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ISPN考试模拟试题(二十三)

Questions

1. A nurse administers an intravenous solution of 0.45% sodium chloride. In what category of fluids does this solution belong?

A. Isotonic

B. Isomeric

C. Hypotonic

D. Hypertonic


2. What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess?

A. Rapid, thready pulse

B. Distended jugular veins

C. Elevated hematocrit level

D. Increased serum sodium level


3.A nurse is caring for a client with diarrhea. In which clinical indicator does the nurse anticipate a decrease?

A. Pulse rate

B. Tissue turgor

C. Specific gravity

D. Body temperature


4.A client reports vomiting and diarrhea for 3 days. What clinical finding will most accurately indicate that the client has a fluid deficit?

A. Presence of dry skin

B. Loss of body weight

C. Decrease in blood pressure

D. Altered general appearance


5.A client is admitted with metabolic acidosis. The nurse considers that two body systems interact with the bicarbonate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assess for compensatory changes?

A. Skeletal and nervous

B. Circulatory and urinary

C. Respiratory and urinary

D. Muscular and endocrine 

Rationales

1.C 

Hypotonic solutions are less concentrated (contain less than 0.85 g of sodium chloride in each 100 mL) than body fluids.

A,Isotonic solutions are those that cause no change in the cellular volume or pressure, because their concentration is equivalent to that of body fluid.

B,This relates to two compounds that possess the same molecular formula but that differ in their properties or in the position of atoms in the molecules (isomers).

D,Hypertonic solutions contain more than 0.85 g of solute in each 100 mL.

Client Need:Pharmacological and Parenteral Therapies;

Cognitive Level:Knowledge;

Nursing Process:Planning/Implementation;

Reference:Ch 3, Fluid and Electrolyte Balance


2.B 

Because of fluid overload in the intravascular space, the neck veins become visibly distended.

A, C,This occurs with a fluid deficit. 

D,If sodium causes fluid retention, its concentration is unchanged; if fluid is retained independently of sodium, its concentration is decreased.

Client Need:Physiological Adaptation;

Cognitive Level:Application;

Nursing Process:Assessment/Analysis;

Reference:Ch 3, General Nursing Care of Clients with Fluid and Electrolyte Problems


3.B 

Skin elasticity will decrease because of a decrease in interstitial fluid.

A,The pulse rate will increase to oxygenate the body’s cells.

C,Specific gravity will increase because of the greater concentration of waste particles in the decreased amount of urine.

D,The temperature will increase, not decrease.

Client Need:Physiological Adaptation;

Cognitive Level:Analysis;

Nursing Process:Assessment/Analysis;

Reference:Ch 3, Acid-Base Balance


4.B 

Dehydration is most readily and accurately measured by serial assessments of body weight; 1L of fluid weighs 2.2 lb.

A, Although dry skin may be associated with dehydration, it also is associated with aging and some disorders (e.g., hypothyroidism).

C,Although hypovolemia willeventually result in a decrease in blood pressure, it is not an accurate, reliable measure because there are many other causes of hypotension.

D,This is too general and not an objective determination of fluid volume deficit.

Client Need:Physiological Adaptation;

Cognitive Level:Analysis;

Nursing Process:Assessment/Analysis;

Reference:Ch 3, Acid-Base Balance


5.C 

Increased respirations blow off carbon dioxide (CO2 ), which decreases the hydrogen ion concentration and the pH increases (less acidity). Decreased respirations result in CO2 buildup, which increases hydrogen ion concentration and the pH falls (more acidity). The kidneys either conserve or excrete bicarbonate and hydrogen ions, which helps to adjust the body’s pH. The buffering capacity of the renal system is greater than that of the pulmonary system, but the pulmonary system is quicker to respond.

A, D,These systems do not maintain the pH.

B,Although the circulatory system carries fluids and electrolytes to the kidneys, it does not interact with the urinary system to regulate plasma pH.

Client Need:Physiological Adaptation;

Cognitive Level:Comprehension;

Nursing Process:Assessment/Analysis;

 Reference:Ch 3, Acid-Base Balance 

小编寄语:你有多努力,就有多幸运!Fighting!


时间:2019-06-05 14:23:34
 
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