ISPN考试模拟试题(二十一)

ISPN考试模拟试题(二十一)

ISPN考试模拟试题（二十一） Practice Test Questions

61. Which of these manifestations in a patient who has had a

mastectomy would require a nurse’s immediate intervention?

A. Bruising around the incision site during the first 24 hours

B. Moderate amount of serosanguinous drainage on the dressing within the first day

C. Large amount of bloody drainage in the tissue drain (Hemovac) in the first hour

D. Decreased sensation around the operative area for the first 48 hours

62. When doing an assessment of a woman who is 5 days postpartum, the nurse should expect the lochia to be

A. rubra.

B. serosa.

C. alba.

D. absent.

63. A 7-week-old infant is to receive 500 mL of fluid intravenously over the next 24 hours. The intravenous apparatus delivers 60 drops per milliliter. Theinfant should receive approximately how many drops per minute?

A. 9

B. 15

C. 21

D. 27

Rationales

61. Key: C ClientNeed: 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.

ISPN考试模拟试题(二十一)

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, thepatient 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 dayspost-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 ClientNeed: Pharmacological and Parenteral Therapies

C. 1. 500ml/24hrs=x ml/1hr

24x = 500

x = 20.8 or 21 ml/hr

2. 21ml/60min=60gtts/1ml

= 21 gtts/min