长沙民政学院二〇一一年下学期末考试试卷（A）考试科目：考试方法：考查/考试适应班级：学号姓名I II II TOTALI.Translation.(Please translate following English words into Chinese.)(2points for every word,total is for 20points)1.dehydration2.jeopardy3.maternal4.hip5.white blood cell6.cervix7.constipation 8.anemia9.excrete 10.oliguriaII.Single choice(Please choose the right answer into the bracket)(2points for every single question,total is for 70pints)( )1.The nurse calls the physician regarding a new medication order because the dosage prescribed is higher than the recommended dosage.The nurse is unable to locate the physician and the medication is due to be administered.Which of the following actions would the nurse take?A,Hold the medication until the physician can be contacted.B, Contact the nursing supervisor.C,Administer the recommended dose until the physician can be located.D, Administer the dose prescribed.( )2.The registered nurse arrives at work and is told to float to the ICU for the day because the ICU is understaffed and needs additional nurses to care for the clients.The nurse has never worked in the ICU,Which of the following is the most appropriate nursing action？A,Refuse to float to the ICU.B,Call the hospital lawyer.C, Report to the ICU and identify tasks that can be performed safely.D, Call the nursing supervisor.( )3.The nurse is assessing the client 24hours following a cholecystectomy(胆囊切除术).The nurse notes that the T-tube has drained 750ml of green-brown drainage,Which nursing intervention is most appropriate?A,Nodify the phycisian.B,Document the findings.C,Irrigate(冲洗) the T-tube.D,Clamp the T-tube.( )4.A nurse assists a physician in performing a liver biopsy.Afer the biopsy ,the nurse plants to place the client in which of the position？AProne.B,Supine.C,A left side-lying position with a small pillow or folded towel under the puncture site.D,A right side-lying position with a small pillow or folded towel under the puncture site.（）5，A client with a peptic ulcer is scheduled for a vagotomy(迷走神经切除术).The client asks the nurse about the purpose of the procedure. The nurse tells the client that the procedureA,Decrease the food absorption in the stomach.B,Heals the gastric mucosa(粘膜).C,Halts stress reaction,D,Reduce the stimulus to acid secretion.( ).6,The client being seen in the physician office has just been scheduled for a barium(钡剂) swallow the next day.The nurse writes down which of following intructions for the client to follow before the test. AFast for 8 hours before the test.B,Eat a regular supper and breakfast.C,Continue to take all the oral medications as scheduled.D,monitor own bowed movement pattern for constipation.( )7.The nurse is caring for a client postoperatively following creation a colostomy（结肠造口）.Which of the following nursing diagnosis would the nurse include in the plan of care?A,Disturbed body image.B,Fear related poor prognosis.C,Imbalanced nutrition:more than body requirements.D,Sexual dysfunction.( )8,The client with a new colostomy is concerned about the odor from stool in the ostomy drainage bag,The nurse teaches the client to include which of the following foods in the diet to reduce odor?A,Yogurt.B,Broccoli.C,Cucumber.D,Eggs( )9,A nurse is caring for a client in labor.The nurse determines that the client is beginning the second stage of babor when which of the following statement is noted?A,The contractions are regular.B,The client begins to expel clear vaginal fluid.C,The cervis is dilated completely.D,The membranes have ruptured.（）10.The is caring for a client in labor who is receiving oxytocin(催产素)by intravenous infusion to stimulate uterine contractions.Which assessment finding indicate to the nurse that the infusion needs to discontinued?A,The fetal heart rate is 90beats/minute.B,Three contractions occurring within a 10-minute period.C,Adequate resting tone of the uterus palpated between contractions.D,Increaed urinary output.（）11.A nurse is caring for a client in labor and is monitoring the fetal heart rate patterns,The notes the presence of episodic acceleration on the electronic fetal monitor tracing,Which of the following actions is most appropriate?A,Document the findings and tell the mother that the monitor indicates fetal well-being.B,Take the mother’s vital signs and tell the mother that bed rest is required to conserve oxygen.C,Notify the physician or the mid-wife for the findingsD,Reposition the mother and check the monitor for changes in the fetal tracing.( )12,A nurse is assessing the patency of an arteriovenous fistula(瘘管) in the left arm of a client who is receiving hemodialysis for the treatment of chronic renal failure,Which finding indicates that the fistula is patent?A,Absence of a bruit on auscultation(听诊) of the fistulaB,Palpation(触诊) of a thrill over the fistulaC,Presence of a radial(桡动脉) pulse in the left wristD,Capillary refill less than 3 seconds in the nail beds of the fingers on the left hand( )13.The client is admitted to the emergency department following a motor vehicle accident.The client was wearing a lap seat belt when the accident occurred.The client has hematuria and lower abdominal pain..To determine further whether the pain is due to bladder trauma,the nurse asks the client if the pain isreferred to which of the following areas？A,ShoulderB,UmbilicusC,Costovertebral angle(肋椎角)D,Hip（）14.The client with chronic renal failure has completed hemodialysis treatment.The nurse would use which of the following standard indicators to evaluate the status of the client after dialysis?A,Potassium level and weightB, Vital signs and weightC,Vital signs and blood urea nitrogen(血尿素氮)D, blood urea nitrogen(血尿素氮) and creatine（肌酐）level（）15.A nurse is conducting a health distory with a client with a primary diagnose of heart failure.Which of the following disorders reported by the client is unlikely to play a role in exacerbating the heart failure?A,Recent upper respiratory infectionB,Nutritional anemiaC,Peptic ulcer diseaseD,Atrial fibrillation(房颤)（）16.A client angina has a 12-lead electrocardiogram(心电图) taken during an episode of chest pain,A nurse examines the tracing for which electrocardiogram change caused by myochardial ischemia?A,Prolonged PR intervalB,Widened QRS complex.C,ST segment elevation or depressionD,Tall,peaked T wave( )17.A client with myocardial ischemia is going into cardiogenic shock.Because of myocardial ischemia,a nurse would assess the client carefully forA,Ventricular dysrhythmias(室性心律失常)B,BradycardiaC,Falling diastolic(收缩期的) blood pressureD,Rising diastolic blood pressure( )18.The nurse has instructed the family of a clent with cerebrovascular accident(脑血管意外) who has homonymous hemianopsia(同向偏盲) about measures to help the client to overcome the deficit.The nursedetermine that the family understand the measures to use if they started toA,Place the objects in the client’s impaired field of vision.B,Approch the client from impaired field of vision.C,Discourage the client from wearing eyeglassesD,Remind the client to turn the head to scan the lost visual field.( )19.The nurse is assessing the adaptation of the client to changes in functional status aftera cerebrovascular accident.The nurse assesses that the client is adapting most successfully if the client A,Experiences bouts of depression and irritabilityB,Has difficulty with using modified feeding utensils.C,Consistently uses adaptive equipment to dressing self.D,Gets angry with family if they interrupt.( )20.The nurse is caring for the client who begins to experience seizure activity while in bed.Which of the following actions by the nurse would be contraindicated?A,Loosening restrictive clothing.B,Removing the pillow and raising the padded side railsC,Restraining the limbs of the client.C,Positioning the client to the side if possible,with head flexed forward.( )21.A nurse develops a plan of care for a client with hyperthyroidism(甲亢) included which of the following in the plan?A,Provide small mealsB,Provide extra blanketsC,Provide high-fiber diet.D,Provide a restful environment.( )22.A nurse is performing an assessment for a client following a thyroidectomy(甲状腺切除术)，The nurse notes that the client has developed hoarseness and a weak voice,Which nursing action is most appropriate?A,Notify the physician immediately.B,Reassure the client that this is usually a temporary condition.C,Check for signs for bleedingD,Administer calcium gluconate(葡萄糖酸钙)（）23.A client with a diagnosis of DKA（酮症酸中毒）is been treated in an emergency room.Which finding would a nurse expect to note as confirming this diagnosis?A,Comatose stateB,Elevated blood glucose level and a low plasma bicarbonate(碳酸氢盐)C,Increasee respirations and an increase in PHD,Decreased urine output.( )24.A physician has prescribed PTU(丙基硫氧嘧啶)for a client with hyperthyroidism(甲亢).A nurse develops a plan of care for the client.A priority nursing assessment to be include in the plan regarding this medication is to assess for.A,Signs and symptoms of hypothyroidism.B,Signs and symptoms of hyperglycemiaC,Relief of painD,Signs of renal toxicity.( )25.A nurse is preparing a teach plan for a client with DM(糖尿病) regarding proper foot care.Which instruction would be included in the plan？A,Soak feet in hot water.B,Apply a moisturizing lotion fo dry feet but not between the toes.C,Always have a podiatrist(足疗医生) cut your toenails; never cut them yourself.D,Avoid using a mild soap on the feet.( )26.A client with no history of cardiovascular disease comes to the ambulatory clinic with flulike symptoms.The client suddenly complains of chest pain.Which of following questions would best help a nurse to discriminate pain causes by a noncardiac problems？A, “Have you ever had this pain before？”B,“Can you describe the pain to me?”C,“Does the pain get worse when you breath in?”D,“Can you rate the pain on a scale of 1-10,with 10 being the worst?”（）27.The client with newly diagnose of chronic renal failure recently has begun hemodialysis.Knowing that the client is at risk of disequilibrium syndrome(失衡综合征)，the nurse assess the client during dialysis forA,Hypertension,tachycardia,and fever.B,Hypotension,bradycardia and hypothermia.C,Restlessness,irritability,and generalized weakness.D,Headache,deteriorating level of consciousness,and twitching.( )28.The hemodialysis client with a left arm fistula is at risk for steal syndrome.The nurse assess theclient for steal syndrome.The nurse assess this client for which of the following manifestation?A,Warmth,redness and pain in the left hand.B,Pallor,diminished pulse,and pain in the left hand.C,Edema and redish discoloration of the left armD,Vital signs and weight( )29.A nurse is monitoring a client in labor,The nurse suspects umbilical cord compression.If which of the following is noted on the external monitor tracing during a contraction?A,Early decelerationsB,Variable decelerationsC,Late decelerationsD,Short-term variability.( )30.A client has just returned to a nursing unit following bronchoscopy(支气管镜检)，A nurse would implement which of the following interventions for this client?A,Encouraging additional fluids for the next 24hoursB,Ensuring the return of gag reflex before offering food and fluidsC,Adminitering Atropine intravenouslyD,Adminitering small doses of Midazolam(咪达唑仑)（）31.A nurse is assessing the status of a client who has suffered a fractured rib.The nurse would expect to note which of the following?A,Pain,especially with inspirationB,Slow,deep respirationC.Rapid,deep respirationD,Paradoxical respiration(反常呼吸)（）32.A client with no history of respiratory disease is admitted with respiratory failure.A nurse assess the arterial blood gas report for which of the following results that are consistent with this disorder?A,Pao2 58mmHg,Paco2 32mmHgB Pao2 60mmHg,Paco2 45mmHgC Pao2 49mmHg,Paco2 52mmHgD Pao2 73mmHg,Paco2 62mmHg( )33.A client has experienced pulmonary embolism.A nurse assesses for which symptom,which is most commonly reported?A,Dysnea when deep breaths are takenB,Hot flushed feelingC,Chest pain that occurs suddenlyD,Sudden chills and fever( )34.A client who is in HIV has Mantoux skin test(结核菌素试验)，The nurse notes a 7-mm area of induration at the site of the skin test.The nurse interprets the results asA,PositiveB,NegativeC,InconclusiveD,The need for repeating testing.( )35,A client has an order to receive purified protein derivative(PPT),0.1ml.intradermally(皮内的).A nurse administers this medication by using a tuberculin(结核菌素) syringe with aA,26-gauge,5/8-inch needle inserted almost parallel to the skin with the bevel(斜面) side upB,6-gauge,5/8-inch needle inserted almost parallel to the skin with the bevel(斜面) side upC,6-gauge,5/8-inch needle inserted almost parallel to the skin with the bevel(斜面) side upD,6-gauge,5/8-inch needle inserted almost parallel to the skin with the bevel(斜面) side upIII.Question:A nurse is caring for a client in the second stage of labor.The electronic fetal monitoring shows an absent variability.Which interventions should be involved in the nursing care plan? (10points)。
