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> 护士证书 > ISPN > ISPN备考 > ISPN课后练习 > 国际护士证ISPN考试课后练习题解析(6-10)

国际护士证ISPN考试课后练习题解析(6-10)

发表日期:2015-12-11 | 来源 :国际护士网 | 作者 :www.the-nurses.com |点击数: 次 收听:
 
 6)  A kosher meal is delivered to a Jewish-American client . Which action by the nurse is most appropriate in assisting the client with the meal?
 
    1. Ask the client to prepare the meal for eating.
    2. Ensure that the client has metal eating utensils.
    3. Prepare the eating utensils and food for the client.
    4. Transfer the food from the paper plates to glass plates.
 
 Correct Answer: 1

Kosher meals arrive on paper plates and with plastic utensils sealed. Health care providers should not unwrap the utensils or place the food on another serving dish. Although the nurse may want to be helpful in assisting the client with the meal, the only appropriate option for this client is option 1.
     
 7)  The nurse notes that a client's parenteral nutrition solution is 4 hours behind. Which action should the nurse take?
 
    1. Assess the infusion pump to be sure it is functioning properly and is set at the correct rate.
    2. Increase the infusion rate to a rate that allows the infusion volume to correct itself within a 2-hour period.
    3. Replace the parenteral nutrition solution with 10% dextrose, and restart the solution the following day.
    4. Administer the parenteral nutrition solution using gravity flow because the infusion pump is malfunctioning.
 
 Correct Answer: 1

If an infusion falls behind schedule, the nurse should not increase the rate in an attempt to catch up, because a hyperosmotic reaction, among other reactions, could result. The solution should not be replaced by another or restarted the next day. An infusion pump should always be used to administer parenteral nutrition solution.
 
8)  A child is admitted to the hospital after being seen in the emergency department with complaints of right lower quadrant abdominal pain, nausea and vomiting, fever, and chills. The health care provider suspects appendicitis. Which assessment finding should the nurse immediately report to the health care provider?
 
    1. Sudden relief of pain
    2. Decreasing oral temperature
    3. Increasing complaints of pain
    4. Refusal to take fluids by mouth
 
 Correct Answer: 1

A sudden relief of pain from a suspected appendicitis is commonly indicative of a ruptured appendix. This places the individual at risk for peritonitis and shock. The health care provider should be notified immediately because of the need to begin intravenous antibiotics to prevent further complications. Although option 3 is a concern, the higher priority is option 1 because of the risk of peritonitis and shock. Options 2 and 3 are findings that should be monitored but are not of highest priority. The child will be placed NPO in anticipation of surgery; therefore option 4 is incorrect.
 
9)  The home health nurse is reviewing medications with a client receiving colchicine for the treatment of gout. The nurse evaluates that the medication iseffective if the client reports a decrease in which measure?
 
    1. Headaches
    2. Blood glucose
    3. Blood pressure
    4. Joint inflammation
 
 Correct Answer: 4

Colchicine is classified as an antigout agent. It interferes with the ability of the white blood cells to initiate and maintain an inflammatory response to monosodium urate crystals. The client should report a decrease in pain and inflammation in the affected joints, as well as a decrease in the number of gout attacks. Headaches, blood glucose, and blood pressure are not associated with the use of this medication.
 
10)  The nurse is developing a plan of care for a client with dysphagia following a stroke (brain attack). Which should the nurse include in the plan? Select all that apply.
 
    1. Thicken liquids.
    2. Assist the client with eating.
    3.Assess for the presence of a swallow reflex.
    4. Place the food on the affected side of the mouth.
    5. Provide ample time for the client to chew and swallow.
 
 Correct Answer: 1,2,3,5,  

Liquids are thickened to prevent aspiration. The nurse should assist the client with eating and place food on the unaffected side of the mouth. The nurse should assess for gag and swallowing reflexes before the client with dysphagia is started on a diet. The client should be allowed ample time to chew and swallow to prevent choking. 

 

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