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ISPN考试模拟试题(345)

Question:

The nurse has just received change-of-shift report for four clients. Based on this report, the nurse should assess which of the following clients first

1. A 38-year-old who is 2 days postmastectomy due to breast cancer, having difficulty coping with the diagnosis. 

2. A 52-year-old with pneumonia and chronic back pain who is requesting pain medication.

3. A 35-year-old admitted after motor vehicle accident whose urine output has totaled 30 mL over the last 2 hours. 

4. An 84-year-old with resolving left-sided weakness who is slightly confused and has been awake most of the night.
 

 

Urine output should be at least 500 mL in 24 hours (20 mL/h); this client’s output has been just 15 mL/h for the past 2 hours requiring further assessment by the nurse. The nurse should first assess all clients and address physiological needs including pain control and safety measures; the nurse should then take time with the client having difficulty coping in order to listen and further determine her needs. 

CN: Reduction of risk potential; CL: Synthesize

Answer:3

 

翻译

 

问题:

护士在接班时收到了四个病人的病历。根据这份病历,护士应首先评估以下哪位病人?

1.一位38岁的妇女,刚做完乳腺癌手术第二天,她的病情稍微有点复杂。

2.一位52岁的病人,患有肺炎和慢性背痛,正在申请服用止痛药。

3.一位35岁的男子,因车祸入院,在过去的2小时内尿量累计达30毫升。

4.一位84岁的老人,左侧肢体无力,失眠和意识障碍。

 

答案:3

24小时内尿量应至少为500毫升(20毫升/小时);过去2小时内,该病人的尿量仅为15毫升/小时,需要护士进一步评估。护士应首先对所有病人进行评估,并解决病人需求,包括疼痛控制和安全措施;然后,护士应与有困难的病人进行交流,以便倾听并进一步确定她的需求。

CN:降低风险可能性;CL:综合

小编寄语Sometimes, we have to shut up, put down our pride and admit that we are wrong. It's not about giving up, it's about growing.有时候,我们必须闭上嘴,放下骄傲,承认是自己错了。这不是认输,而是成长。

时间:2020/9/10 11:49:53
 
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