ISPN考试模拟试题（一）

Question:

Following surgery for removal of a brain tumor, a client is coughing, short of breath, and has a “bad” feeling. The nurse obtains the following vital signs: blood pressure of 80/60 mm Hg, pulse rate of 120 bpm, and respiratory rate of 30 shallow breaths/min. What should the nurse do first? 

1. Call the neurosurgeon. 

2. Place the client in the Trendelenburg position. 

3. Consult the neurologic Clinical Nurse Specialist (CNS). 

4. Activate the rapid response team (RRT).

RRTs, or medical emergency teams, provide a team approach to evaluate and treat immediately clients with alterations in vital signs or neurological deterioration. Calling the neurosurgeon or consulting the CNS may not result in a rapid response. The Trendelenburg position is usually used in treating shock, but because the client has had brain surgery, the head should not be lower than the trunk. 

CN: Physiological adaptation; CL: Synthesize

Answer:4

翻译

问题：

脑瘤切除手术后，病人咳嗽，呼吸急促，有一种“不好”的感觉。护士获得以下生命体征：血压为80/60毫米汞柱，脉搏率为120次/分钟，呼吸频率为30次/分钟。护士应首先做什么？1.打电话给神经外科医生。2.将病人置于Trendelenburg位置（在Trendelenburg体位，身体仰卧，或平放在背部15-30度的斜面上，双脚高于头部）。3.咨询神经内科临床护士专家（CNS）。4.启动快速反应小组（RRT）。
答案：4快速反应小组或医疗急救小组提供了一种团队方法来评估和治疗生命体征改变或神经系统恶化的病人。打电话给神经外科医生或咨询中枢神经系统可能不会导致快速反应。Trendelenburg体位通常用于治疗休克，但由于病人接受过脑部手术，头部不应低于躯干。CN：生理适应；CL：合成

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