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《Kaplan NCLEX-RN Question Trainer Test-1》(962-964)

发表日期:2016-12-19 | 来源 :国际护士网 | 作者 :www.the-nurses.com |点击数: 次 收听:
 
962. The nurse is caring for clients in the postanesthesia care unit (PACU). Which of the following clients require IMMEDIATE attention by the nurse?

1. A client with a new tracheotomy with a small amount of serosanguineous drainage on the dressing.
2. A client who is responsive with a moderate amount of clear fluid draining from the NG tube.
3. A client with a chest tube and dark red drainage in the collection chamber.
4. A client who is unresponsive to verbal stimuli with the oral airway out of place.

Strategy: Remember the ABCs.

(1) expected outcome, patient is stable
(2) no indication of complications, stable client
(3) expected outcome, gently “milk” tubing in the direction of the drainage, if needed
(4) correct—reinsert airway to maintain patent airway
  

963. A 57-year-old man admitted with metastatic cancer has been receiving chemotherapy for 3 months. His lab values include: RBC 3.8 million/mm3, WBC 3,000/mm3, Hgb 9.3 g/dL, platelets 50,000/mm3. The nurse would expect the patient to exhibit which of the following symptoms?

1. BP 120/70, pulse 100, respirations 16.
2. Ankle edema and ascites.
3. Flushed face and light stools.
4. Nausea, anorexia, and vomiting.

Strategy: Determine how each answer choice relates to the situation.

(1) correct—increased pulse and respirations are caused by decreased oxygenation of tissues
(2) no information to suggest this is provided in the question  
million/mm3, decreased with anemia; normal WBC 4,500–11,000/mm3, decreased (leukopenia) causes susceptibility to infection; normal Hgb – male 13.5–17.5 g/dL, female 12–16 g/dL, decreased with anemia
(4) not related to information provided in the question

964. A physician has written an order for an HIV-positive infant to receive an oral polio immunization. Which of the following nursing actions is  OST appropriate?

1. Wear gloves and a gown when administering the immunization.
2. Administer the immunization as the infant is being discharged.
3. Call the physician and discuss the rationale for the immunization.
4. Administer the medication in the same manner as you would to any other infant.

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

(1) does not address the identified problem of the compromised immune system
(2) does not address the identified problem of the compromised immune system
(3) correct—polio vaccine contains live virus and should not be given to children who are immunocompromised
(4) does not address the identified problem of the compromised immune system

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