网站首页  |  关于我们  |  最新公告  |  新闻动态  |  备考指南  |  下载中心  |  考点简介  |  培训基地展示  |  在线留言  |  联系我们
ISPN学习中心
护理名人堂
    最新公告
    新闻动态
    下载中心
    法律声明
    备考指南
    考点简介
    培训基地展示
 
    
 
  

  

 
 
 首页信息中心 备考指南知识题库
 
ISPN考试模拟试题(四十四)

Questions

1.What must the nurse do to determine a client’s pulse pressure?

A.Multiply the heart rate by the stroke volume.

B.Subtract the diastolic from the systolic reading.

C.Determine the mean blood pressure by averaging the two.

D.Calculate the difference between the apical and radial rate.


2.After surgery for insertion of a coronary artery bypass graft (CABG), a client develops a temperature of 102° F (38.8° C). What priority concern related to elevated temperatures does a nurse consider when notifying the health care provider about the client’s temperature?

A.A fever may lead to diaphoresis.

B.A fever increases the cardiac output.

C.An increased temperature indicates cerebral edema.

D.An increased temperature may be a sign of hemorrhage.


3.A nurse is teaching a group of clients with peripheral vascular disease about a smoking cessation program. Which physiologic effect of nicotine should the nurse explain to the group?

A.Constriction of the superficial vessels dilates the deep vessels.

B.Constriction of the peripheral vessels increases the force of flow.

C.Dilation of the superficial vessels causes constriction of collateral circulation.

D.Dilation of the peripheral vessels causes reflex constriction of visceral vessels.


4.During an interview, the nurse discovers that the spouse of a debilitated, chronicall constipated client digitally removes stool from the client’s rectum.What response to disimpaction is the nurse attempting to prevent by presenting other strategies to regulate the client’s bowel movements?

A.Increased pulse rate

B.Slowing of the heart

C.Dilation of the bronchioles

D.Coronary artery vasodilation


5.A nurse is assessing the legs of a client with a history of chronic venous insufficiency. What physiologic changes should the nurse conclude are the result of this disease process? Select all that apply.

A.Stasis ulcer

B.Necrotic tissue

C.Ecchymotic areas

D.Diminished pulses

E.Brown discoloration

Rationales

1.B 

Pulse pressure is obtained by subtracting the diastolic from the systolic reading after the blood pressure has been recorded.

A,This is the definition of cardiac output;it is not the pulse pressure.

C,This is not pulse pressure.

D,This is the pulse deficit.

Client Need:Reduction of Risk Potential;

Cognitive Level:Application;

Nursing Process:Assessment/Analysis;

Reference:Ch6,Review of Anatomy and Physiology, Blood Vessels


2.B 

Temperatures of 102° F (38° C) or greater lead to an increased metabolism and cardiac workload.

A,Although diaphoresis is related to an elevated temperature, it is not the reason for notifying the health care provider.

C,An elevated temperature is not an early sign of cerebral edema. Open heart surgery is not associated with cerebral edema.

D,Fever is unrelated to hemorrhage; in hemorrhage with shock, the temperature decreases.

Client Need:Physiological Adaptation;

Cognitive Level:Comprehension;

Integrated Process:Communication/Documentation;

Nursing Process:Planning/Implementation;

Reference:Ch6,Cardiac Surgery,Nursing Care


3.B

Constriction of the peripheral blood vessels and the resulting increase in blood pressure impair circulation and limit the amount of oxygen being delivered to body cells, particularly in the extremities.

A,Nicotine constricts all peripheral vessels, not just superficial ones; its primary action is vasoconstriction; it will not dilate deep vessels.

C,D,Nicotine constricts rather than dilates peripheral vessels.

Client Need:Health Promotion and Maintenance;

Cognitive Level:Comprehension;

Integrated Process:Teaching/Learning;

Nursing Process:Planning/Implementation;

Reference:Ch6,Vascular Disease,Nursing Care


4.B 

Disimpaction can cause vagal stimulation,which slows the heart.The vagus is the principal nerve of the parasympathetic portion of the autonomic nervous system,and its axon terminals release acetylcholine.The response of the viscera to acetylcholine varies, but in general the organ is in a relaxed state.

A,This is an action of the sympathetic nervous system (accelerator nerve) caused by the release of norepinephrine.

C,Stimulation of the sympathetic nervous system dilates bronchioles in the lungs; the vagus nerve constricts them.

D,There are parasympathetic fibers to the coronary blood vessels;sympathetic impulses dilate these vessels.

Client Need:Physiological Adaptation;

Cognitive Level:Application;

Nursing Process:Planning/Implementation;

Reference:Ch6,Review of Anatomy and Physiology,Regulatory Mechanisms Affecting Circulation


5. Answer: A, E.

A,Stasis ulcers result from edema or minor injury to the limb; they frequently form over the medial malleolus (inner ankle).

B,Necrotic tissue is associated with peripheral arterial disease.

C, Ecchymosis is caused by bleeding.

D,Diminished pulses are associated with peripheral arterial disease.

E,The release of iron from hemoglobin as erythrocytes disintegrate in tissue results in ferrous sulfide formation, causing darkening of the tissues.

Client Need:Physiological Adaptation;

Cognitive Level:Analysis;

Nursing Process:Assessment/Analysis;

Reference:Ch6,Vascular Disease,Data Base

小编寄语:成功没有捷径!Fighting!

时间:2019-07-08 16:20:13
 
上一篇:ICN精彩回放                          下一篇:ISPN考试模拟试题(四十五)  
 
  
邮箱:cgfnscn2012@126.com   法律声明 Copyright 2012   版权所有  All Rights Reserved