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ISPN考试模拟试题(四十一)

Questions

1.A nurse checking the perineum of a client with a radium implant for cervical cancer observes the packing protruding from the vagina. Why must the nurse notify the health care provider to remove it immediately?

A.The radioactive packing will injure healthy tissue.

B.Removal of the packing will prevent excessive blood loss.

C.The exposure of radium to the environment will diminish its effectiveness.

D.Removal of the packing will minimize life-threatening contact with the radiation.


2.A nurse is caring for a client who has a radium implant for cancer of the cervix. What is the priority nursing action?

A. Store urine in lead-lined containers.

B. Restrict visitors to a ten-minute stay.

C. Wear a lead-lined apron when giving care.

D. Avoid giving injections in the gluteal muscle.


3.A client was treated with a radium implant for cancer of the cervix. What information is important for the nurse to teach the client when giving discharge instructions?

A.Limit daily fluid intake.

B.Return for follow-up care.

C.Continue a low-residue diet.

D.Take daily mineral supplements.


4.A client has corrective surgery for a bladder laceration. What nursing intervention takes priority during this client’s postoperative period?

A.Turning frequently

B.Raising side rails on the bed

C.Providing range-of-motion exercises

D.Massaging the back three times a day


5. A postmenopausal woman who has cancer of the breast decides to have a lumpectomy followed by chemotherapy. After receiving chemotherapy for several weeks, she says to a nurse at the clinic, “I don’t feel well.” The nurse reviews the chemotherapeutic medications the client is receiving, checks the laboratory results,and obtains the client’s vital signs. Based on this information, what does the nurse conclude is the client’s priority need?

1.Promoting rest

2. Preventing infection

3. Avoiding bodily harm

4. Maintaining fluid balance

Rationales

1.A 

Packing maintains a radium implant in its correct placement; correct placement minimizes the effect on healthy tissue.

B,There should not be active bleeding with a radium implant; cellular sloughing is expected.

C,This is not true.

D,Although exposure to the radioactive packing damages healthy tissue, it is not life threatening.

Client Need:Safety and Infection Control;

Cognitive Level:Application;

Integrated Process:Communication/Documentation;

Nursing Process:Planning/Implementation;

Reference:Ch3,General Nursing Care of Clients with Neoplastic Disorders


2.B 

Restriction of each visitor to a 10-minute stay minimizes the risk for exposure. Some institutions will not allow visitors while an implant is in place.

A,The urine is not radioactive.

C,Lead-lined aprons are not effective shields against rays emitted by internal sources of radiation.D,Radium implants will not affect the location of intramuscular injections.

Client Need:Reduction of Risk Potential;

Cognitive Level:Application;

Nursing Process:Planning/Implementation;

Reference:Ch3,General Nursing Care of Clients with Neoplastic Disorders


3.B 

Before discharge it is important for the nurse to instruct the client to return for follow-up care at specified intervals.

A,Fluids are not reduced unless cardiac or renal pathology is present.

C,When the implant is in place,a low-residue diet is indicated to avoid pressure from a distended colon; when the radium implant is removed, the client can return to a regular diet.

D,If the diet is adequate, mineral supplements are unnecessary.

Client Need:Health Promotion and Maintenance;

Cognitive Level:Application;

Integrated Process:Teaching/Learning;

Nursing Process:Planning/Implementation;

Reference:Ch3, General Nursing Care of Clients with Neoplastic Disorders


4.A 

Frequent position changes are important to ensure urinary drainage; gravity promotes flow, which prevents obstruction.

B,This is not a priority unless the client is sedated.

C,Range-of-motion exercises are of minimal importance because the client is able to move without limitation.

D,Back care is necessary, but it is not the priority.

Client Need:Physiological Adaptation;

Cognitive Level:Application;

Nursing Process:Planning/Implementation;

Reference:Ch3,General Nursing Care of Clients during the Postoperative Period


5.B 

The prevention of infection is the priority because an infection can be life-threatening for a client who is immunocompromised. Chemotherapeutic medications depress the bone marrow,causing leukopenia. This client’s white blood cell count is below the expected range of 4500 to 11,000/mm3 for an older female adult. While the elevation in the client’s temperature, pulse, and respirations may be related to the direct effects of the chemotherapeutic agents, they also may reflect that the client is resisting a microbiologic stress.

A,Although a balance between rest and activity is important, it is not the priority. While chemotherapeutic medications depress the bone marrow and cause anemia, this client’s redblood cell count is within the expected range of 4.0 to 5.0 million/mm3 for an older female adult. The client’s hemoglobin level is within the expected range of 11.5 to 16.0g/dL.

C,Even though preventing injury is important, it is not the priority. Although chemotherapeutic medications depress the bone marrow, causing thrombocytopenia, this client’s platelet count is within the expected range of 150,000 to 400,000/mm3 for an adult.

D,While maintaining fluid balance is important, it is not the priority. The client’s hematocrit is within the expected range of 38% to 41% for an older female adult, indicating that the client is not dehydrated. The client’s blood pressure is not decreased, which occurs with dehydration. Although chemotherapeutic medications may cause nausea, vomiting, and diarrhea,the client did not indicate that these occurred.

Client Need:Reduction of Risk Potential;

Cognitive Level:Analysis;

Nursing Process:Assessment/Analysis;

Reference:Ch3,General Nursing Care of Clients with Neoplastic Disorders


小编寄语:一分耕耘,一分收获!Fighting!


时间:2019-07-03 16:30:11
 
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