【最新ISPN测试题】ISPN测试题(184)
2016/6/6 河南安琪职业培训学校

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     Exercise:

     1、The emergency department nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the emergency department. The nurse should take which initial action?

     1. Prepare the triage rooms.

     2. Activate the emergency response plan.

     3. Obtain additional supplies from the central supply department.

     4.Obtain additional nursing staff to assist in treating the casualties.

     Correct Answer:2

     In an external disaster (a disaster that occurs outside of the institution or agency), many victims may be brought to the emergency department for treatment. The initial nursing action must be to activate the emergency response plan. Once the emergency response plan is activated, the actions in the other options will occur.

     2、Lactulose (Chronulac) is prescribed for a client with a diagnosis of hepatic encephalopathy. The nurse should determine that this medication has had a therapeutic effect if assessment reveals which finding?

     1.Increased protein level

     2.Increased red blood cell count

     3.Decreased serum ammonia level

     4.Decreased white blood cell count

     Correct Answer:3

     Lactulose is prescribed for the client with hepatic encephalopathy to reduce bacterial breakdown of protein in the bowel. The medication creates an acidic environment in the bowel and causes the ammonia to leave the bloodstream and enter the colon. Ammonia then becomes trapped in the bowel. Lactulose also has a laxative effect that allows for the elimination of the ammonia.

     3、The nurse working in a long-term care facility is assessing a client who is experiencing chest pain. The nurse should interpret that the pain is most likely caused by myocardial infarction (MI) on the basis of what assessment finding?

     1.The client is not experiencing dyspnea.

     2.The client is not experiencing nausea or vomiting.

     3.The pain has not been relieved by rest and nitroglycerin tablets.

     4.The client says the pain began while she was trying to open a stuck dresser drawer.

     Correct Answer:3

     The pain of MI is not relieved by rest and nitroglycerin and requires opioid analgesics, such as morphine sulfate, for relief. The pain of angina may radiate to the left shoulder, arm, neck, or jaw. It often is precipitated by exertion or stress, is accompanied by few associated symptoms, and is relieved by rest and nitroglycerin. The pain of MI also may radiate to the left arm, shoulder, jaw, and neck. It typically begins spontaneously, lasts longer than 30 minutes, and frequently is accompanied by associated symptoms (such as nausea, vomiting, dyspnea, diaphoresis, or anxiety).

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