【最新ISPN测试题】ISPN测试题(188)
2016/6/13 河南安琪职业培训学校

     点击「箭头所指处」可快速关注微信号：edu-hnangel

     Exercise:

     1、A client has a prescription to receive purified protein derivative (PPD), 0.1 mL, intradermally. The nurse should administer the medication by using a tuberculin syringe according to which guidelines?

     1.20-gauge, 1-inch needle inserted at a 30-degree angle, with the bevel side down

     2.26-gauge, 5/8-inch needle inserted at a 45-degree angle, with the bevel side down

     3.20-gauge, 1-inch needle inserted almost parallel to the skin, with the bevel side up

     4.26-gauge, 5/8-inch needle inserted almost parallel to the skin, with the bevel side up

     Correct Answer:4

     A tuberculin skin test is administered by giving 0.1 mL of PPD intradermally. Administration involves drawing the medication into a tuberculin syringe with a 25- to 27-gauge, 5/8-inch needle. The injection is given by inserting the needle as close as possible to a parallel position with the skin and with the needle bevel facing up. This results in formation of a wheal when the PPD is administered correctly.

     2、The nurse is assessing a newborn with heart failure before administering the prescribed digoxin (Lanoxin). In reviewing the laboratory data, the nurse notes that the newborn has a digoxin blood level of 2.4 ng/mL and an apical heart rate of 98 beats/min. The mother also tells the nurse that the newborn just vomited her formula. Which intervention should the nurse take?

     1.Retake the apical pulse.

     2.Administer the medication.

     3.Withhold the medication for 1 hour.

     4.Withhold the medication and notify the health care provider.

     Correct Answer:4

     The apical pulse rate for a newborn is 120 to 140 beats/min. The therapeutic digoxin level ranges from 0.5 to 2.0 ng/dL. Because the apical rate is low and the digoxin blood level is elevated, indicating toxicity, the nurse would withhold the medication and notify the health care provider. Therefore options 1, 2, and 3 are incorrect.

     3、A nurse is interviewing a client in crisis to assess the risk for self-harm. The nurse interprets that the client is most at risk for suicide if which is assessed?

     1.Client exhibits impulsive behavior.

     2.Client exhibits disorganized behavior.

     3.Client has a history of suicide attempts.

     4.Client has an immediate plan for a suicide attempt.

     Correct Answer:4

     A client who has a specific suicide plan is most at risk for actually committing suicide, especially if the method is highly lethal and available to the client. The client also presents a lethality potential if the client appears disorganized and impulsive. Clients at higher risk for suicide include those with a history of a dual diagnosis of mental illness and substance abuse, a personal or family history of suicide attempts, depression, alcoholism, or psychotic episodes.

     回复关键字获得更多相关内容，如ispn﹑视频等等

     请点击右上角--分享到朋友圈!

    

     河南安琪职业培训学校联系方式

     安琪国际护理官网：http://www.hnangel.com

     ISPN/RN一元淘宝：http://hnangel.taobao.com

     地址：郑州市金水区经三路32号(财富广场)4号楼第18层1804室

     电话：4008-167-671

     传真：0371-65721730

    http://www.duyihua.cn
返回 河南安琪职业培训学校 返回首页 返回百拇医药