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《Kaplan NCLEX-RN Question Trainer Test-1》(968-970)

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:
 
968. Which of the following is a priority nursing goal in the plan of care for a client with paralysis from a cerebrovascular accident (CVA)?

1. Maintain adduction of the affected shoulder.
2. Prevent flexion of the affected extremities.
3. Observe active range of motion (ROM) daily to all extremities.
4. Maintain external rotation of the affected hip.

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

(1) to prevent deformities, the nurse needs to prevent adduction of the affected shoulder
(2) correct—flexor muscles are stronger than extensor muscles
(3) client will be unable to perform active ROM, will need assistance from nurse
(4) to prevent deformities, the nurse needs to prevent external rotation of the hip joint, prevent foot drop (plantar flexion), and place the hand in slight supination so that the fingers are barely flexed
  

969. The physician orders an arterial blood gas (ABG) for a client receiving oxygen at 6 L/min. What information concerning the patient is MOST important for the nurse to document on the lab slip that accompanies the blood sample?

1. The patient’s position in bed and the respiratory rate.
2. The site used to obtain the blood specimen.
3. The use of supplemental oxygen.
4. The patient’s diagnosis and blood type.

Strategy: Think about each answer choice and how it relates to blood gases.

(1) unnecessary to document positioning
(2) unnecessary to document site used
(3) correct—necessary for accurate test results
(4) unnecessary to document blood type, should document diagnosis

970. Which of the following statements, if made by the parents of a nine-year-old client with an ostomy, would indicate to the nurse that they are providing quality home care?

1. “We change the bag at least once a week, and we carefully inspect the stoma at that time.”
2. “We change the bag every day so that we can inspect the stoma and the skin.”
3. “We encourage our daughter to watch TV while we change her ostomy bag.”
4. “We only have to change the ostomy bag every ten days.”

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

(1) correct—ostomy bags should be changed at least once a week; good time for stoma to be closely inspected
(2) bag should be changed at least once a week or when seal around stoma is loose or leaking
(3) does not encourage client participation or foster independence
(4) bag should be changed more often
  

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