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ISPN模拟试题76

发表日期:2017-01-12 | 来源 :国际护士网 | 作者 :www.the-nurses.com |点击数: 次 收听:
 
151. Which would be the priority expected outcome when caring for an infant with croup?
a. Infant remains free of infection.
b. Infant takes clear fluids as prescribed.
c. Infant’s temperature returns to normal within 24 hours of antibiotic therapy.
d. Infant remains free of laryngospasm.

152. Which client would be most at risk for developing aspiration pneumonia?
a. An infant with a tracheoesophageal defect repair
b. An alert 10-year old with cystic fibrosis
c. A 50-year old with fractured ribs and a fractured leg from a MVA
d. A confused 75-year old with a CVA

注释:
Laryngospasm 喉痉挛
Tracheoesophageal 气管食管的

Rationale

151. Correct answer: d.
Croup is a condition that results from acute obstruction at or just below the larynx. Laryngospasm, which is the spasmodic closure of the larynx produces the brassy or barking cough, hoarseness, and respiratory distress that are the S&S of croup and therefore must be prevented. Avoiding infection is a desirable goal but it is not the priority for this infant who already has experienced croup. Similarly, clear fluids are prescribed for infants with croup but laryngospasm that can block the airway is a greater priority than fluid intake. Infants with croup are typically afebrile and since croup is viral, not bacterial, in origin antibiotics are not needed.

152. Correct answer: d.
Confusion and impaired gag reflex are two of the major risk factors for aspiration pneumonia. Following a repair, an infant is not at particularly high risk for aspiration nor is an alert 10-year old with cystic fibrosis. A 50-year old with fractured ribs and a broken leg has some degree of immobility but no other risk factors.

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