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ISPN模拟试题100

发表日期:2017-01-14 | 来源 :国际护士网 | 作者 :www.the-nurses.com |点击数: 次 收听:
 
199.Which instructions should a nurse provide to a client following delivery regarding care of the episiotomy site to prevent infection?

Select all that apply.
    1.Report a foul-smelling discharge.
    2.Take a warm sitz baths three times a day.
    3.Change the perineum pads three times a day.
    4.Use warm water to rinse the perineum after elimination.
    5.Wipe the perineum from front to back after voiding and

defecation.
  
Correct Answer:1,2,4,5
Warm sitz baths and cleansing with warm water are helpful for relieving pain, and these measures will promote cleanliness in the perineal area to prevent infection. The client should also be instructed to wipe the perineum from front to back after voiding and defecation to decrease the risk for contamination with microorganisms from the anus to the vagina. Warm water should be used to rinse the perineum after elimination. The client also should be instructed that the perineal pad should be changed after each elimination and may be changed in between.
 
200.A homebound client confidentially discusses suicidal plans with the visiting nurse. Based on professional duty to observe confidentiality, which statementbest describes the nurse's obligation to the client?
    1.The nurse must have the client go to the local mental health

center daily for counseling.
    2.The nurse must ask the client not to reveal suicidal plans if

the information needs to be kept confidential.
    3.The nurse cannot tell anyone what the client said and must

strictly adhere to the professional duty for confidentiality.
    4.The nurse must override the duty to observe confidentiality and

notify the client's health care provider (HCP) about the suicidal

ideation.
 
Correct Answer:4
In this situation, the nurse must override the duty to observe confidentiality and notify the client's HCP about the client's suicidal ideation. Option 1 is incorrect because the client is homebound. Option 2 is incorrect because the nurse has a professional obligation to intervene when a client tells the nurse about ideas or plans to harm himself or herself or others. Option 3 is incorrect because the nurse has a moral obligation to protect the client. 

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