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《Kaplan NCLEX-RN Question Trainer Test-1》(953-955)

发表日期:2016-12-17 | 来源 :国际护士网 | 作者 :www.the-nurses.com |点击数: 次 收听:
 
953. Butorphanol tartrate (Stadol) 1 mg IM is ordered for a 35-year-old woman one-day postpartum. Which of the following actions is MOST important for the nurse to take after administering the medication?

1. Observe the woman for sedation.
2. Monitor the vital signs.
3. Assess for visual disturbances.
4. Evaluate fluid status.

Strategy: Determine the cause of each answer choice and how it relates to Stadol.

(1) causes sedation, but not most important
(2) correct—decreases rate and depth of respirations
(3) diplopia and blurred vision are side effects, but not most important
(4) not side effect of medication
  

954. The nurse knows that which of the following plans would be a priority for an infant with a positive PKU blood test?

1. Place the infant on Lofenlac formula.
2. Administer medium-chain triglyceride (MCT) oil with each feeding.
3. Provide genetic counseling for the family.
4. Place the infant on Lorenzo’s Oil treatments.

Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) correct—Guthrie blood test evaluates neonate for phenylketonuria (PKU); Lofenalac formula is low in phenylalanine, but contains minerals and vitamins to provide a balanced nutritional formula
(2) could be a plan for a child with cystic fibrosis
(3) important, but is not as high a priority as answer choice #1
(4) would be a plan of care for a child with adrenoleukodystrophy (ALD)

955. The nurse is conducting preoperative teaching with the family of a 62-year-old man who is scheduled for a total laryngectomy. Which of the following statements, if made by the family, would indicate to the nurse a need for further teaching?

1. “We will need to learn other ways to communicate with each other.”
2. “My father will require a special kind of tube in his neck for his airway.”
3. “My husband will require a feeding tube for several months.”
4. “My dad may develop some difficulty with taste and smell after the surgery.”

Strategy: “Further teaching is necessary” indicates an incorrect response.

(1) will communicate in writing initially, then artificial larynx or esophageal speech
(2) will require laryngectomy tube to prevent scar tissue contracture
(3) correct—requires nutritional support for 10 days until wound heals, then gradually resumes oral intake
(4) common with total laryngectomy
  

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