ISPN考试模拟试题(九)
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Practice Test Questions
25. When changing a patient’s abdominal dressing, a nurse observes that the wound is dehisced and a small portion of the bowel is eviscerated. Which of these actions should the nurse take first?
A. Apply a sterile saline dressing over the wound
B. Place a pressure dressing over the wound
C. Report the findings to the primary care provider
D. Irrigate the wound with diluted hydrogen peroxide
26. Which of the following orders should a nurse question for a client who is scheduled for surgery?
A. Demerol (meperidine) 200 mg IM
B. Atropine sulfate 0.4 mg IM
C. Valium (diazepam) 2 mg IM
D. Phenergan (promethazine) 25 mg IM
27. A mother brings her 2-week-old infant to the clinic for a
well-child visit. The nurse notes that the infant’s weight is 10% less than the birthweight. To accurately interpret this information, the nurse should take which of these actions?
A. Weigh the baby on another scale
B. Obtain a history of the baby’s feeding pattern since birth
C. Ask the mother how many bowel movements the baby has each day
D. Measure the baby’s abdominal girth
Rationales
25. Key: A Client Need: Management of Care
A. The wound should be covered and kept moist.
B. Pressure should not be placed on an eviscerated bowel.
C. Finding should be reported after covering the wound and checking the patient’s vital signs.
D. Wound should be covered with a saline dressing. Hydrogen peroxide is too caustic for irrigating fluid.
26. Key: A Client Need: Safety and Infection Control
A. The dosage of Demerol is high. The normal range is 50–150 mg. This order should be questioned.
B, C & D.
Valium and Phenergan are both appropriate for preoperative sedation. Atropine is appropriate for preoperative decrease
in secretions. The dose listed is appropriate.
27. Key: B Client Need: Health Promotion and Maintenance
B. Feeding pattern will provide information about weight loss/gain ininfants.
A. Using another scale will not help to accurately interpret results.
C. Record of bowel movements is not the most important aspect ofassessment.
D. Measurement of abdominal girth will not give information about weight loss.