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ISPN考试模拟试题(二十四)

Questions

1.A nurse is reviewing a client’s serum electrolyte laboratory report. What is a comparison between blood plasma and interstitial fluid?

A. They both contain the same kinds of ions.

B. Plasma exerts lower osmotic pressure than does interstitial fluid.

C. Plasma contains more of each kind of ion than does interstitial fluid.

D. Sodium is higher in plasma, whereas potassium is higher in interstitial fluid.


2.A nurse explains to an obese client that the rapid weight loss during the first week after initiating a diet is because of fluid loss. The weight of extracellular body fluid is approximately 20% of the total body weight of an average individual. Which component of the extracellular fluid contributes the greatest proportion to this amount?

A. Plasma

B. Interstitial

C. Dense tissue

D. Body secretions


3.A nurse assesses a client’s serum electrolyte levels in the laboratory report. What electrolyte in intracellular fluid should the nurse consider most important?

A. Sodium

B. Calcium

C. Chloride

D. Potassium


4.A nurse is reviewing the laboratory report of a client with a tentative diagnosis of kidney failure. What mechanism does the nurse expect to be maintained when ammonia is excreted by healthy kidneys?

A. Osmotic pressure of the blood

B. Acid-base balance of the body

C. Low bacterial levels in the urine

D. Normal red blood cell production


5.A nurse is evaluating the effectiveness of treatment for a client with excessive fluid volume. What clinical finding indicates that treatment has been successful?

A. Clear breath sounds

B. Positive pedal pulses

C. Normal potassium level

D. Increased urine specific gravity 

Rationales

1.A

Blood plasma and interstitial fluid are both part of the extracellular fluid and are of the same ionic composition.

B,The osmotic pressure is the same.

C,The composition is the same.

D,The main cation of both extracellular fluids is sodium.

Client Need:Physiological Adaptation;

Cognitive Level:Comprehension;

Nursing Process:Assessment/Analysis;

Reference:Ch 3, Acid-Base Balance


2.B

Interstitial fluid constitutes about 16% of body weight, which is 10 to 12 L in an adult male of 68 kg (150 lb).

A, Plasma is 4% of body weight.

C, Dense tissue is part of the intracellular component.

D, Body secretions are derived from extracellular fluid and are calculated as part of the 20% of the total body weight.

Client Need:Physiological Adaptation;

Cognitive Level:Comprehension;

Nursing Process:Assessment/Analysis;

Reference:Ch 3, Acid-Base Balance


3.D 

The concentration of potassium is greater inside the cell and is important in establishing a membrane potential, a critical factor in the cell’s ability to function.

A,Sodium is the most abundant cation of the extracellular compartment, not the intracellular compartment.

B,Calcium is the most abundant electrolyte in the body; 99% is concentrated in the teeth and bones, and only 1% is available for bodily functions.

C,Chloride is an extracellular, not intracellular, anion.

Client Need:Physiological Adaptation;

Cognitive Level:Comprehension;

Nursing Process:Assessment/Analysis;

Reference:Ch 3, Acid-Base Balance


4.B 

The excreted ammonia combines with hydrogen ions in the glomerular filtrate to form ammonium ions, which are excreted from the body. This mechanism helps rid the body of excess hydrogen, maintaining acid-base balance.

A, D,This is not affected by excretion of ammonia. 

C,Ammonia is formed by the decomposition of bacteria in the urine; ammonia excretion is not related to the process and does not control bacterial levels.

Client Need:Physiological Adaptation;

Cognitive Level: Comprehension;

Nursing Process: Assessment/Analysis;

Reference: Ch 3, Acid-Base Balance


5.A 

Excess fluid can move into the lungs, causing crackles; clear breath sounds support that treatment was effective.

B,While it may make palpation more difficult, excess fluid will not diminish pedal pulses.

C,A normal potassium level can be maintained independently of fluid excess correction.

D,As the client excretes excess fluid, the urine specific gravity will decrease, not increase.

Client Need:Physiological Adaptation;

Cognitive Level:Analysis;

Nursing Process:Evaluation/Outcomes;

Reference:Ch 3, Acid-Base Balance

小编寄语:越努力,越幸运!Fighting!


时间:2019-06-06 17:20:23
 
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