 Rationale: TPN is indicated in clients whose gastrointestinal (Gl) tracts are not functional, or who cannot take in a diet enterally for extended periods of time. Examples of these conditions include those of the clients identified in options 1, 3, and 4. Other clients would be those who have had extensive surgery, have multiple fractures, are septic, or have advanced cancer or acquired immunodeficiency syndrome (AIDS). The client with the open cholecystectomy is not a candidate because this client would resume a diet within a few days following surgery.
  85. A nurse is planning to hang the first bag of total parenteral nutrition (TPN) solution via the central line of an assigned client. The nurse plans to obtain which of the following most essential pieces of equipment before hanging the solution?
  86. Electronic infusion pump
  87. Blood glucose meter
  88. Urine test strips
  89. Noninvasive blood pressure monitor infusion pump 输液泵 strip （纸）条 noninvasive 非侵害的，无创的 3.1 Rationale: The nurse obtains an electronic infusion pump before hanging a TPN solution. Because of the high glucose content, it is necessary to use an infusion pump to ensure that the solution does not infuse too rapidly or fall too far behind. Because the client's blood glucose is monitored every 4 to 6 hours during administration of TPN, a blood glucose meter will also be needed, but this is not the most essential item needed prior to hanging of the solution. Urine test strips (to measure glucose) are rarely used since the advent of blood glucose monitoring. A noninvasive blood pressure monitor is unnecessary for this procedure.
  90. A home care nurse is monitoring a client's response to total parenteral nutrition (TPN). The client's weight 1 week ago was 114 pounds. The nurse determines that the client is not gaining weight too rapidly if this morning's weight was:
  91. 116 pounds
  92. 119 pounds
  93. 120 pounds
  94. 122 pounds
  95. 1 Rationale: The client receiving TPN should not gain more than 3 pounds per week, with optimal weight gain being 1 to 3 pounds per week. The weight goal for the client on TPN is individual and depends on the client's metabolic needs and baseline weight (whether underweight, overweight, or at optimal weight). The correct option identifies a reasonable weight gain of 2 pounds per week. Options 2, 3, and 4 indicate a weekly weight gain that is greater than expected.
  96. A nurse is assigned to a client receiving TPN who had a blood glucose measurement done at 06:00. The nurse documents on the client's clinical worksheet for the day that the blood glucose level should be checked at which of the following times?
  97. 08:00
  98. 12:00
  99. 16:00
  100. 18:00 worksheet 工作表 insufficient 不足的 , 不充分的 5.2 Rationale: The client's blood glucose level should be monitored every 4 to 6 hours during TPN. Depending on agency policy, this may be done every 8 hours instead. It is unnecessary to monitor the blood glucose level every 2 hours (option 1). Monitoring every 10 or 12 hours (options 3 and 4) is insufficient.
  101. A client is receiving nutrition by means of total parenteral nutrition (TPN). A nurse monitors the client for complications of the therapy and assesses the client for which of the following signs of hyperglycemia?
  102. Nausea, vomiting, and oliguria
  103. Sweating, chills, and abdominal pain
  104. Fever, weak pulse, and thirst
  105. Weakness, thirst, and increased urine output complication 并发症 hyperglycemia 高血糖 , 高血糖症 oliguria 少尿 chills 寒战 output 出量 anuria 无尿 biliuria 胆汁尿 hypercalciuria 高钙尿症 polyuria 【医】多尿症 ; 多尿 6.4 Rationale: The high glucosse concentration in TPN places the client at risk for hyperglycemia. Signs of hyperglycemia include excessive thirst, fatigue, restlessness, confusion, weakness, Kussmaul's respirations, diuresis, and coma, when hyperglycemia is severe. If the client presents with these symptoms, the blood glucose level should be checked immediately. Options 1, 2, and 3 do not identify signs specific to hyperglycemia.
  106. At 8: 00 A .M. a nurse checks the amount of solution left in a total parenteral nutrition (TPN) infusion bag for an assigned client. It is a 3000 mL bag with 1000 mL remaining. The solution is running at a rate of 100 mL/hr. The bag was hung the previous day at 12:00 noon. The nurse plans to change the infusion bag and tubing today at:
  107. 12:00 noon
  108. 2:00 P.M.
  109. 4:00 P.M.
  110. 8:00 P.M. bacterial 细菌的 aseptic technique 无菌技术
  111. 1 Rationale: TPN solution should be changed every 24 hours because the TPN solution is a high-concentrate glucose, and is a medium for bacterial growth. Infection control is also aided by use of aseptic technique with bag and tubing changes. Most agencies recommend that tubing be changed every 24 hours along with the bag, although some agencies recommend changing tubing every 48 to 72 hours. Specific agency policies should always be adhered to. Options 2, 3, and 4 identify insufficient time frames and present the risk for infection.
  112. A nurse is changing the central line dressing of a client receiving total parenteral nutrition (TPN). The nurse notes that the catheter insertion site appears reddened. The nurse next assesses which of the following items?
  113. Tightness of tubing connections
  114. Client's temperature
  115. Expiration date on the bag
  116. Time of last dressing change catheter 导管 ； 导尿管 insertion 插入 , 附着处 redden 变红 connections 联接 expiration date 有效期 dressing 敷料 8.2 Rationale: Redness at the catheter insertion site is a possible indication of infection. The nurse would next assess for other signs of infection. Of the options given, the temperature is the next item to assess. The tightness of tubing connections should be assessed each time the TPN is checked; loose connections would result in leakage, not skin redness. The expiration date on the bag is a viable alternative, but that also should be checked at the time the solution is hung, and with each shift change. The time of the last dressing change should be checked with each shift change.
  117. A nurse is preparing to hang a fat emulsion. The nurse notes that fat globules are visible at the top of the solution. The nurse takes which of the following actions?
  118. Runs the bottle of solution under warm water
  119. Rolls the bottle of solution gently
  120. Shakes the bottle of solution vigorously
  121. Obtains a different bottle of solution fat emulsion 脂肪乳剂 globule 小球 ; 水珠 vigorously 有力地 9.4 Rationale: The nurse should examine the bottle of fat emulsion for separation of emulsion into layers or fat globules, or for the accumulation of froth. The nurse should not hang a fat emulsion if any of these observations are made and should remm the solution to the pharmacy. Options 1, 2, and 3 are inappropriate actions.
  122. A client is being weaned from total parenteral nutrition (TPN) and is expected to begin taking solid food today. The ongoing solution rate ha been 100 mL/hr. A nurse anticipates that which of the following orders regarding the TPN solution will accompany the diet order?
  123. Discontinue the TPN
  124. Continue current infusion rate orders for TPN
  125. Decrease TPN rate to 50 mL/hr
  126. Hang 1000 mL 0.9% normal saline wean 脱离 , 断奶 , 放弃 ongoing 正在进行的 discontinue 中止 , 中断 normal saline 生理盐水
  127. 3 Rationale: When a client begins taking a diet after a period of receiving parenteral nutrition, the TPN is gradually decreased. TPN that ii discontinued abruptly can cause hypoglycemia. Clients often have anorexia after being without food for some time, and the digestive tract is also not used to producing the digestive enzymes that will be needed. Gradually decreasing the infusion rate allows the client to remain adequately nourished during the transition to a normal diet and prevents the occurrence of hypoglycemia. Even before clients are started on a solid diet, they are given clear liquids followed by full liquids to further ease the transition. A solution of normal saline will not provide the glucose needed during the transition of discontinuing the TPN and could also cause the client to experience hypoglycemia.
  128. A nurse is preparing to change the total parenteral nutrition (TPN) solution bag and tubing. The client's central venous line is located in the right subclavian vein. The nurse asks the client to do which of the following most essential items during the tubing change?
  129. Take a deep breath, hold it, and bear down
  130. Exhale slowly and evenly
  131. Turn the head to the right
  132. Breathe normally subclavian vein 锁骨下静脉 exhale 呼气 evenly 均匀地
  133. I Rationale: The client should be asked to perform the Valsalva maneuver during tubing changes. This helps to avoid air embolism during tubing changes. This is commonly achieved by asking the client to take a deep breath, hold it, and bear down. Ifthe IV line is on the right, the client tums the head to the left. This position will increase intrathoracic pressure. Options 2 and 4 are inappropriate and could cause the potential for an air embolism during the tubing change.
  134. A client with total parenteral nutrition (TPN) infusing has disconnected the tubing from the central line catheter. A nurse assesses the client and suspects an air embolism. The nurse should immediately place the client in which of the following positions?
  135. On the left side with the head higher than the feet
  136. On the left side with the head lower than the feet
  137. On the right side with the head higher than the feet
  138. On the right side with the head lower than the feet disconnect 分离 , 断开 air embolism 空气栓塞
  139. 2 Rationale: When air embolism is suspected, the client should be placed in a left side-lying position. The head should be lower than the feet. This position is used to try to minimize the effect of the air traveling as a bolus to the lungs by trapping it in the right side of the heart. Options 1, 3, and 4 are incorrect positions if an air embolism is suspected.
  140. A client receiving total parenteral nutrition (TPN) complains of a headache. A nurse notes that the client has an increased blood pressure, bounding pulse, jugular vein distention, and crackles bilaterally. The nurse interprets that the client is experiencing which complication of TPN therapy?
  141. Hyperglycemia
  142. Air embolism
  143. Sepsis
  144. Fluid overload complain 自诉 bounding pulse 洪脉 jugular vein 颈静脉 crackles 湿罗音 bilaterally 双侧 sepsis 败血症 ; 脓毒症 Fluid overload 液体过剩
  145. 4 Rationale: The client's signs and symptoms are consistent with fluid overload. The increased intravascular volume increases the blood pressure, while the pulse rate increases as the heart tries to pump the extra fluid volume. The volume also causes neck vein distention, and shifting of fluid into the alveoli, resulting in lung crackles. The signs and symptoms presented in the question are not indicative of hyperglycemia, air embolism, or sepsis.
  146. A client receiving TPN suddenly spikes a fever. A nurse notifies the physician and the physician initially orders that the solution and tubing be changed. The nurse should do which of the following with the discontinued materials?
  147. Return them to the hospital pharmacy
  148. Send them to the laboratory for culture
  149. Save them for return to the manufacturer
  150. Discard them in the unit trash spike 波峰，升高 pharmacy 药房 culture 培养 manufacturer 生产商 discard 丢弃 , 抛弃 trash 废料 ， 垃圾
  151. 2 Rationale: When the client who is receiving TPN spikes a temperature, a catheter-related infection should be suspected. The solution and tubing should be changed, and the discontinued materials should be cultured for infectious organisms. The other options are incorrect.
  152. A nurse enters the room of a client receiving total parenteral nutrition (TPN) and discovers that the electronic infusion pump has been shut off. After checking the line for patency and restarting the infusion, the nurse assesses the client for which of the following signs and symptoms?
  153. Weakness, thirst, and excessive urination
  154. Fever and chills
  155. Weakness, shakiness, diaphoresis, and complaints of hunger
  156. Dyspnea and hypotension patency 开放 urination 排尿 shakiness 震动 , 颤抖 dyspnea 呼吸困难 hypotension 低血压
  157. 3 Rationale: If the pump that is infusing TPN becomes shut off for a period of time, the nurse assesses the diem for signs and symptoms of hypoglycemia. These include weakness, shakiness, headache, anxiety, diaphoresis, and complaints of hunger. The blood glucose level will be less than 70 mg/dL. The other signs and symptoms described are those of hyperglycemia (option 1), infection (option 2), and air embolism (option 4).
  158. A nurse is making initial rounds at the beginning of the shift. The total parenteral nutrition (TPN) bag of an assigned client is empty. Which of the following solutions readily available on the nursing unit should the nurse hang until another TPN solution is mixed and delivered to the nursing unit?
  159. 5% dextrose in water
  160. 5% dextrose in 0.9% sodium chloride
  161. 5% dextrose in Ringer's lactate
  162. 10% dextrose in water 16.4 Rationale: The solution containing the highest amount of glucose should be hung until the new TPN becomes available. Since TPN solutions contain high glucose concentrations, the 10% dextrose in water solution is the best of the choices presented. The solution selected should be one that minimizes the risk of hypoglycemia. Options 1, 2, and 3 will not be as effective in minimizing the risk of hypoglycemia.
  163. At the beginning of a shift, a nurse assesses a client receiving TPN with fat emulsion piggybacked to the line. The nurse notes that the fat emulsion tubing has an in-line 0.22-micron ( μ ) filter. Which of the following actions by the nurse is most appropriate?
  164. Inspect the filter for clogging
  165. Remove the filter
  166. Leave the system alone
  167. Check the line for patency piggyback 旁路（给药），加壶（给药） in-line 直接插入的 ，（管道） 内置的 micron 微米 filter 过滤器 clogging 堵塞
  168. 2 Rationale: The most appropriate action by the nurse is to remove the filter. A 0.22-micron (B) filter is appropriate for the administration of TPN, and fat emulsion should be administered without a filter. If fat emulsion is mixed into the TPN solution, then a 1.2-micron (g) filter or a larger filter should be used to all hhxcttxs 发表于 11:12:02 | 阅读全文 | 评论 (0) | 引用 (Trackback 0) | 编辑 2005-10-09 体位 TAG： 试题 cgfns 体位
  169. A client has just returned to a nursing unit after an above-the-knee amputation of the right leg. A nurse places the client in which of the following most appropriate positions?
  170. Supine with the stump flat on the bed
  171. Supine with the stump elevated
  172. Reverse Trendelenburg
  173. Prone 1.2 Rationale: The stump is elevated for the first 24 hours following surgery to promote venous return and decrease edema, which will increase mobility. After the first 24 hours, the stump is placed flat on the bed to reduce hip contracture. Edema is also controlled by stump-wrapping techniques. Options 1, 3, and 4 are inappropriate positions for the client immediately after surgery.
  174. A nurse is caring for a client with a severe burn. The client is scheduled for an autograft to be placed on the lower extremity. The nurse develops a postoperative plan of care for the client and includes which of the following in the plan?
  175. Maintain surgical extremity in a flat position
  176. Keep surgical extremity covered with a blanket
  177. Maintain the client in a prone position
  178. Elevate and immobilize the grafted extremity 2.4 Rationale: Autografts placed over joints or on lower extremities are elevated and immobilized following surgery for 3 to 7days, depending on the surgeon's preference. This period of immobilization allows the autograft time to adhere and attach to the wound bed, and the elevation minimizes edema. Keeping the client in a prone position and covering theextremity with a blanket can disrupt the graft site.
  179. A nurse is preparing to care for a client who has returned to the nursing unit following cardiac catheterization performed through the femoral artery. The nurse plans to ensure which most appropriate client position/activity following the procedure?
  180. Bed rest with head elevation at 60 degrees
  181. Bed rest with head elevation no greater than 30 degrees
  182. Bed rest with bathroom privileges only
  183. Bed rest in high-Fowlers position 3.2 Rationale: After cardiac catheterization, the extremity in which the catheter was inserted is kept straight for 4 to 6 hours. If the femoral artery was used, strict bed rest is enforced for 6 to 12 hours. The client may turn from side to side. The affected leg is kept straight and the head is elevated no greater than 30 degrees until hemostasis is adequately achieved.
  184. A nurse is providing instructions to a client and the family regarding home care after right eye cataract removal. Which statement, if made by the client, would indicate effective teaching?
  185. "I will not sleep on my right side."
  186. "I will not sleep on my left side."
  187. "I will not sleep with my head elevated."
  188. "I will not wear my glasses until my physician says it is OK."
  189. 1 Rationale: After cataract surgery, the client should not sleep on the side of the body that was operated on. The client should also be placed in a semi-Fowler's position to assist in minimizing edema and an increase in intraocular pressure. During the day, the client may wear glasses or a protective shield; at night, the protective shield alone is sufficient.
  190. A nurse assists a physician in performing a liver biopsy. After the biopsy, the nurse plans to place the client in which of the following positions?
  191. Supine
  192. Prone
  193. A left side-lying position with a small pillow or folded towel under the puncture site
  194. A right side-lying position with a small pillow or folded towel under the puncture site 5.4 Rationale: After a liver biopsy,, the client is assisted to assume a right side-lying position with a small pillow or folded towel under the puncture site for 2 hours. This position compresses the liver against the chest wall at the biopsy site.
  195. A nurse is adminisstering a cleansing enema to client with a fecal impaction. Before administering the enema, the nurse places the client in which of the following positions?
  196. On the left side of the body, with the head of the bed elevated 45 degrees
  197. On the right side of the body, with the head of the bed elevated 45 degrees
  198. Left Sims' position
  199. Right Sims' position 6.3 Rationale: For administering an enema, the client is placed in a left Sims' position so that the enema solution can flow by gravity in the natural direction of the colon. The head of the bed is not elevated in the Sims' position.
  200. A client is being prepared for a thoracentesis. A nurse assists the client to which of the following positions for the procedure?
  201. Lying in bed on the affected side, with the head of the bed elevated 45 degrees
  202. Lying in bed on the unaffected side, with the head of the bed elevated 45 degrees
  203. Prone with the head turned to the side and supported by a pillow
  204. Sims' position with the head of the bed flat 7.2 Rationale: To facilitate removal of fluid from the chest wall, the client is positioned sitting at the edge of the bed leaning over the bedside table with the feet supported on a stool, or lying in bed on the unaffected side with the head of the bed elevated 30 to 45 degrees. The prone and Sims' positions are inappropriate positions for this procedure.
  205. A nurse assists a physician with the insertion of a Harris tube in a client with a bowel obstruction. Following insertion of the tube, the nurse assists the client to which of the following positions initially?
  206. Prone
  207. Supine with the head flat
  208. Right side
  209. Sims' 8.3 Rationale: The Harris tube is a single-lumen, mercury-weighted tube. The weight of the mercury tube carries the tub by gravity. After insertion, to facilitate movement of the tube, the client is positioned 2 hours on the right side, 2 hours on the back with the head elevated, and 2 hours on the left.
  210. A client is diagnosed with deep vein thrombophlebitis. A nurse develops a plan of care for the client and includes which client position/activity in the plan?
  211. Bed rest with the affected extremity in a dependent position
  212. Out-of-bed activities as desired
  213. Bed rest with the affected extremity kept flat
  214. Bed rest with elevation of the affected extremity 9.4 Rationale: Elevation of the affected leg facilitates blood flow by the force of gravity and also decreases venous pressure, which in turn relieves edema and pain. Bed rest is indicated to prevent emboli and to prevent pressure fluctuations in the venous system that occur with walking.
  215. A nurse is preparing to care for a client who has had a supratentorial craniotomy. The nurse plans to place the client in which position?
  216. Prone
  217. Supine
  218. Semi-Fowler's
  219. Dorsal recumbent
  220. 3 Rationale: After supratentofial surgery (surgery above the brain's tentofium), the client's head is usually elevated 30 degrees to promote venous outflow through the jugular veins. Options 1, 2, and 4 are incorrect positions after this surgery. hhxcttxs 发表于 11:10:46 | 阅读全文 | 评论 (0) | 引用 (Trackback 0) | 编辑 分页: 日历 TAG 登录 搜索 最后更新 最新评论 存档 访问统计： 链接