国外护士执业模拟试题.docx

国外护士执业模拟试题.docx

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国外护士执业模拟试题

1.Aclientwithawoundinfectionandosteomyelitisistoreceivehyperbaricoxygentherapy.Duringthetherapy,thenurseimplementswhichpriorityintervention?

A:

MaintainsanintravenousaccessB:

EnsuresthatoxygenisbeingdeliveredC:

AdministerssedationtopreventclaustrophobiaD:

Providesemotionalsupporttotheclient’sfamilyAnswer:

BRationale:

Hyperbaricoxygentherapyisaprocessbywhichoxygenisadministeredatgreaterthanatmosphericpressure.Whenoxygenisinhaledunderpressure,theleveloftissueoxygenisgreatlyincreased.Thehighlevelsofoxygenpromotetheactionofphagocytesandpromotehealingofthewound.Becausetheclientisplacedinaclosedchamber,theadministrationofoxygenisofprimaryimportance.Althoughoptions1,3,and4maybeappropriateinterventions,option2isthepriority.

2.Thenurseiscaringforaclientwithheartfailurewhohasamagnesiumlevelof1.4mg/dL.Thenurseshould:

A.Monitortheclientforirregularheartrhythms.B.Encouragetheintakeofantacidswithphosphate.C.Teachtheclienttoavoidfoodshighinmagnesium.D.Provideadietofgroundbeef,eggs,andchickenbreast.Answer:

ARationale:

Thenormalmagnesiumlevelrangesfrom1.8to3.0mg/dL.Thereforethisclientisexperiencinghypomagnesemia.Theclientshouldbemonitoredfordysrhythmiasbecausemagnesiumplaysanimportantroleinmyocardialnervecellimpulseconduction;thus,hypomagnesemiaincreasestheclient’sriskofventriculardysrhythmias.Thenurseavoidsadministeringphosphateinthepresenceofhypomagnesemiabecauseitaggravatesthecondition.Thenurseinstructstheclienttoconsumefoodshighinmagnesium;groundbeef,eggs,andchickenbreastarelowinmagnesium.

3.Thenurseiscaringforaclientwithaherniatedlumbarintervertebraldiskwhoisexperiencinglowbackpain.Thenurseplanstoplacetheclientinwhichpositiontominimizethepain?

A.FlatwiththekneesraisedB.HighFowler’spositionwiththefootofthebedflatC.Semi-Fowler’spositionwiththefootofthebedflatD.Semi-Fowler’spositionwiththekneesslightlyRaisedAnswer:

DRationale:

Clientswithlowbackpainareoftenmorecomfortableinthesemi-Fowler’spositionwiththekneesraisedsufficientlytoflextheknees（William’sposition）.Thisrelaxesthemusclesofthelowerbackandrelievespressureonthespinalnerveroot.Keepingthebedflatwiththekneesraisedwouldexcessivelystretchthelowerback.Keepingthefootofthebedflatwillenhanceextensionofthespine.

4.Aclientwithafracturedrightanklehasashortlegcastappliedintheemergencydepartment.Duringdischargeteaching,thenurseprovideswhichinformationtotheclienttopreventcomplications?

A.Trimtheroughedgesofthecastafteritisdry.B.Weight-bearingontherightlegisallowedoncethecastfeelsdry.C.Expectburningandtinglingsensationsunderthecastfor3to4days.D.Keeptherightankleelevatedabovetheheartlevelwithpillowsfor24hours.Answer:

DRationale:

Legelevationisimportanttoincreasevenousreturnanddecreaseedema.Edemacancausecompartmentsyndrome,amajorcomplicationoffracturesandcasting.Theclientand/orfamilymaybetaughthowto“petal”thecasttopreventskinirritationandbreakdown,butroughedges,iftrimmed,canfallintothecastandcauseabreakinskinintegrity.Weight-bearingonafracturedextremityisprescribedbythephysicianduringfollow-upexamination,afterradiographsareobtained.Additionally,awalkingheelorcastshoemaybeaddedtothecastiftheclientisallowedtobearweightandwalkontheaffectedleg.Althoughtheclientmayfeelheatafterthecastisapplied,burningand/ortinglingsensationsindicatenervedamageorischemiaandarenotexpected.Thesecomplaintsshouldbereportedimmediately.

5.Aclientwasadmittedtothehospital24hoursagoaftersustainingbluntchesttrauma.Thenursemonitorsforwhichearliestclinicalmanifestationofacuterespiratorydistresssyndrome（ARDS）?

A.CyanosisandpallorB.DiffusecracklesandrhonchionchestauscultationC.Increaseinrespiratoryratefrom18to30breathsperminuteD.Hazinessor“white-out”appearanceoflungsonchestradiographAnswer:

CRationale:

Acuterespiratorydistresssyndromeusuallydevelopswithin24to48hoursafteraninitiatingevent,suchaschesttrauma.Inmostcasestachypneaanddyspneaaretheearliestclinicalmanifestationsasthebodycompensatesformildhypoxemiathroughhyperventilation.Cyanosisandpallorarelatefindingsandaretheresultofseverehypoxemia.BreathsoundsintheearlystagesofARDSareusuallyclearbutthenprogresstodiffusecracklesandrhonchiaspulmonaryedemaoccurs.Chestradiographicfindingsmaybenormalduringtheearlystagesbutwillshowdiffusehazinessor“white-out”appearanceinthelaterstages.

6.AprenatalclienthasbeendiagnosedwithavaginalinfectionfromtheorganismCandidaalbicans.Whichfinding（s）shouldthenurseexpecttonoteonassessmentoftheclient?

A.CostovertebralanglepainB.Pain,itching,andvaginaldischargeC.AbsenceofanysignsandsymptomsD.Proteinuria,hematuria,edema,andhypertensionAnswer:

B

Rationale:

ClinicalmanifestationsofaCandidainfectionincludepain,itching,andathick,whitevaginaldischarge.Proteinuria,edema,andhypertensionaresignsofgestationalhypertension.Hematuria,proteinuria,andcostovertebralanglepainareclinicalmanifestationsassociatedwithurinarytractinfections.

7.Aprenatalclientissuspectedofhavingirondeficiencyanemia.Whichfindingshouldthenurseexpecttonoteregardingtheclient’sstatus?

A.ExcessfluidvolumeB.DeficientfluidvolumeC.AlowhemoglobinandhematocritlevelD.AhighhemoglobinandhematocritlevelAnswer:

CRationale:

Pathologicalanemiaofpregnancyisprimarilycausedbyirondeficiency.Whenthehemoglobinlevelisbelow11mg/dL,irondeficiencyissuspected.Anindirectindexoftheoxygen-carryingcapacityisdeterminedviaapackedredbloodcellvolumeorhematocritlevel.Options1and2arenursingdiagnosesthatarenotnotedinirondeficiencyanemia.

8.Anurseiscaringforapostpartumclient.Whichfindingwouldmakethenursesuspectendometritisinthisclient?

A.BreastengorgementB.ElevatedwhitebloodcellcountC.LochiarubraontheseconddaypostpartumD.Feverover38_C,beginning2dayspostpartumAnswer:

DRationale:

Endometritisisacommoncauseofpostpartuminfection.Thepresenceoffeverof38_Cormoreon2successivedaysofthefirst10postpartumdays（notcountingthefirst24hoursafterbirth）isindicativeofapostpartuminfection.Breastengorgementisanormalresponseinthepostpartumperiodandisnotassociatedwithendometritis.Thewhitebloodcellcountofapostpartumwomanisnormallyelevated.Thusthismethodofdetectinginfectionisnotofgreatvalueinthepuerperium.Lochiarubraontheseconddaypostpartumisanormalfinding.

9.Apostterminfant,deliveredvaginally,isexhibitingtachypnea,grunting,retractions,andnasalflaring.Thenurseinterpretsthattheseassessmentfindingsareindicativeof:

A.HypoglycemiaB.RespiratorydistresssyndromeC.MeconiumaspirationsyndromeD.TransienttachypneaofthenewbornAnswer:

CRationale:

Tachypnea,grunting,retractions,andnasalflaringaresymptomsofrespiratorydistressrelatedtomeconiumaspirationsyndrome（MAS）.MASoccursofteninpostterminfantsanddevelopswhenmeconiumintheamnioticfluidentersthelungsduringfetallifeoratbirth.Thesymptomsnotedinthequestionareunrelatedtohypoglycemia.Respiratorydistresssyndromeisacomplicationofpreterminfants.Transienttachypneaofthenewbornisprimarilyfoundininfantsdeliveredviacesareansection.

10.Anurseiscaringforaclientwhohadanorthopedicinjuryofthelegrequiringsurgeryandapplicationofacast.Postoperatively,whichnursingassessmentisofhighestpriority?

A.MonitoringforheelbreakdownB.MonitoringforbladderdistentionC.MonitoringforextremityshorteningD.MonitoringforlossofblanchingabilityoftoenailbedsAnswer:

DRationale:

Withcastapplication,concernforcompartmentsyndromedevelopmentisofthehighestpriority.Ifpostsurgicaledemacompromisescirculation,theclientwilldemonstratenumbness,tingling,lossofblanchingoftoenailbeds,andpainthatwillnotberelievedbyopioids.Althoughheelbreakdown,bladderdistention,orextremitylengtheningorshorteningcanoccur,thesecomplicationsarenotpotentiallylife-threateningcomplications.

11.Anurseiscaringforaclientwithhypertensionreceivingtorsemide（Demadex

）5mgorallydaily.Whichofthefollowingwouldindicatetothenursethattheclientmightbeexperiencingasideeffectrelatedtothemedication?

A.Achloridelevelof98mEq/LB.Asodiumlevelof135mEq/LC.Apotassiumlevelof3.1mEq/LD.Abloodureanitrogen（BUN）of15mg/dL

Answer:

CRationale:

Torsemide（Demadex）isaloopdiuretic.Themedicationcanproduceacute,profoundwaterloss,volumeandelectrolytedepletion,dehydration,decreasedbloodvolume,andcirculatorycollapse.Option3istheonlyoptionthatindicateselectrolytedepletionbecausethenormalpotassiumlevelis3.5to5.1mEq/L.Thenormalchloridelevelis98to107mEq/L.Thenormalsodiumlevelis135to145mEq/L.ThenormalbloodBUNis5to20mg/dL.

12.Anurseiscaringforatermnewborn.Whichassessmentfindingwouldpredisposethenewborntotheoccurrenceofjaundice?

A.PresenceofacephalhematomaB.InfantbloodtypeofOnegativeC.Birthweightof8pounds6ouncesD.AnegativedirectCoombs’testresultAnswer:

ARationale:

Acephalhematomaisswellingcausedbybleedingintoanareabetweenthe