57. Key: C Client Need: Health Promotion and Maintenance
C. Fetal heart movement on ultrasound occurs in the 10th to 12th week of pregnancy.
A. Breast tenderness may occur in other conditions.
B. Identification of fetal movement by the primary care provider rather than the client is a positive sign of pregnancy.
D. HCGH in the urine is not one of the three positive signs of pregnancy.
58. Key: A Client Need: Pharmacological and Parenteral Therapies
A. Low-dose aspirin is given to patients post total knee replacement to reduce the possibility of clot formation.
B. Aspirin may control inflammation but is not the purpose for this patient.
C. Aspirin may relieve pain but not the primary purpose for this patient.
D. Aspirin has antipyretic properties but it is not given to this patient for that purpose.
59. Key: D Client Need: Reduction of Risk Potential
D. The larynx is considered the “voice box”. Damage to the laryngeal nerve would affect the patient’s ability to speak.
A. Frequent swallowing may indicate bleeding but not laryngeal nerve damage.
B. Dry mucous membranes are not related to laryngeal nerve damage.
C. Muscle strength is unrelated to laryngeal nerve damage.
60. Key: B Client Need: Physiologic Adaptation
B. As the retina detaches, the patient’s sight becomes impaired.
A. Loss of vision, rather than double vision, is present in retinal detachment.
C. This patient statement might indicate color blindness.
D. Retinal detachment is painless.
61. Key: C Client Need: Management of Care
C. Large amounts of bloody drainage may indicate hemorrhage, which requires immediate intervention.
A. Normal finding. Because of the manipulation of tissue during surgery, bruising would be expected afterward.
B. Normal finding. A small amount of bloody drainage can be expected immediately post-operative but the drainage becomes serosanguinous over time.
D. Normal finding. Because the incision disrupts nervous tissue, the patient would experience decreased sensation around the operative site.
62. Key: B Client Need: Health Promotion and Maintenance
B. Thin, pink or brownish in color lochia continue through 10 days post-delivery.
A. The first discharge is red in color and lasts no more than 3-4 days after birth.
C. White or yellow-white lochia occur from the second to sixth week after delivery.
D. Lochia usually are absent from the sixth week after delivery.
63. Key: C Client Need: Pharmacological and Parenteral Therapies
C. 1. 500 ml = x ml 24 hrs 1 hr 24x = 500 x = 20.8 or 21 ml/hr 2. 21 ml x 60 gtts 60 min 1ml = 21 gtts/min
64. Key: A Client Need: Reduction of Risk Potential
A. The manifestations may be indicative of a pulmonary embolism. Oxygen should be administered to facilitate breathing and oxygenation.
B. The nurse’s primary action is to maintain oxygenation of the patient.
C. Deep breathing and coughing is a normal post-operative activity. It does not address the immediate signs and symptoms of the patient.
D. Previous lab results will not give information about the immediate situation.
65. Key: A Client Need: Physiologic Adaptation
A. The heart in atrial fibrillation does not beat efficiently. It may not be able to pump an adequate amount of blood out to the body, including the brain, with each heartbeat, which may lead to confusion.
B. Inadequate coronary output causes a drop in blood pressure.
C. Urine output may be decreased due to inadequate coronary output.
D. Pupillary response is generally not altered.
66. Key: C Client Need: Management of Care
C. The patient will have an abduction pillow in place to maintain hip alignment after surgery. The patient should be taught about abduction and measures to maintain it.
A. Generally, patients are instructed about methods to relieve abdominal distention when it occurs. This is not a priority topic or the pre-operative teaching plan.
B. The patient should be given general information about post-operative physical therapy prior to the surgery, but it is not a priority topic for the pre-operative teaching plan.
D. The patient may use an overhead trapeze to facilitate movement in bed but this is not a priority topic for the teaching plan.
67. Key: D Client Need: Pharmacological and Parenteral Therapies
D. A side effect of digitalis administration is anorexia.
A. Increased thirst is not indicative of digitalis toxicity.
B. Dry, hacking cough is a side effect of ACE inhibitor administration.
C. Tingling in the fingers may be indicative of a vitamin deficiency or circulatory problems.
68. Key: B Client Need: Reduction of Risk Potential
B. A patient who has had a tonsillectomy and is hemorrhaging tries to rid the back of the throat of accumulating fluid (blood) by swallowing more frequently.
A. Bright red rather than pink-tinged saliva would be an indicator of hemorrhage.
C. Alteration in pitch of voice is not an indicator of post-operative hemorrhage.
D. Refusal to move the head is more an indicator of pain than hemorrhage.
69. Key: D Client Need: Physiologic Adaptation
D. Sores in the mouth indicate a weakened immune system and the development of opportunistic infections.
A. Numbness of the extremities may be indicative of neurologic problems rather than AIDS.
B. Easy bruising may be indicative of alterations in clotting mechanism rather than AIDS.
C. Changes in urinary patterns may be indicative of renal disease rather than AIDS.
70. Key: C Client Need: Management of Care
C. Patients with hyperparathyroidism may have thinning of the bones and be at risk for fractures.
A. Patients with hyperparathyroidism should participate in weight-bearing exercises to increase bone density.
B. It is not necessary to control environmental stimuli.
D. Sodium intake should be maintained at adequate levels.
上一篇：2015 ISPN 考试 -- 试题
下一篇：2016年国际护士执业水平（ISPN）考试安排
当前位置：
