國際護(hù)士資格考試（ISPN）練習(xí)題（下）

51.Afterwhichsurgicalprocedurewouldthenurseplantomonitortheclient's

ankle-brachialindex(ABI)?

a.Offpumpcoronaryarterybypass

b.Dynamiccardiomyoplasty

c.Carotidendarterectomy

d.Femoral-poplitealbypass

52.Theeveningnursegoesintocareforaclientwhohadamodifiedmastectomy

thatmorning.Whichfactisessentialforthenursetoknowtoprovidesafecare?

a.Theinvolvedarmshouldbewearinganelasticsleeve.

b.TheinvolvedarmshouldnotbeusedforBPmeasurement.

c.Theinvolvedarmshouldbenotbeexercisedfor10days.

d.Theinvolvedarmshouldbemaintainedattheleveloftheheart.

注釋：

ankle-brachialindex(ABI)裸臂血壓指數(shù)

bypass搭橋術(shù)；旁路

cardiomyoplasty心肌成形術(shù)

carotidendarterectomy頸動脈內(nèi)膜切除術(shù)

mastectomy乳房切除術(shù)

Rationale

51.Correctanswer:d.

Ankle-brachialindexisatestofarterialstatusinthelowerextremity.Normalarteries

inthefoot(dorsalispedisandposteriortibial)haveanindexof1.0-1.2.Anindex

below1.0indicatesarterialobstruction.Afterabypassgraftprocedureintheleg,ABI

ismeasuredevery8hoursforthefirst24hoursandthenonceaday.Peripheralpulses,

color,andsensationintheextremityarealsomonitored.Arterialstatusofthefootis

notamajorconcernafteroffpumpcoronaryarterybypass,dynamiccardiomyoplasty,

orcarotidendarterectomy.

52.Correctanswer:b.

BPshouldnotbemeasuredonthearmontheoperativesidebecausetheprocedure

interfereswithcirculationandcancausevenouscongestionintheaffectedextremity.

Elasticsleevesareusedinthemanagementoflymphedemaafteramastectomy.

Limitedexercisesoftheaffectedarmarestartedontheeveningofsurgery.The

involvedarmshouldnotbekeptinadependentpositionforanextendedlengthof

timeandifedemaispresent,itshouldbeelevatedasmuchtimeaspossible.

53.Whichassessmentfinding(s)onaclientwhohadatransurethralresectionofthe

prostateforBPH4hoursagowouldindicatetheneedtonotifythephysician?

a.Redbloodyurinewithsmallclots

b.BPof110/50mmHg,pulse130bpm

c.Urinaryoutputof200mlgreaterthanintake

d.Painrelatedtobladderspasms

54.Thenurseshouldinterpretacomplaintofjointpainfromaclientwitha

mechanicalheartvalveaspotentiallyindicativeofwhichproblem?

a.Streptococcalinfection

b.Vegetativeembolus

c.Bleeding

d.Hypoxemia

注釋：

transurethral經(jīng)尿道的

prostate前列腺

BPH(beingprostatichyperplas⑶良性前列腺增生癥

clot血塊

streptococcalinfection鏈球菌感染

hypoxemia低氧血癥

Rationale

53.Correctanswer:b.

ArapidpulsewithalowBPisapotentialsignofexcessivebloodlossandphysician

shouldbenotifiedbasedonthisfinding.Somehematuriaisusualforseveraldays

aftersurgery.Aurinaryoutputof200mlorgreaterthanintakeisadequate.Bladder

spasmsareexpectedtooccurfollowingsurgery.

54.Correctanswer:c.

Mechanicalvalvesrequirethataclientbeonanticoagulanttherapyforlifebecauseof

theriskofthromboemboli.Therefore,theclientisatriskforbleedingassociatedwith

anticoagulation,signsofwhicharejointpain,blackortarrystools,bloodintheurine,

andbleedinggums.Streptococcalinfectionoccursanywhereinthebodyand

symptomsdependinpartonlocationoftheinfection.Osteomyelitismaybe

streptococcalinoriginandbonepainoccursbutnotnecessarilyjointpain.A

vegetativeembolusisacomplicationofinfectiveendocarditisinwhichapieceofthe

plateletfibrinbacteriamasscalledvegetationwhichformsontheheartvalvesbreaks

offandtravelsinthebloodstream.Symptomsofanembolusdependonwhereit

lodgesinthebodyandtowhatextentbloodflowtothetissuesaredisrupted.

HypoxemiareferstodecreasedoxygenintheblooddefinedasabelownormalPaO2;

hypoxiaisoxygenlackatthetissuelevel.Jointpainduetohypoxiaisseenin

vasoocclusivecrisisinsicklecelldisease.

55.Aclientwithatrialfibrillationsuddenlycomplainsofacute,severepainintheleft

arm.Onassessmentthenursefindsthearmtobecold,pale,andwithoutpalpable

pulses.Whichproblemshouldthenursesuspect?

a.Myocardialinfarction

b.Compartmentsyndrome

c.Arterialembolus

d.Hypovolemicshock

56.Whencaringforapostoperativeclientwhohashadathyroidectomy,which

medicationshouldthenurseensureisimmediatelyavailableatthebedside?

a.Calciumgluconate

b.Propylthiouracil

c.SSKI

d.Synthroid

注釋：

fibrillation纖維性顫動

palpable可觸知的,明顯的

myocardialinfarction心肌梗塞

hypovolemicshock低血容性休克

thyroidectomy甲狀腺切除術(shù)

calciumgluconate葡萄糖酸鈣

propylthiouracil丙基硫氧喀咤

SSKI飽和碘化鉀溶液

synthroid左旋甲狀腺素鈉

Rationale

55.Correctanswer:c.

Arterialemboliareoftenassociatedwithatrialfibrillationandoftencauseacute

arterialocclusiontheS&Sofwhicharepainintheaffectedarea,paralysis,absenceof

pulses,pallor,paresthesias,numbnessandcoolness.MIcancauseanarterialembolus

butanMIitselfdoesnotcausethesesymptoms.Compartmentsyndromeoccurs

whenpressure,usuallyfromedema,bleeding,orrestrictivedressing,increasesina

limitedanatomicspaceandcompromisescirculationandfunctionoftissueswithin

thespace.Itisnotcausedbyatrialfibrillationandsymptomsareunrelentingpain,

pallor,pulselessness,andparesthesias.Symptomsofhypovolemicshockaresystemic,

notlimitedtooneextremity.

56.Correctanswer:a.

Calciumgluconateshouldbeimmediatelyavailableatthebedsideofaclientwhohas

hadathyroidectomybecauseoftheriskofhypocalcemictetany.Propylthiouracil,an

antithyroiddrug,blockssynthesisofthyroidhormoneandisusedinthetreatmentof

hyperthyroidism.SSKIdecreasesbloodflowtothethyroidgland.Synthroidisa

thyroidhormonereplacementdrugandisusedinthetreatmentofhypothyroidism.

57.Aclienthavingsurgeryforglaucomaasksthenursehowthedoctorwillknowif

thesurgeryissuccessful.Whichwouldbeanappropriateresponseforthenurseto

make?

a.IOPwilldecrease

b.Abilitytoreadsmallprintwillimprove

c.Pupilwillremainpermanentlydilated

d.Peripheralvisionwillincrease

58.Whichadvicewouldbeappropriateforthenursetogivetoaclientwithdumping

syndrome?

a.Takeadrinkaftereveryfourtofivebitesoffoodatameal

b.Eatseveralsmallmealsperdayofwetfoods

c.Remaininanuprightpositionfor30-60minutesaftereating

d.Avoidfoodsthatareconcentratedcarbohydrates

注釋：

glaucoma青光眼

IOP(intra-ocularpressure)眼內(nèi)壓

peripheralvision外周視覺

dumpingsyndrome胃切除后綜合征

carbohydrates碳水化合物

Rationale

57.Correctanswer:a.

ThereasonsurgeryisdoneforglaucomaistolowerIOPbecauseincreasedIOPcauses

progressivelossofvision.Surgeryisdonewhenmedicationisineffective.Damage

donebyincreasedIOPispermanent;therefore,abilitytoreadisnotimproved.The

pupilisnotaffectedbythesurgerysocontractionanddilationoccurnormally.

Glaucomacauseslossofperipheralvisionbeforelossofcentralvisionandthislossis

irreversible.

58.Correctanswer:d.

Foodsthatareconcentratedcarbohydratesshouldbeavoided.Dumpingsyndrome

hasvasomotor(tachycardia,diaphoresis,flushing,weakness,palpitations,andanxiety)

andGIsymptoms(distention,nausea,vomiting,anddiarrhea)andoccurswhenthere

isarapidentryofbolusesofhyperosmolarfooddirectlyintothesmallintestine.To

decreasethesymptomsofdumpingsyndrome,aclientalsoshouldeatsixsmallmeals

perdayofdryfoodsandshouldnotdrinkfluidswithmeals;avoidveryhotorcold

foods;andliedownfor30-60minutesaftereating.

59.Whencaringforaclientwhohashadakidneytransplant,thenurseassessesfor

signsofrejection.ForwhichS&Swouldthenurseobserve?Markallthatapply.

a.Changeinurinaryoutput

b.Flankpain

c.Edema

d.Suddenweightgain

60.AfterwhichprocedurewouldthenursebeexpectedtotitrateIVfluidstoreplace

outputduringthefirst24hours?

a.Livertransplant

b.Hearttransplant

c.Kidneytransplant

d.Lungtransplant

注釋：

Transplant移植

Rejection排斥

S&S(signsandsymptoms)體征和癥狀

Edema水腫

Titratev.滴定測量

I&O(intake/inputandoutput)攝入量與排出量

Rationale

59.Correctanswers:a,b,c,andd.

Changeinurinaryoutput,flankpain,edema,andsuddenweightgainthatisreflective

ofedemabecausewaterhasweightareallsymptomsofrejectionofakidney

transplant.

60.Correctanswer:c.

Maintenanceoffluidandelectrolytestatusisakeyaspectofcarefollowingliver,heart,

kidney,andlungtransplants.However,itisonlyfollowingakidneytransplantthat

I&OischeckedhourlyandIVfluidsaretitratedtoreplaceoutputforthefirst12-24

hours.

61.Whichactionshouldthenursetakewhenduringassessment;he/shefindsthe

clientwhois2dayspostalivertransplanthasatemperaturepersistentof101.5°F,

pulse95,andrespiratoryrateof18?

a.Repositiontheclient

b.Administeroxygen

c.Administerpainmedication

d.Callthephysician

62.Whenconductingdischargeteachingforatransplantclient,thenursemustmake

suretheclientandfamilyunderstandtheimportanceofwhichselfcareactivities?

Markallthatapply.

a.Medicationcompliance

b.ReportingofS&Setc.

c.Keepingfollow-upappointments

d.Establishingasetsleep/wakeroutine

注釋：

Persistent持續(xù)的

Administeroxygen輸氧

S&S(signsandsymptoms)體征和癥狀

Immunosuppressed免疫功能不全的

Tachypnea呼吸急促

Rationale

61.Correctanswer:d.

Becauseimmunosuppressedclientsdonothaveasrobustanimmuneresponseto

infectionandsymptomswillbemoresubtlesuchasatemperatureof101.5°F,

tachycardia,andtachypnea.Infectionanditstreatmentarethecriticalconcernsinthis

situationforthisclientandnoneoftheotheroptionsaddressthese.

62.Correctanswers:a,b,andc.

Establishingasetsleep/wakeroutineisnotessentialforthetransplantclientandis

notapartofroutinedischargeteachingfortheseclients.

63.Whichdirectionswouldthenursegivetoaclientwhoisbeingpreparedfor

dischargefollowingapneumonectomy?Markallthatapply.

a.Continuebreathingexercisesathome.

b.Exercisearmandshoulderfivetimesperday.

c.Practicestandingstraightwithshoulderseveninfrontofthemirror.

d.Donotliftmorethan20lbforatleastamonth.

e.Stopanyactivitythatcausesdyspnea,chestpain,orexcessivefatigue.

f.Obtaininfluenzaandpneumoniavaccines.

g.Expectanintermittentcoughwithincreasedsputum.

64.Aclientwithwhichproblemneedscarefulassessmentforthedevelopmentof

ARDS?

a.Pericarditis

b.Anemia

c.Acutepancreatitis

d.Pyelonephritis

注釋：

Pneumonectomy肺切除術(shù)

Dyspnea呼吸困難

Vaccines疫苗

Intermittent間歇的

ARDS急性呼吸窘迫綜合癥

Pericarditis心包炎

Pancreatitis胰腺炎

Rationale

63.Correctanswers:a,b,c,e,andf.

Breathingexercisesneedtobecontinuedusuallyforabout3weeks.Armand

shoulderexercisesneedtobecontinuedfivetimesadaywith10-20repetitionseach

time.Clientsneedtopracticestandingstraightwithshouldersevenbecausethe

shoulderontheaffectedsidewilltendtobelowerduetothetransectionofmuscles

andnaturaltendencytoguardsoreareas.Lookinginthemirroristhebestwaytosee

howtheshoulderneedstobeheldforposturetobecorrect.Anyactivitythatcauses

dyspnea,chestpain,orexcessivefatigueshouldbestopped;thesearesignsof

exceedingtheabilityoftheremaininglungtomeetthedemandforoxygen.Chest

painmayindicateinadequateoxygenreachingthemyocardium.Obtainingthe

pneumoniaandinfluenzavaccinesisimportantbecausewithonlyoneremaininglung

thereisalmostnorespiratoryreserveandsotheabilitytocopewitharespiratory

infectionisseverelycompromised.Itisincorrecttotelltheclientnottoliftmorethan

20lbforatleastamonthbecauseheavyliftingmustbeavoidedfor3-6months.An

intermittentcoughwithincreasedsputumisnotexpected.Infactifthisoccurs,it

shouldbereportedimmediately.

64.Correctanswer:c.

ARDSisacomplicationofacutepancreatitisusuallydeveloping3-7daysafterthe

onsetofthepancreatitis.Itismostcommoninclientswithseverevolumedepletion.

Thecomplicationassociatedwithpericarditisispericardialeffusion,withanemiathe

riskisforcongestiveheartfailure.Withpyelonephritis,intractableinfectionthatmay

requiresurgery,evennephrectomy,toeradicateit.

65.Aclienthavingcryosurgeryforremovalofasquamouscellcarcinomaasksifthe

procedurewillhurt.Whichisthecorrectanswerforthenursetogive?

a.”Youwillnotfeelanything."

b."Therewillbeabrieftinglingpain.”

c."Therewillbenopainbutyoumayexperienceaslightoddsmell.”

d."Therewillbeamomentary,stabbingpain."

66.Whenplanningforthepostoperativecareofclientshavingathyroidectomy,

whichpieceofequipmentismostessentialforthenursetohaveavailableatthe

bedside?

a.Suctionmachine

b.Tracheostomyset

c.Cardiacmonitor

d.Humidifier

注釋：

Cryosurgery冷凍手術(shù)

squamouscellcarcinoma鱗狀細(xì)胞癌

thyroidectomy甲狀腺切除術(shù)

Tracheostomyset氣管切開器

Rationale

65.Correctanswer:b.

Abrieftinglingpainisfeltwithcryosurgery.Anunpleasantodorcanoccurwhen

electrocauteryisusedtoburnabnormaltissueasincasesofcervicaldysplasiaor

genitalwarts.

66.Correctanswer:b.

Atracheostomysetisneededatthebedsidebecauseoftheriskofrespiratorydistress

fromcompressionofthetracheafrombleedingoredema,laryngealspasmfrom

hypocalcemictetany,orvocalcordspasmsecondarytolaryngealnervedamage.

67.WhichS&Soccurringinaclient48hourspost-adrenalectomyindicatethat

glucocorticoiddosageneedstobeincreased?

a.Markedweakness,anorexia,nausea,orvomiting.

b.Severedyspnea,tachycardia,apprehension

c.Paresthesias,numbnessandtinglingintheextremities,musclespasms

d.Orthostatichypotension,depressedreflexes,slowmentation.

68.Avisitorwithanobviousupperrespiratoryinfectionarrivestoseeaclient24hours

postoperativefromanadrenalectomy.Thenurseexplainsthatitisveryimportantthat

theclientnotbeexposedtoanyonewithacontagiousillness.Thevisitoraskswhy.

Whichfactshouldbethebasisofthenurse'sanswer?

a.Theclientisunabletofightinfectionbecauseoflossofstresshormones.

b.Fluidandelectrolytefluctuationscreateanenvironmentinwhichinfective

organismscanthrive.

c.Riskofinfectionisgreatlyincreasedbecauseofexcesscortisol.

d.Theimmunesystemissuppressedaspartofthepreparationforsurgeryandit

takes3-4weeksforittoregainnormalfunction.

注釋：

S&S[=signsandsymptoms]體征和癥狀

Adrenalectomy腎上腺切除術(shù)

Glucocorticoid腎上腺糖皮質(zhì)激素

Dosage齊ij量

Anorexia厭食癥

Dyspnea呼吸困難

Paresthesias感覺異常

Cortisol皮質(zhì)醇

Rationale

67.Correctanswer:a.

Markedweakness,anorexia,nausea,orvomitingareS&Sindicatingthatthedoseof

glucocorticoidsneedstobeincreased.Severedyspnea,tachycardia,and

apprehensionareS&Sofrespiratory/cardiovascularproblemssuchaspulmonary

edema.Paresthesias,numbness,tinglingintheextremities,andmusclespasmsare

symptomsofhypocalcemictetany.Orthostatichypotensionoccurs

postadrenalectomybutdoesnotindicateaneedforincreasedglucocorticoidsnordo

depressedreflexesandslowmentation.

68.Correctanswer:c.

Excesscortisolincreasestheriskofinfectionbecauseitdecreasestheinflammatory

response.Lossofepinephrineandnorepinephrinearenottheimportantfactorsinthe

increasedriskofinfection.Fluidandelectrolytefluctuationsdonotcreatean

environmentinwhichinfectiveorganismscanthrive.Theimmunesystemisnot

suppressedinpreparationforsurgery.

69.Whenteachingself-caretoaclientwhohashadabdominalliposuction,which

informationshouldthenurseinclude?

a.Wearthecompressiongarmentwhenupfor2weeks

b.Takeaspirinasneededfordiscomfort

c.Expectasymmetryinthefirstfewweeksafterwhichitwilltaperoff.

d.Avoidweightgainsoeffectofsurgeryisnotnegated.

70.Whichstatementmadebyaclientwhohashadablepharoplastyindicatesthe

needforfurtherteaching?

a."Iwillavoidreadingfor2-3days."

b.”Iwillnotbeabletowearmycontactlensesforatleast2weeks."

c."Iwillapplywarmcompressestocontrolswelling/1

d."Ineedtoavoidalcoholfor3weeks.”

注釋：

Liposuction抽脂術(shù)

Asymmetry不對稱（現(xiàn)象）

Blepharoplasty眼瞼成形術(shù)

Rationale

69.Correctanswer:d.

Weightgainwillnegatetheeffectofthesurgery.Thecompressiongarmentmustbe

wornfor7-10days.Aspirin,aswellasallanticoagulants,mustbeavoidedbecauseof

theriskofbleeding.Asymmetryisacomplicationoftheliposuction,itisnotexpected.

70.Correctanswer:c.

Icedcompressesareusedtocontrolswellinganddiscoloration.Allotherstatements

correctlyapplytotheclientwhohashadablepharoplasty.

71.Aclientscheduledforanephrectomyasksduringthepreoperativeteaching

sessionwhenthedraininthewoundwillberemoved.Whichisthebestreplyforthe

nursetogive?

a.Atthesametimethesuturesareremoved.

b.Notuntilurinaryoutputisclearandatleast600ml/24hr.

c.Afternarcoticsarenolongerrequiredforpainrelief.

d.Whendrainagehasdecreasedtolessthan30ml/d

72.Whichproblemplacesaclientscheduledforanephrostomyatthegreatestriskfor

postoperativehemorrhage?

a.Diabetesmellitus

b.Historyofurinarytractinfections

c.Uncontrolledhypertension

d.Perniciousanemia

注釋：

Nephrectomy腎切除術(shù)

Suture縫合線

Narcotic麻醉劑

Nephrostomy腎造瘦術(shù)

Hemorrhage出血

Rationale

71.Correctanswer:d.

TheJackson-Prattdrainisremovedwhenthereislessthan30mlofdrainagein24

hours.Suturesareremovedin7-10dayswhentheincisionhashealed.Urinaryoutput

isviatheremainingkidneyandhasnorelationshiptotheneedforadraininthe

operativearea.Incisionalpainismanagedwithopioidanalgesicsbutpainisunrelated

todrainageandtheneedforadrain.

72.Correctanswer:c.

BPneedstobetightlycontrolledinclientsundergoinganephrostomybecauseofthe

riskofhemorrhage.Diabetesmellitus,priorurinarytractinfections,orpernicious

anemiasdonotincreasetheriskofhemorrhagefromtheprocedure.

73.Fortheclientinsicklecellcrisis,thenurseshouldfrequentlyassessfor

a.amountoffluidintake

b.levelofpain

longederectioninmales

d.lowerlegulcers

74.Whichinformationshouldbeincludedintheteachingplanforaclientwhohas

hadanureterosigmoidostomy?

a.Lifelongprophylacticantibioticswillbeneeded.

b.Annualsigmoidoscopyshouldbeobtainedstarting10yearsaftersurgery.

c.Fluidintakeshouldnotexceed1200ml/d.

d.Dietshouldbehighinfiberandlowinfat.

注釋：

sicklecell鐮狀細(xì)胞

ulcer潰瘍

ureterosigmoidostomy輸尿管乙狀結(jié)腸吻合術(shù)

prophylactic預(yù)防疾病的

sigmoidoscopy乙狀結(jié)腸鏡檢查

Rationale

73.Correctanswer:b.

Painistheprimarysymptomofsicklecellcrisis.Prolongederectionandlowerleg

ulcersarechronicproblemsassociatedwithsicklecelldisease.

74.Correctanswer:b.

Anannualsigmoidoscopyisrecommendedstarting10yearsaftersurgerybecauseof

theincreasedriskofneoplasiadevelopinginthesigmoidcolonatthesiteof

anastomosisoftheureters.Prophylacticantibioticsarenotgiven,however,because

thereistheriskofkidneyinfectionfromrefluxoffeces,anytemperatureoflOlror

more,costovertebralanglepain,orsignificantchangesincolor,consistency,or

amountofoutputshouldbereportedtothehealthcareprovider.Thereisno

limitationonfluidintakeandnodietaryrestrictions.

75.Thenursegoesintomeetandassessherclientwhohadavulvectomy2daysago.

TheclientisdozinginbedinFowler'spositionbutstatessheisuncomfortable,when

asked.Whichactionshouldthenursetakefirst?

a.Callthephysician

b.Repositiontheclientinsemi-Fowler's

c.Administerpainmedication

d.Explainitisnormaltobeuncomfortableafterthesurgery

76.Thenurseshouldinterpretaweightgainof5.5lbover24hoursinaclientwitha

biologiccardiacvalvereplacementasasignofthedevelopmentofwhichproblem?

a.Graftrejection

b.Pericarditis

c.Congestiveheartfailure

d.Pyelonephritis

注釋：

Vulvectomy外陰切除術(shù)

semi-Fowler半坐臥位

Pericarditis心包炎

Rationale

75.Correctanswer:b.

Changeclientspositiontosemi-Fowler'stoalleviatediscomfortandtensionon

sutureline;sittinginaFowler'spositionputsdirectpressureonsutureline(s)and

causesdiscomfort.Painmedicationcannotbeadministeredwithoutfirstcheckingfor

anorderanddeterminingwhenitwaslastgiven.Inaddition,changeinpositionthat

mayrelievethediscomfortcanbedoneimmediatelywhilethenurseisatthebedside,

soitisthefirstactionthenurseshouldtake.Explainingdiscomfortisnormalmay

relieveanxietybutclientshavearighttopainreliefwhetherpainisexpectedornot.

76.Correctanswer:c.

Weightgain,dyspnea,andtachycardiaaresymptomsofCHF,whichcanoccurwith

graftfailure.Hyperacutegraftrejectionisalmostexclusivelylimitedtotransplanted

kidneysandisarareeventbecauseofcarefulcrossmatchingbeforetransplant.

Symptomsofpericarditisincludesevereprecordialpain,whichisworsewhenlying

supineandreducedwhensittingup,fever,tachycardia,andmyalgia.Symptomsof

pyelonephritisincludefever,chills,flankpain,costovertebralangletenderness,and

signsoflowerUTI.

77.Afterwhichsurgicalprocedurewouldthenurseplantomonitortheclient's

ankle-brachialindex(ABI)?

a.Offpumpcoronaryarterybypass

b.Dynamiccardiomyoplasty

c.Carotidendarterectomy

d.Femoral-poplitealbypass

78.Theeveningnursegoesintocareforaclientwhohadamodifiedmastectomy

thatmorning.Whichfactisessentialforthenursetoknowtoprovidesafecare?

a.Theinvolvedarmshouldbewearinganelasticsleeve.

b.TheinvolvedarmshouldnotbeusedforBPmeasurement.

c.Theinvolvedarmshouldbenotbeexercisedfor10days.

d.Theinvolvedarmshouldbemaintainedattheleveloftheheart.

注釋:

ankle-brachialindex踝臂指數(shù)

cardiomyoplasty心肌成形術(shù)

Carotidendarterectomy頸動脈內(nèi)膜切除術(shù)

Mastectomy乳房切除

Rationale

77.Correctanswer:d.

Ankle-brachialindexisatestofarterialstatusinthelowerextremity.Normalarteries

inthefoot(dorsalispedisandposteriortibial)haveanindexof1.0-1.2.Anindex

below1.0indicatesarterialobstruction.Afterabypassgraftprocedureintheleg,ABI

ismeasuredevery8hoursforthefirst24hoursandthenonceaday.Peripheralpulses,

color,andsensationintheextremityarealsomonitored.Arterialstatusofthefootis

notamajorconcernafteroffpumpcoronaryarterybypass,dynamiccardiomyoplasty,

orcarotidendarterectomy.

78.Correctanswer:b.

BPshouldnotbemeasuredonthearmontheoperativesidebecausetheprocedure

interfereswithcirculationandcancausevenouscongestionintheaffectedextremity.

Elasticsleevesareusedinthemanagementoflymphedemaafteramastectomy.

Limitedexercisesoftheaffectedarmarestartedontheeveningofsurgery.The

involvedarmshouldnotbekeptinadependentpositionforanextendedlengthof

timeandifedemaispresent,itshouldbeelevatedasmuchtimeaspossible.

79.Whichassessmentfinding(s)onaclientwhohadatransurethralresectionofthe

prostateforBPH4hoursagowouldindicatetheneedtonotifythephysician?

a.Redbloodyurinewithsmallclots

b.BPof110/50mmHg,pulse130bpm

c.Urinaryoutputof200mlgreaterthanintake

d.Painrelatedtobladderspasms

80.Thenurseshouldinterpretacomplaintofjointpainfromaclientwitha

mechanicalheartvalveaspotentiallyindicativeofwhichproblem?

a.Streptococcalinfection

b.Vegetativeembolus

c.Bleeding

d.Hypoxemia

注釋：

Transurethral經(jīng)尿道的

Prostate前列腺

Streptococcalinfection鏈球菌感染

Hypoxemia低氧血癥

Embolus栓子，栓塞

Rationale

79.Correctanswer:b.

ArapidpulsewithalowBPisapotentialsignofexcessivebloodlossandphysician

shouldbenotifiedbasedonthisfinding.Somehematuriaisusualforseveraldays

aftersurgery.Aurinaryoutputof200mlorgreaterthanintakeisadequate.Bladder

spasmsareexpectedtooccurfollowingsurgery.

80.Correctanswer:c.

Mechanicalvalvesrequirethataclientbeonanticoagulanttherapyforlifebecauseof

theriskofthromboemboli.Therefore,theclientisatriskforbleedingassociatedwith

anticoagulation,signsofwhicharejointpain,blackortarrystools,bloodintheurine,

andbleedinggums.Streptococcalinfectionoccursanywhereinthebodyand

symptomsdependinpartonlocationoftheinfection.

Osteomyelitismaybestreptococcalinoriginandbonepainoccursbutnotnecessarily

jointpain.Avegetativeembolusisacomplicationofinfectiveendocarditisinwhicha

pieceoftheplateletfibrinbacteriamasscalledvegetationwhichformsontheheart

valvesbreaksoffandtravelsinthebloodstream.Symptomsofanembolusdepend

onwhereitlodgesinthebodyandtowhatextentbloodflowtothetissuesare

disrupted.Hypoxemiareferstodecreasedoxygenintheblooddefinedasabelow

normalPaO2;hypoxiaisoxygenlackatthetissuelevel.Jointpainduetohypoxiais

seeninvasoocclusivecrisisinsicklecelldisease.

81.Aclientwithatrialfibrillationsuddenlycomplainsofacute,severepainintheleft

arm.Onassessmentthenursefindsthearmtobecold,pale,andwithoutpalpable

pulses.Whichproblemshouldthenursesuspect?

a.Myocardialinfarction

b.Compartmentsyndrome

c.Arterialembolus

d.Hypovolemicshock

82.Whencaringforapostoperativeclientwhohashadathyroidectomy,which

medicationshouldthenurseensureisimmediatelyavailableatthebedside?

a.Calciumgluconate

b.Propylthiouracil

c.SSKI

d.Synthroid

注釋：

Fibrillation纖維性顫動

Palpable明顯的，可觸知的

Myocardialinfarction心肌梗塞

Compartmentsyndrome腔室癥候群

Hypovolemicshock低血溶性休克

Thyroidectomy甲狀腺切除

Propylthiouracil丙基硫氧喀咤

SSKI飽和碘化鉀溶液

Synthroid左甲狀腺素

Rationale

81.Correctanswer:c.

Arterialemboliareoftenassociatedwithatrialfibrillationandoftencauseacute

arterialocclusiontheS&Sofwhicharepainintheaffectedarea,paralysis,absenceof

pulses,pallor,paresthesias,numbnessandcoolness.MIcancauseanarterialembolus

butanMIitselfdoesnotcausethesesymptoms.Compartmentsyndromeoccurs

whenpressure,usuallyfromedema,bleeding,orrestrictivedressing,increasesina

limitedanatomicspaceandcompromisescirculationandfunctionoftissueswithin

thespace.Itisnotcausedbyatrialfibrillationandsymptomsareunrelentingpain,

pallor,pulselessness,andparesthesias.Symptomsofhypovolemicshockaresystemic,

notlimitedtooneextremity.

82.Correctanswer:a.

Calciumgluconateshouldbeimmediatelyavailableatthebedsideofaclientwhohas

hadathyroidectomybecauseoftheriskof