Saunders Comprehensive 12

3. Diuretic phase a) Urine output rises slowly followed by diuresis (4-5 L/day). b) Excessive urine output indicates that damaged nephrons are recovering their ability to excrete wastes. c) Dehydration, hypovolemia, hypotension, and tachycardia can occur. d) Level of consciousness improves. e) IV fluids may be prescribed and may contain electrolytes to replace losses. 4. Recovery phase (convalescent) a) Recovery is a slow process. Complete recovery may take 1 to 2 years. b) Urine volume returns to normal. c) Memory improves. d) Strength increases. e) The older adult is less likely than a younger adult to regain full kidney function. f) The signs and symptoms of acute kidney injury are primarily caused by the retention of nitrogenous wastes, the retention of fluids, and the inability of the kidneys to regulate electrolytes.

3.利尿期 a）尿量缓慢增加，然后利尿（4-5 L /天）。 b）尿量过多表明受损的肾单位正在恢复其排泄废物的能力。 c）可能发生脱水，血容量不足，低血压和心动过速。 d）意识水平提高。 e）可以开具静脉输液，并可能包含电解质以弥补损失。 4.恢复阶段（恢复期） a）恢复是一个缓慢的过程。 完全恢复可能需要1到2年。 b）尿量恢复正常。 c）记忆力得到改善。 d）力量增加。 e）老年人比年轻人恢复全部肾脏功能的可能性要小。 f）急性肾脏损伤的体征和症状主要是由含氮废物的滞留，液体的滞留以及肾脏无法调节电解质引起的。

3. Data collection a) Early signs include diminished accommodation and increased intraocular pressure. b) Primary open-angle glaucoma (POAG): painless, and vision changes are slow; results in "tunnel" vision. c) Primary angle-closure glaucoma (PACG): blurred vision, halos around lights, and ocular erythema. 4. Interventions for acute angle-closure glaucoma Acute angle-closure glaucoma is a medical emergency that causes sudden eye pain and possible nausea and vomiting. a) Treat acute angle-closure glaucoma as a medical emergency. b) Assist to administer medications as prescribed to lower IOP. c) Prepare the client for peripheral iridectomy, which allows aqueous humor to flow from the posterior to the anterior chamber.

3.数据收集 a）早期体征包括适应能力下降和眼压升高。 b）原发性开角型青光眼（POAG）：无痛且视力改变缓慢；导致"隧道"视觉。 c）原发性闭角型青光眼（PACG）：视力模糊，光晕和眼部红斑。 4.急性闭角型青光眼的干预措施急性闭角型青光眼是一种医疗急症，可引起突然的眼痛以及可能的恶心和呕吐。 a）将急性闭角型青光眼视为医疗急症。 b）协助按规定服用药物以降低IOP。 c）为客户准备外围设备 虹膜切除术，可使房水从后房流到前房。

3. Interventions: a) Surgical removal of the lens, one eye at a time, is performed. b) With extracapsular extraction, the lens is lifted out without removing the lens capsule. The procedure may be performed by phacoemulsification in which the lens is broken up by ultrasonic vibrations and is extracted. c) With intracapsular extraction, the lens and capsule are removed completely. d) A partial iridectomy may be performed with the lens extraction to prevent acute secondary glaucoma. e) A lens implantation may be performed at the time of the surgical procedure. 4. Preoperative interventions: a) Reinforce instructions to the client regarding the postoperative measures, such as the importance of handwashing, and measures to prevent or decrease IOP such as bending over, coughing, straining, or rubbing the eye. b) Stress to the client that care after surgery requires instillation of different types of eyedrops several times a day for 2 to 4 weeks. c) Administer eye medications preoperatively including mydriatics and cycloplegics as prescribed. 5. Postoperative interventions: a) Elevate the head of the bed 30 to 45 degrees. b) Turn the client to the back or nonoperative side. c) Provide an eye patch as prescribed. Orient the client to the environment. d) Position the client's personal belongings to the nonoperative side. e) Use side rails for safety (follow agency policies on the use of side rails). f) Assist with ambulation.

3.干预措施： a）手术摘除晶状体，一次一只眼睛。 b）进行囊外摘除时，无需取出镜囊即可将其提起。可以通过超声乳化来执行该过程，在超声乳化中，透镜由于超声振动而破裂并被抽出。 c）进行囊内提取后，将晶状体和囊完全取出。 d）晶状体摘除术可进行部分虹膜切除术，以预防急性继发性青光眼。 e）可以在外科手术时进行晶状体植入。 4.术前干预： a）加强对服务对象的指示，说明其术后措施，例如洗手的重要性，以及预防或减少眼压的措施，例如弯腰，咳嗽，拉伤或摩擦眼睛。 b）向服务对象强调，手术后的护理需要每天数次滴入不同类型的眼药水，持续2至4周。 c）术前应按规定使用眼药，包括散瞳药和散瞳药。 5.术后干预： a）将床头抬高30至45度。 b）将服务对象转向后侧或非手术侧。 c）按照规定提供眼罩。使客户适应环境。 d）将客户的私人物品放在非作业方。 e）为了安全起见，请使用侧栏杆（遵循有关使用侧栏杆的机构政策）。 f）协助步行。

5. Interventions for the client with glaucoma a) Reinforce instructions to the client on the importance of medications (miotics) to constrict the pupils, to decrease the production of aqueous humor (carbonic anhydrase inhibitors), and to decrease the production of aqueous humor and IOP (β- blockers). b) Reinforce instructions to the client on the need for lifelong medication use and to wear a MedicAlert bracelet, to avoid anticholinergic medications to prevent increased IOP, and to contact the primary health care provider (PHCP) before taking medications, including over-the-counter medications. c) Reinforce instructions to the client to report eye pain, halos around the eyes, and changes in vision to the PHCP. d) Reinforce instructions to the client that when maximal medical therapy has failed to halt the progression of visual field loss and optic nerve damage, surgery will be recommended. e) Prepare the client for trabeculectomy, as prescribed, which allows the drainage of aqueous humor into the conjunctival spaces by the creation of an opening.

5.对青光眼患者的干预 a）加强对客户的指示，说明药物（模仿物）对瞳孔收缩，减少房水（碳酸酐酶抑制剂）的产生以及减少房水和IOP（β受体阻滞剂）产生的重要性。 b）加强对客户的指示，告知他们需要终身使用药物，并佩戴MedicAlert手镯，避免使用抗胆碱药物以防止IOP增加，并在服药之前与初级保健提供者（PHCP）联系，包括过度使用-非处方药。 c）加强对服务对象的指示，以向PHCP报告眼痛，眼周光晕和视力变化。 d）加强对客户的指示，即当最大的药物治疗未能阻止视野丧失和视神经损害的进展时，将建议进行手术。 e）按照规定为小梁切除术做好服务对象的准备，这可以通过开孔将房水排入结膜腔。

4. Surgical procedures: a) Draining fluid from the subretinal space so that the retina can return to the normal position. b. Sealing retinal breaks by cryosurgery, a cold probe applied to the sclera, to stimulate an inflammatory response leading to adhesions. c. Diathermy, the use of an electrode needle and heat through the sclera, to stimulate an inflammatory response. d. Laser therapy to stimulate an inflammatory response and to seal small retinal tears before the detachment occurs. e. Scleral buckling to hold the choroid and retina together with a splint until scar tissue forms and closes the tear. f. Insertion of gas or silicone oil to promote reattachment. These agents float against the retina to hold it in place until healing occurs. 5. Postoperative interventions: a) Maintain eye patches as prescribed. b) Monitor for hemorrhage. c) Prevent nausea and vomiting and monitor for restlessness, which can cause hemorrhage. d) Monitor for sudden, sharp eye pain (notify the RN and PHCP). e) Encourage deep breathing, but avoid coughing. f) Provide bed rest as prescribed. g) Position the client as prescribed. (Positioning depends on the location of the detachment.) h) Assist with the administration of eye medications as prescribed. i) Assist the client with activities of daily living. j) Avoid sudden head movements or anything that increases IOP. k) Reinforce instructions to the client to limit reading for 3 to 5 weeks. l) Reinforce instructions to the client to avoid squinting, lifting heavy objects, bending from the waist, and to make an effort to prevent straining and constipation. m) Reinforce instructions to the client to wear dark glasses during the day and an eye patch at night. n. Encourage follow-up care because of the danger of recurrence or occurrence in the other eye.

4.手术程序： a）从视网膜下腔排出液体，以使视网膜可以恢复到正常位置。 b。通过冷冻手术（一种应用于巩膜的冷探针）密封视网膜裂口，以刺激导致粘连的炎症反应。 C。透热疗法，使用电极针并通过巩膜加热以刺激炎症反应。 d。激光治疗可刺激炎症反应并在视网膜脱离前封堵小眼泪。 e。巩膜屈曲将脉络膜和视网膜与夹板固定在一起，直到形成疤痕组织并闭合眼泪。 F。插入气体或硅油以促进重新附着。这些药物漂浮在视网膜上以将其固定在适当位置，直到发生愈合。 5.术后干预： a）保持规定的眼罩。 b）监测出血情况。 c）防止恶心和呕吐，并监测可能引起出血的躁动。 d）监测突然的剧烈眼痛（通知RN和PHCP）。 e）鼓励深呼吸，但避免咳嗽。 f）按规定提供卧床休息。 g）按照规定放置客户。 （位置取决于分队的位置。） h）协助按规定服用眼药。 i）协助客户进行日常活动。 j）避免头部突然移动或任何会增加IOP的动作。 k）加强对客户的指示，以限制阅读3到5周。 l）加强对服务对象的指示，避免斜眼，抬起重物，从腰部弯曲，并努力防止拉伤和便秘。 m）加强对服务对象的指示，白天要戴墨镜，晚上要戴眼罩。 。由于另一只眼睛复发或发生的危险，应鼓励进行后续护理。

B) Loop diuretics: 1. Loop diuretics inhibit sodium and chloride reabsorption from the loop of Henle and the distal tubule. 2. Loop diuretics have little effect on the blood glucose level; however, they cause depletion of water and electrolytes, an increase in uric acid levels, and the excretion of calcium. 3. Loop diuretics are more potent than thiazide diuretics causing rapid diuresis and thus decreasing vascular fluid volume, cardiac output, and BP. 4. Loop diuretics are used for hypertension, pulmonary edema, edema associated with heart failure, hypercalcemia, and renal disease. 5. Use loop diuretics with caution in the client taking digoxin or lithium and the client taking aminoglycosides, anticoagulants, corticosteroids, or amphotericin.

B）利尿剂： 1.袢利尿剂抑制钠离子和氯的重吸收从亨利氏环和远端小管。 2.袢利尿剂对血糖水平的影响不大; 但是，它们会导致水和电解质耗竭，尿酸水平升高以及钙排泄。 3.袢利尿剂比噻嗪类利尿剂引起快速利尿并由此降低血管的流体体积，心输出量，和BP更有效。 4.袢利尿剂用于高血压，肺水肿，心脏衰竭，高钙血症和肾脏疾病有关的水肿。 5.服用地高辛或锂的患者和服用氨基糖苷类，抗凝剂，皮质类固醇或两性霉素的患者应谨慎使用loop利尿剂。

D) Other antilipemic medications: 1. Description a) Gemfibrozil should not be taken with anticoagulants because they compete for protein sites. If the client is taking an anticoagulant, the anticoagulant dose should be reduced during antilipemic therapy and the INR should be monitored closely. b) Do not administer gemfibrozil with HMG-CoA reductase inhibitors because it increases the risk for myositis, myalgias, and rhabdomyolysis. c) Fish oil supplements have been associated with a decreased risk for cardiovascular heart disease. Plant stanol and sterol esters and cholestin have been associated with reducing cholesterol levels. 2. Interventions a) Monitor vital signs. b) Monitor the liver enzyme levels. c) Monitor the serum cholesterol and triglyceride levels. d) Reinforce instructions to the client to restrict intake of fats, cholesterol, carbohydrates, and alcohol. e) Reinforce instructions to the client to follow an exercise program. f) Reinforce instructions to the client that it will take several weeks before the lipid level declines. g) Reinforce instructions to the client to have an annual eye examination and report any change in vision. h) Reinforce instructions to the client with diabetes mellitus who is taking gemfibrozil to monitor their blood glucose level regularly. i) Reinforce instructions to the client to increase fluid intake. j) Note that nicotinic acid has numerous side effects including gastrointestinal disturbances, flushing of the skin, elevated liver enzyme levels, hyperglycemia, and hyperuricemia. k) Reinforce instructions to the client that aspirin or nonsteroidal antiinflammatory drugs taken 30 minutes before may assist with reducing the side effect of cutaneous flushing from nicotinic acid. l) Reinforce instructions to the client to take nicotinic acid with meals to reduce gastrointestinal discomfort.

D）其他抗血脂药物： 1.说明 a）吉非贝齐不宜与抗凝剂一起服用，因为它们竞争蛋白质位点。如果患者服用抗凝剂，则在抗血脂治疗期间应降低抗凝剂的剂量，并应密切监测INR。 b）不要将吉非贝齐与HMG-CoA还原酶抑制剂一起使用，因为它会增加肌炎，肌痛和横纹肌溶解的风险。 c）鱼油补充剂与降低心血管心脏病的风险有关。植物甾烷醇和固醇酯以及胆甾醇与降低胆固醇水平有关。 2.干预 a）监测生命体征。 b）监测肝酶水平。 c）监测血清胆固醇和甘油三酸酯水平。 d）加强对客户的指示，以限制脂肪，胆固醇，碳水化合物和酒精的摄入。 e）加强对客户的指示，以遵循锻炼计划。 f）加强对客户的指示，即血脂水平下降需要几周的时间。 g）加强对服务对象的指示，以进行年度眼睛检查并报告视力变化。 h）加强对服用吉非贝齐定期监测血糖水平的糖尿病患者的指导。 i）加强对客户的指示以增加液体摄入量。 j）请注意，烟酸具有许多副作用，包括胃肠道不适，皮肤潮红，肝酶水平升高，高血糖症和高尿酸血症。 k）加强对服务对象的说明，即在30分钟前服用阿司匹林或非甾体抗炎药可能有助于减轻烟酸引起的皮肤潮红的副作用。 l）加强对服务对象的指示，以在用餐时服用烟酸以减少胃肠道不适感。

Functions of the kidneys 1. Maintain acid-base balance 2. Excrete end products of body metabolism 3. Control fluid and electrolyte balance 4. Excrete bacterial toxins, water-soluble drugs, and drug metabolites 5. Secrete renin to regulate the blood pressure (BP) and erythropoietin to stimulate the bone marrow to produce red blood cells. 6. Synthesize vitamin D for calcium absorption and regulation of the parathyroid hormones

肾脏的功能 1.维持酸碱平衡 2.人体代谢的最终产物 3.控制液体和电解质的平衡 4.排泄细菌毒素，水溶性药物， 和药物代谢物 5.分泌肾素调节血压（BP），促红细胞生成素刺激骨髓产生红细胞。 6.合成维生素D以吸收钙并调节甲状旁腺激素.

Contusions: 1. Description a) Bleeding into the soft tissue as a result of an injury. b) A contusion causes a black eye and the discoloration disappears in about 10 days. c) Pain, photophobia, edema, and diplopia may occur. 2. Interventions a) Place ice on the eye immediately. b) Reinforce instructions to the client to receive a thorough eye examination.

挫伤： 1.说明 a）由于受伤而渗入软组织。 b）挫伤引起黑眼圈，变色在大约10天内消失。 c）可能会出现疼痛，畏光，水肿和复视。 2.干预 a）立即将冰放在眼睛上。 b）加强对服务对象的指示，以进行彻底的眼睛检查。

Macular degeneration: 1. A deterioration of the macula, the area of central vision. 2. Can be atrophic (age-related or dry) or exudative (wet). 3. Age-related: Caused by gradual blocking of retinal capillaries leading to an ischemic and necrotic macula; rods and cones photoreceptors die. 4. Exudative: Serous detachment of pigment epithelium in the macula occurs, and fluid and blood collect under the macula resulting in scar formation and visual distortion. 5. Interventions are aimed at maximizing the remaining vision. 6. Data collection a) A decline in central vision b) Blurred vision and distortion 7. Interventions a) Initiate strategies to assist with maximizing remaining vision and maintaining independence. b) Assist with providing referrals to community organizations. c) Laser therapy or photodynamic therapy may be prescribed to seal the leaking blood vessels in or near the macula.

黄斑变性： 1.黄斑恶化，是中心视力区域。 2.可以是萎缩的（年龄相关的或干燥的）或渗出的（湿润的）。 3.与年龄有关：由于逐渐阻塞视网膜毛细血管导致缺血性坏死性黄斑引起； 视锥细胞感光器死亡。 4.渗出液：黄斑中出现色素上皮的浆膜脱离，黄斑下积聚了液体和血液，导致疤痕形成和视觉变形。 5.干预旨在最大程度地发挥剩余作用。 6.数据收集 a）中心视野下降 b）视力模糊和失真 7.干预 a）制定策略，以帮助最大程度地保持视野和保持独立性。 b）协助推荐给社区组织。 c）可以开激光疗法或光动力疗法来密封黄斑内或附近的渗漏血管。

B) Audiometry 1. Description: a) Audiometry measures hearing acuity. b) Audiometry uses two types: pure tone audiometry and speech audiometry. c) Pure tone audiometry is used to identify problems with hearing, speech, music, and other sounds in the environment. d) In speech audiometry, the client's ability to hear spoken words is measured. e) After testing, audiogram patterns are depicted on a graph to determine the type and level of hearing loss. 2. Interventions: a) Inform the client regarding the procedure. b) Reinforce instructions to the client to identify the sounds as they are heard.

B）听力测试 1.说明： a）听力测验可测量听力敏锐度。 b）听力测验使用两种类型：纯音测听法和语音测听法。 c）纯音测听法用于识别环境中听觉，语音，音乐和其他声音的问题。 d）在语音测听中，将评估客户听口语的能力。 e）测试后，在图表上描绘听力图模式，以确定听力损失的类型和水平。 2.干预措施： a）告知客户有关程序。 b）加强对客户的指示，以识别听到的声音。

C) HMG-CoA reductase inhibitors 1. Description a) Lovastatin is highly protein-bound and should not be administered with anticoagulants. b) Lovastatin should not be administered with gemfibrozil. c) Lovastatin is administered with caution to the client taking immunosuppressive medications. 2. Interventions a) Monitor serum liver enzyme levels. b) Reinforce instructions to the client to receive an annual eye examination because the medications can cause cataract formation. c) If lovastatin is not effective in lowering the lipid level after 3 months, it should be discontinued. d) The client who is taking an antilipemic medication is instructed to report any unexplained muscular pain to the PHCP immediately.

C）HMG-CoA还原酶抑制剂 1.说明 a）洛伐他汀高度结合蛋白质，不应与抗凝剂一起使用。 b）洛伐他汀不应与吉非贝齐一起服用。 c）服用免疫抑制剂的患者应谨慎服用洛伐他汀。 2.干预 a）监测血清肝酶水平。 b）加强对服务对象的指示，要求其接受年度眼睛检查，因为这些药物会导致白内障形成。 c）如果洛伐他汀在3个月后不能有效降低血脂水平，应停止使用。 d）指示正在服用降血脂药的服务对象应立即向PHCP报告任何无法解释的肌肉疼痛。

C) Interventions 1. Monitor vital signs before, during, and after dialysis; the client's temperature may elevate because of the slight warming of the blood from the dialysis machine. (Notify the RN who will notify the PHCP about excessive temperature elevations because this could indicate sepsis; assist to obtain samples for blood culture as prescribed for excessive temperature elevations.) 2. Monitor laboratory values, specifically the BUN, creatinine, and complete blood cell counts before, during, and after dialysis. 3. Monitor the client for fluid overload before dialysis and fluid volume deficit after dialysis. 4. Weigh the client before and after dialysis to determine fluid loss. Note that the client will not urinate or will urinate small amounts (may be less than 30 mL per hour). 5. Monitor the patency of the blood access device before, during, and after dialysis. 6. Monitor for bleeding. Heparin is added to the dialysis bath to prevent clots from forming within the dialyzer or the blood tubing. 7. Monitor for hypovolemia and shock during dialysis, which can occur from blood loss or excess fluid and electrolyte removal. 8. Provide adequate nutrition. The client may eat before or during dialysis. 9. Identify the client's reactions to the treatment and support coping mechanisms. Encourage independence and involvement in care. 10. Withhold antihypertensives and other medications that can affect the BP or result in hypotension until after the hemodialysis treatment. Also withhold medications that could be removed by dialysis such as water-soluble vitamins, certain antibiotics, and digoxin.

C）干预 1.在透析之前，期间和之后监测生命体征；由于透析机血液的略微升温，客户的体温可能会升高。 （通知RN，RN将把过度升高的温度通知PHCP，因为这可能表示败血症；按照过度升高的规定，协助获取血液培养样本。） 2.在透析之前，期间和之后，监测实验室值，尤其是BUN，肌酐和完整血细胞计数。 3.在透析前监测患者的液体超负荷情况，并在透析后监测液体容量不足。 4.在透析前后称量服务对象以确定液体的流失。请注意，服务对象不会小便或小便（每小时可能少于30毫升）。 5.在透析之前，期间和之后监测血液通路设备的通畅性。 6.监测出血情况。将肝素添加到透析浴中，以防止在透析器或血液管道内形成凝块。 7.监测透析过程中的血容量不足和休克，这可能是由于失血或过多的液体和电解质去除而引起的。 8.提供足够的营养。服务对象可能在透析之前或期间进食。 9.确定客户对治疗和支持应对机制的反应。鼓励独立和参与护理。 10.在进行血液透析治疗之前，应停用可能影响BP或导致低血压的抗高血压药和其他药物。还保留可以通过透析去除的药物，例如水溶性维生素，某些抗生素和地高辛。

C) Percutaneous lithotripsy 1. Performed for stones in the bladder, ureter, or kidney 2. An invasive procedure in which a guide is inserted under fluoroscopy near the area of the stone; an ultrasonic wave is aimed at the stone to break it into fragments. 3. Percutaneous lithotripsy may be performed via cystoscopy or nephroscopy. 4. No incision is required for cystoscopy; a small flank incision is needed for nephroscopy. 5. The client may possibly have an indwelling bladder catheter. 6. A nephrostomy tube may be placed to administer chemical irrigations to break up the stone. The nephrostomy tube may remain in place for 1 to 5 days. 7. Encourage the client to drink 3000 mL to 4000 mL of fluid/day following the procedure as prescribed. 8. Monitor for and instruct the client to observe for complications of infection, hemorrhage, and extravasation of fluid into the retroperitoneal cavity.

C）经皮碎石 1.适用于膀胱，输尿管或肾脏结石 2.一种侵入性手术，其中在荧光检查下在石头区域附近插入导向器。超声波对准石头将其破碎成碎片。 3.经皮碎石术可通过膀胱镜或肾镜检查进行。 4.膀胱镜检查不需要切口；肾镜检查需要一个小侧面切口。 5.服务对象可能有留置膀胱导管。 6.可以放置肾造口术管进行化学冲洗，以打碎结石。肾造口术管可能会保留1至5天。 7.鼓励服务对象按照规定的程序每天喝3000到4000毫升液体。 8.监测并指导服务对象观察感染，出血和液体渗入腹膜后腔的并发症。

D) Ureterolithotomy 1. An open surgical procedure is performed if lithotripsy is not effective for the removal of a stone in the ureter. 2. An incision is made through the lower abdomen or flank and then into the ureter to remove the stone. 3. The client may have a drain, a ureteral stent catheter, and an indwelling bladder catheter. E) Pyelolithotomy and nephrolithotomy 1. Pyelolithotomy is an incision into the renal pelvis to remove a stone. A large flank incision is required, and the client may have a drain and an indwelling bladder catheter. 2. Nephrolithotomy is an incision into the kidney made to remove a stone. A large flank incision is required, and the client may have a nephrostomy tube and an indwelling bladder catheter.

D）输尿管结石 1.如果发生以下情况，则应进行开放性手术 碎石术不能有效去除输尿管中的结石。 2.穿过小腹或腹侧切开一个切口，然后切入输尿管以去除结石。 3.病人可能有引流管，输尿管支架导管和留置膀胱导管。 E）肾盂切开术和肾镜取石术 1.肾盂切开术是在肾盂切开一个结石。需要一个大的侧面切口，并且服务对象可能有引流管和留置的膀胱导管。 2.肾切开取石术是在肾脏上切开一个切口，以切除结石。需要一个大的侧面切口，并且服务对象可能有肾造口术管和留置的膀胱导管。

c) The treatment goal is to raise the INR to an appropriate value. d) An INR of 2 to 3 is appropriate for standard warfarin therapy; an INR of 3 to 4.5 is appropriate for high-dose warfarin therapy. e) If the PT value is longer than 30 seconds and the INR is greater than 3.0 in a client receiving standard warfarin therapy, initiate bleeding precautions. f) If the INR is below the recommended range, warfarin sodium should be increased. g) Clients may sometimes be prescribed "bridge therapy," whereby heparin sodium is used concurrently with warfarin sodium until the INR reaches the recommended range. Once this occurs, the heparin is discontinued. 4. Interventions a) Monitor PT and INR. b) Observe for bleeding gums, bruises, nosebleeds, hematuria, hematemesis, occult blood in the stool, and petechiae.

c）治疗目标是将INR提高至适当值。 d）对于标准的华法林疗法，INR为2至3是适当的； 对于大剂量华法林治疗，INR为3至4.5是合适的。 e）如果接受标准华法林治疗的患者的PT值大于30秒且INR大于3.0，则应采取止血措施。 f）如果INR低于建议范围，则应增加华法林钠。 g）有时可能会给客户开"桥梁疗法"的处方，其中肝素钠与华法林钠同时使用，直到INR达到建议的范围。 一旦发生这种情况，将停用肝素。 4.干预 a）监视PT和INR。 b）观察牙龈，瘀伤，流鼻血，血尿，呕血，大便隐血和瘀点是否出血。 C。 加强对服务对象的指示，以防止流血。 d。 华法林的解毒剂是植物酮二酮。

D) Aqueous humor 1. The aqueous humor is a clear, watery fluid that fills the anterior and posterior chambers of the eye. 2. The aqueous humor is produced by the ciliary processes and the fluid drains into the canal of Schlemm. 3. The anterior chamber lies between the cornea and the iris. 4. The posterior chamber lies between the iris and the lens. E) Lens: 1. A transparent convex structure behind the iris and in front of the vitreous body 2. The lens bends rays of light so that the light falls on the retina. 3. The curve of the lens changes to focus on near or distant objects. F) Conjunctiva: The thin, transparent mucous membrane

d）房水 1.房水是一种透明的水状液体，充满了眼睛的前房和后房。 2.房水是由睫状突产生的，而液体则排入Schlemm的管中。 3.前房位于角膜和虹膜之间。 4.后房位于虹膜和晶状体之间。 E）镜头： 1.虹膜后和玻璃体前的透明凸结构 2.透镜弯曲光线，使光线落在视网膜上。 3.镜头的曲线发生变化，以聚焦在近处或远处的物体上。 F）结膜：薄透明粘膜

A client is diagnosed with acute myocardial infarction and is receiving tissue plasminogen activator, alteplase. Which action is a priority nursing intervention? 1. Monitor for kidney failure. 2. Monitor psychosocial status. 3. Monitor for signs of bleeding. 4. Have heparin sodium available. 3 Rationale: Tissue plasminogen activator is thrombolytic. Hemorrhage is a complication of any type of thrombolytic medication. The client is monitored for bleeding. Monitoring for renal failure and monitoring the client's psychosocial status are important but are not the most critical interventions. Heparin is given after thrombolytic therapy, but the question is not asking about follow-up medications.

一个客户被诊断出患有急性心肌梗塞，并且正在接受组织纤溶酶原激活剂阿替普酶。优先采取哪种行动？ 1.监测肾功能衰竭。 2.监测社会心理状况。 3.监测是否有出血迹象。 4.备有肝素钠。 3 理由：组织纤溶酶原激活剂是溶栓剂。出血是任何类型的溶栓药物的并发症。监视客户是否流血。监测肾功能衰竭和监测服务对象的心理状况很重要，但不是最关键的干预措施。溶栓治疗后给予肝素，但问题不在于后续药物。

Bethanechol chloride is prescribed for a client with urinary retention. Which disorder should be a contraindication to the administration of this medication? 1. Gastric atony 2. Urinary strictures 3. Neurogenic atony 4. Gastroesophageal reflux 2 Rationale: Bethanechol chloride can be harmful to clients with urinary tract obstruction or weakness of the bladder wall. The medication has the ability to contract the bladder and thereby increase pressure within the urinary tract. Elevation of pressure within the urinary tract could rupture the bladder in clients with these conditions.

乙二酰氯被规定用于有尿retention留的病人。哪种疾病应禁忌使用这种药物？ 1.胃无力 2.尿道狭窄 3.神经源性无力 4.胃食管反流 2 理由：苯乙二酰氯可能对患有尿路阻塞或膀胱壁无力的患者有害。药物具有使膀胱收缩从而增加尿道内压力的能力。在这些情况下，泌尿道内压力升高可能会使患者的膀胱破裂

Mastoiditis 1. Description a) Mastoiditis may be acute or chronic and results from untreated or inadequately treated chronic or acute otitis media. b) The pain is not relieved by myringotomy. 2. Data collection a) Swelling behind the ear and pain with minimal movement of the head. b) Cellulitis on the skin or external scalp over the mastoid process c) A reddened, dull, thick, immobile tympanic membrane with or without perforation d) Tender and enlarged postauricular lymph nodes e) Low-grade fever 3. Interventions a) Prepare the client for surgical removal of infected material. b) Monitor for complications. c) Simple or modified radical mastoidectomy with tympanoplasty is the most common treatment. d) Once the infected tissue is removed, the tympanoplasty is performed to reconstruct the ossicles and the tympanic membranes in an attempt to restore normal hearing. 4. Postoperative interventions a) Monitor for dizziness. b) Monitor for signs of meningitis as evidenced by a stiff neck and vomiting. c) Prepare for a wound dressing change 24 hours postoperatively. d) Monitor the surgical incision for edema, drainage, and redness. e) Position the client flat with the operative side up. f) Restrict the client to bed with bedside commode privileges for 24 hours as prescribed. g) Assist the client with getting out of bed to prevent falling or injuries from dizziness. h) With the reconstruction of the ossicles via a graft, take precautions to prevent dislodging of the graft.

乳突炎 1.说明 a）乳突炎可以是急性或慢性的，可能是由于未经治疗或治疗不充分的慢性或急性中耳炎引起的。 b）不能通过鼓膜切开术缓解疼痛。 2.数据收集 a）耳朵后部肿胀，头部移动不灵活。 b）乳突过程中皮肤或外头皮上的蜂窝组织炎 c）有或没有穿孔的发红，钝，厚，不动的鼓膜 d）嫩度和扩大的耳后淋巴结 e）低烧 3.干预 a）为服务对象做好手术清除感染材料的准备。 b）监测并发症。 c）带鼓膜成形术的简单或改良的根治性乳突切除术是最常见的治疗方法。 d）一旦去除了感染的组织，便进行鼓膜成形术以重建小骨和鼓膜，以恢复正常的听力。 4.术后干预 a）监视头晕。 b）监测脑膜炎的迹象，如颈部僵硬和呕吐。 c）术后24小时准备更换伤口敷料。 d）监测手术切口的水肿，引流和发红情况。 e）将服务对象平放，使操作者一侧朝上。 f）按照规定，限制服务对象在卧床马桶特权下就寝24小时。 g）协助服务对象起床，以防止跌倒或头晕受伤。 h）通过移植物重建小骨时，请采取预防措施以防止移植物脱落。

Conductive hearing loss: 1. Description: a) Conductive hearing loss occurs when sound waves are blocked to the inner ear fibers because of the external ear or middle ear disorders. b) Disorders often can be corrected with no damage to hearing or with minimal permanent hearing loss. 2. Causes: a) Any inflammatory process or obstruction of the external or middle ear b) Tumors c) Otosclerosis d) A buildup of scar tissue on the ossicles from previous middle ear surgery

传导性听力损失： 1.说明： a）当由于外耳或中耳疾病而使声波阻塞内耳纤维时，就会发生传导性听力损失。 b）通常可以在不损害听力或减少永久性听力损失的情况下纠正疾病。 2.原因： a）外耳或中耳的任何炎症过程或阻塞 b）肿瘤 c）耳硬化症 d）先前中耳手术引起的小骨上的疤痕组织积聚

A hospitalized client with coronary artery disease complains of substernal chest pain. After checking the client's heart rate and blood pressure, the nurse administers nitroglycerin, 0.4 mg, sublingually. After 5 minutes, the client states, "My chest still hurts." Which appropriate actions should the nurse take? Select all that apply. 1. Call a code blue. 2. Contact the client's family. 3. Check the client's pain level. 4. Check the client's blood pressure. 5. Administer a second nitroglycerin, 0.4 mg, sublingually. 3, 4, 5 Rationale: The usual guideline for administering nitroglycerin tablets for a hospitalized client with chest pain is to administer one tablet every 5 minutes PRN for chest pain for a total dose of three tablets. The registered nurse is notified immediately if a client complains of chest pain. In this situation, because the client is still complaining of chest pain, the nurse would administer a second nitroglycerin tablet. The nurse would check the client's pain level and the client's blood pressure before administering each nitroglycerin dose. There are no data in the question that indicate the need to call a code blue. In addition, it is not necessary to contact the client's family unless the client has requested this.

住院的冠心病患者抱怨胸骨下胸痛。检查服务对象的心率和血压后，护士会在舌下给予0.4毫克的硝酸甘油。 5分钟后，服务对象说："我的胸部仍然疼痛。"护士应采取哪些适当的措施？选择所有符合条件的。 1.将代码称为蓝色。 2.与客户的家人联系。 3.检查服务对象的疼痛程度。 4.检查服务对象的血压。 5.舌下施用第二次硝酸甘油0.4毫克。 3 4 5 理由：对于住院的胸痛患者，服用硝酸甘油片的通常指导原则是每5分钟PRN服用一次用于治疗胸痛的片剂，总剂量为3片。如果服务对象抱怨胸痛，将立即通知注册护士。在这种情况下，由于服务对象仍在抱怨胸痛，因此护士会给您服用第二种硝酸甘油片剂。在每次服用硝酸甘油之前，护士会检查服务对象的疼痛程度和血压。问题中没有数据表明需要将代码称为蓝色。此外，除非客户要求，否则无需联系客户的家人。

A client arrives in the emergency department after an automobile crash. The client's forehead hit the steering wheel and a hyphema has been diagnosed. Which position should the nurse prepare to position the client? 1. Flat on bed rest 2. On bed rest in a semi-Fowler's position 3. In lateral position on the unaffected side 4. In the lateral position on the affected side 2 Rationale: A hyphema is the presence of blood in the anterior chamber. It is produced when a force is sufficient to break the integrity of the blood vessels in the eye. It can be caused by direct injuries, such as a penetrating injury from a BB pellet, or indirectly, such as from striking the forehead on a steering wheel during an accident. The client is treated by bed rest in a semi-Fowler's position to assist gravity in keeping the hyphema away from the optical center of the cornea.

发生车祸后，一名客户到达急诊室。服务对象的额头碰到方向盘，并诊断出一种前房积血。护士应准备哪个位置来定位服务对象？ 1.卧床休息 2.以半福勒的姿势躺在床上 3.在未受影响侧的横向位置 4.在患侧的横向位置 2 理由：前房积血是指前房中存在血液。它是 当力足以破坏眼睛血管完整性时产生。它可能是由于直接伤害（例如BB弹丸的穿透性伤害）引起的，也可能是由于意外事故（例如，撞向方向盘上的前额）引起的间接伤害。通过在半福勒的位置上卧床休息来治疗病人，以帮助重力使眼前屈光远离角膜的光学中心。

Chest Pain Occurs in a Hospitalized Client with Cardiac Disease: 1. The client is quickly assessed, specifically for characteristics of pain, heart rate and rhythm, and blood pressure (BP). 2. Apply oxygen 3. A nitroglycerin tablet is administered. 4. The client should not be left alone. 5. The client is reassessed in 5 minutes. 6. Another nitroglycerin tablet is administered if pain is not relieved and the BP is stable. 7. The client is reassessed in 5 minutes. 8. A third nitroglycerin tablet is administered if pain is not relieved and the BP is stable. 9. The client is reassessed in 5 minutes. The PHCP is contacted if the third nitroglycerin tablet does not relieve the pain. 10. The event, actions taken, and the client's response to treatment are documented. 11. The registered nurse is immediately notified if the client experiences chest pain. The usual guidelines for administering nitroglycerin tablets for chest pain include administering one tablet every 5 minutes PRN for chest pain for a total dose of three tablets. If the client does not obtain relief after taking a third dose of nitroglycerin, the PHCP is notified.

住院的心脏病患者发生胸痛： 1.对服务对象进行快速评估，特别是针对疼痛，心率和节律以及血压（BP）的特征。 2.吸氧 3.施用硝酸甘油片剂。 4.不应让客户独处。 5.在5分钟内重新评估客户。 6.如果疼痛仍未缓解并且服用另一种硝酸甘油片剂 血压稳定。 7.在5分钟内重新评估客户。 8.如果疼痛仍未缓解且血压稳定，则再服用第三次硝酸甘油片剂。 9.在5分钟内重新评估客户。如果第三个硝酸甘油片剂不能缓解疼痛，请与PHCP接触。 10.记录事件，采取的措施以及服务对象对治疗的反应。 11.如果服务对象感到胸痛，则立即通知注册护士。用于治疗胸痛的硝酸甘油片剂的常见指导原则包括：每5分钟对PRN进行一次用于胸痛的片剂，总剂量为三片。如果客户在服用第三剂硝酸甘油后仍未缓解，则通知PHCP。

Enoxaparin-low-molecular-weight heparin: 1. Description: a) Enoxaparin has the same mechanism of action and use as heparin, but is not interchangeable. b) It has a longer half-life than heparin. 2. Interventions a) Administered only to the recumbent client by subcutaneous injection only in the anterolateral or posterolateral abdominal wall; do not expel the air bubble from the prefilled syringe or aspirate during the injection. b) Monitor the same laboratory values as for heparin and observe for bleeding. c) The antidote to enoxaparin is protamine sulfate.

依诺肝素低分子量肝素： 1.说明： a）依诺肝素的作用机理和用途与肝素相同，但不可互换。 b）它的半衰期比肝素更长。 2.干预 a）仅在前外侧或后外侧腹壁中通过皮下注射仅对卧床的患者给药； 不要在注射过程中将气泡从预填充的注射器中排出或吸出。 b）监测与肝素相同的实验室值，并观察出血情况。 c）依诺肝素的解毒剂是硫酸鱼精蛋白。

Potassium-sparing (retaining) diuretics: 1. Potassium-sparing diuretics act on the distal tubule to promote sodium and water excretion and potassium retention. 2. Used for edema and hypertension, to increase urine output, and to treat fluid retention and overload associated with heart failure, ascites resulting from cirrhosis or nephrotic syndrome, and diuretic-induced hypokalemia. 3. Potassium-sparing diuretics are contraindicated in severe kidney or hepatic disease and severe hyperkalemia. 4. Potassium-sparing diuretics should be used with caution in the client with diabetes mellitus, taking antihypertensives or lithium, taking angiotensin-converting enzyme inhibitors or potassium supplements because hyperkalemia can result. 5. The primary concern with administering potassium-sparing (retaining) diuretics is hyperkalemia.

保钾利尿剂： 1.保钾利尿剂作用于末梢小管，以促进钠和水的排泄以及钾的保留。 2.用于水肿和高血压，以增加尿量，并治疗与心力衰竭，肝硬化或肾病综合征引起的腹水以及利尿剂引起的低钾血症相关的体液fluid留和超负荷。 3.保钾利尿剂在严重的肾脏或肝脏疾病和严重的高钾血症中禁用。 4.对于患有糖尿病，服用降压药或锂，服用血管紧张素转化酶抑制剂或钾补充剂的患者，应谨慎使用保钾利尿剂，因为这可能导致高钾血症。 5.施用保钾（保留）利尿剂的主要问题是高钾血症。

The nurse is assigned to care for a client with a detached retina. Which finding should the nurse expect to be documented in the client's record? 1. Blurred vision 2. Pain in the affected eye 3. A yellow discoloration of the sclera 4. A sense of a curtain falling across the field of vision 4 Rationale: A characteristic clinical manifestation of retinal detachment described by clients is the feeling that a shadow or curtain is falling across the field of vision. There is no pain associated with detachment of the retina. A retinal detachment is an ophthalmic emergency and even more so if visual acuity is still normal. Options 1 and 3 are not specifically associated with a detached retina.

分配护士来照顾视网膜脱离的病人。护士期望将哪项发现记录在服务对象的记录中？ 1.视力模糊 2.患眼疼痛 3.巩膜黄变 4.整个视野中的帷幕感 4 理由：服务对象描述的视网膜脱离的典型临床表现是阴影或帘子落在整个视野中的感觉。没有与视网膜脱离相关的疼痛。视网膜脱离是眼科急症，如果视力仍正常，则更是如此。选项1和3与视网膜脱离无关。

Warfarin sodium: 1. Description a) Warfarin suppresses coagulation by acting as an antagonist of vitamin K, thereby inhibiting four dependent clotting factors (X, IX, VII, and II). b) Warfarin prolongs clotting time and is monitored by the prothrombin time (PT) and the international normalized ratio (INR). c) It is used for long-term anticoagulation, mainly to prevent thromboembolic conditions such as thrombophlebitis, pulmonary embolism, and embolism formation caused by atrial fibrillation, thrombosis, myocardial infarction, or heart valve damage. 2. Blood levels a) The normal PT is 11 to 12.5 seconds (conventional and SI units). b) Warfarin sodium prolongs the PT. The therapeutic range is 1.5 to 2 times the control value. 3. International normalized ratio (INR) a) The normal INR for both conventional and standard units is 0.81 to 1.2 (0.81-1.2). b) The INR is determined by multiplying the observed PT ratio (the ratio of the client's PT to a control PT) by a correction factor specific to a particular thromboplastin preparation used during testing.

华法林钠： 1.说明 a）华法林通过充当维生素K拮抗剂来抑制凝血，从而抑制四个依赖性凝血因子（X，IX，VII和II）。 b）华法林延长凝血时间，并通过凝血酶原时间（PT）和国际标准化比率（INR）进行监测。 c）用于长期抗凝，主要用于预防血栓栓塞性疾病，例如血栓性静脉炎，肺栓塞和由房颤，血栓形成，心肌梗塞或心脏瓣膜损害引起的栓塞形成。 2.血液水平 a）正常PT是11到12.5秒（常规和SI单位）。 b）华法林钠可延长PT。治疗范围是对照值的1.5至2倍。 3.国际标准化比率（INR） a）常规和标准单位的正常INR为0.81至1.2（0.81-1.2）。 b）INR是通过将观察到的PT比率（客户PT与对照PT的比率）乘以特定于测试过程中使用的特定凝血活酶制剂的校正因子来确定的。

The client who has a cold is seen in the emergency department with an inability to void. Because the client has a history of benign prostatic hyperplasia, the nurse determines that the client should be questioned about the use of which class of medications? 1. Diuretics 2. Antibiotics 3. Antitussives 4. Decongestants 4 Rationale: Episodes of urinary retention can be triggered by certain medications such as decongestants, anticholinergics, and antidepressants. Diuretics, antibiotics, and antitussives generally do not trigger urinary retention. Retention also can be precipitated by other factors such as alcoholic beverages, infection, bed rest, and becoming chilled.

在急诊室看到感冒的病人无法虚脱。由于服务对象有前列腺增生的病史，因此护士确定应询问服务对象哪种药物的使用？ 1.利尿剂 2.抗生素 3.镇咳药 4.充质剂 4 理由：某些药物（例如充血药，抗胆碱药和抗抑郁药）可触发尿retention留。利尿剂，抗生素和镇咳药通常不会触发尿retention留。诸如酒精饮料，感染，卧床休息和变冷等其他因素也可能导致滞留

Peripheral Vasodilators: 1. Peripheral vasodilators decrease peripheral resistance by exerting a direct action on the arteries or the arteries and the veins. 2. Peripheral vasodilators increase blood flow to the extremities and are used in peripheral vascular disorders of venous and arterial vessels. 3. Peripheral vasodilators are most effective for disorders resulting from vasospasm (Raynaud's disease). 4. These medications may decrease some symptoms of cerebral vascular insufficiency.

外围血管扩张剂： 1.外周血管扩张剂通过对动脉或动脉和静脉施加直接作用来降低外周阻力。 2.外周血管扩张剂增加了流向四肢的血液，并用于静脉和动脉血管的外周血管疾病。 3.外周血管扩张剂对血管痉挛（雷诺氏病）引起的疾病最有效。 4.这些药物可以减轻某些脑血管功能不全的症状。

External otitis 1. Description a) External otitis is an infective inflammatory or allergic response involving the structure of the external auditory canal or the auricles. b) An irritating or infective agent comes in contact with the epithelial layer of the external ear. c) Contact leads to an allergic response or signs and symptoms of an infection. d) The skin becomes red, swollen, and tender to touch during movement. e) The extensive swelling of the canal can lead to conductive hearing loss because of obstruction. f) External otitis is more common in children, is termed "swimmer's ear," and occurs more often in hot, humid environments. g) Prevention includes the elimination of irritating or infecting agents. 2. Data collection a) Pain b) Itching c) Plugged feeling in the ear d) Redness and edema e) Exudate f) hearing loss 3. Interventions a) Apply heat locally for 20 minutes three times a day. b) Encourage rest to assist in reducing pain. c) Administer antibiotics or corticosteroids as prescribed. d) Administer analgesics such as aspirin or acetaminophen for the pain as prescribed. e) Reinforce instructions to the client that the ears should be kept clean and dry. f) Reinforce instructions to the client to use earplugs for swimming. g) Reinforce instructions to the client that irritating agents such as hair products or headphones should be discontinued.

外耳炎 1.说明 a）外耳炎是一种感染性炎症或过敏反应，涉及外耳道或耳廓的结构。 b）刺激性或感染性物质与外耳的上皮层接触。 c）接触导致过敏反应或感染的体征和症状。 d）在运动过程中，皮肤变红，肿胀，触手可及。 e）由于阻塞，运河的广泛肿胀可能导致传导性听力损失。 f）外耳道炎在儿童中更为常见，被称为"游泳者的耳朵"，在热，潮湿的环境中更常见。 g）预防包括消除刺激性或感染性物质。 2.数据收集 a）痛苦 b）瘙痒 c）耳塞的感觉 d）发红和浮肿 e）渗出液 f）听力损失 3.干预 a）一天三遍，局部加热20分钟。 b）鼓励休息，以减轻疼痛。 c）按规定使用抗生素或皮质类固醇。 d）按规定使用止痛药如阿司匹林或对乙酰氨基酚。 e）加强对服务对象的指示，要求耳朵保持清洁干燥。 f）加强对服务对象的说明，以使用耳塞游泳。 g）加强对客户的指示，即应停止使用刺激性物质，例如护发产品或耳机。

A client is scheduled for intravenous pyelography (IVP). Which priority nursing action should the nurse take? 1. Restrict fluids. 2. Administer a sedative. 3. Determine if there is a history of allergies. 4. Administer an oral preparation of radiopaque dye. 3 Rationale: An iodine-based dye may be used during the IVP and can cause allergic reactions such as itching, hives, rash, tight feeling in the throat, shortness of breath, and bronchospasm. Checking for allergies is the priority.

安排客户进行静脉肾盂造影（IVP）。护士应采取哪种优先护理措施？ 1.限制液体。 2.服用镇静剂。 3.确定是否有过敏史。 4.施用不透射线染料的口服制剂。 3 基本原理：在IVP期间可使用基于碘的染料，它会引起过敏反应，例如瘙痒，荨麻疹，皮疹，喉咙紧绷感，呼吸急促和支气管痉挛。检查过敏是重中之重。

A client sustains a chemical eye injury from a splash of battery acid. The nurse should prepare the client for which immediate measure? 1. Checking visual acuity 2. Covering the eye with a pressure patch 3. Swabbing the eye with antibiotic ointment 4. Irrigating the eye with sterile normal saline 4 Rationale: Emergency care after a chemical burn to the eye includes irrigating the eye immediately with sterile normal saline or ocular irrigating solution. The irrigation should be maintained for at least 10 minutes. After this emergency treatment, visual acuity is assessed. Options 2 and 3 are not immediate measures.

客户因飞溅的电池酸而遭受化学性眼睛伤害。护士应为服务对象准备立即采取的措施？ 1.检查视力 2.用压力贴片遮盖眼睛 3.用抗生素药膏擦拭眼睛 4.用无菌生理盐水冲洗眼睛 4 原理：化学灼伤眼睛后的紧急护理包括立即用无菌生理盐水或眼睛冲洗液冲洗眼睛。灌溉应至少维持10分钟。紧急治疗后，评估视力。选项2和3不是立即采取的措施。

A client has epididymitis as a complication of a urinary tract infection (UTI). The nurse is giving the client instructions to prevent recurrence. The nurse determines that the client needs further teaching if the client states the intention to do which action? 1. Drink an increased amount of fluids. 2. Limit the force of the stream during voiding. 3. Continue to take antibiotics until all symptoms are gone. 4. Use condoms to eliminate risk associated with chlamydia and gonorrhea. 3 Rationale: The client who experiences epididymitis from UTI should increase intake of fluids to flush the urinary system. Because organisms can be forced into the vas deferens and epididymis from strain or pressure during voiding, the client should limit the force of the stream. Condom use can help prevent urethritis and epididymitis from STIs. Antibiotics are always taken until the full course of therapy is completed.

客户患有附睾炎，是尿路感染（UTI）的并发症。护士正在给服务对象指示，以防止再次发生。如果服务对象声明打算采取哪种行动，则护士会确定服务对象需要进一步的教学？ 1.多喝水。 2.在排空期间限制流的作用力。 3.继续服用抗生素直至所有症状消失。 4.使用避孕套消除与衣原体和淋病相关的风险。 3 理由：患有UTI附睾炎的服务对象应增加液体摄入量以冲洗泌尿系统。由于排尿过程中的压力或压力会使生物被迫进入输精管和附睾，因此服务对象应限制水流的作用力。使用避孕套可以帮助预防性传播感染引起的尿道炎和附睾炎。始终服用抗生素，直到完成整个疗程。

The nurse is monitoring an older client suspected of having a urinary tract infection (UTI) for signs of infection. Which sign/symptom is likely to present first? 1. Fever 2. Urgency 3. Confusion 4. Frequency 3 Rationale: In an older client, the only symptom of a UTI may be something as vague as increasing mental confusion or frequent unexplained falls. Frequency and urgency may commonly occur in an older client, and fever can be associated with a variety of conditions.

护士正在监视疑似患有尿路感染（UTI）的老年患者感染的迹象。 哪个症状可能首先出现？ 1.发烧 2.紧急性 3.困惑 4.频率 3 原理：在年长的客户中，UTI的唯一症状可能是精神错乱加剧或频繁的无法解释的跌倒。 频率和紧迫感通常发生在年龄较大的客户中，发烧可能与多种情况相关。

A client is taking nicotinic acid for hyperlipidemia, and the nurse reinforces instructions to the client about the medication. Which statement by the client indicates an understanding of the instructions? 1. "It is not necessary to avoid the use of alcohol." 2. "The medication should be taken with meals to decrease flushing." 3. "Clay-colored stools are a common side effect and should not be of concern." 4. "Ibuprofen taken 30 minutes before the nicotinic acid should decrease the flushing." 4 Rationale: Flushing is a side effect of this medication. Aspirin or a nonsteroidal antiinflammatory drug can be taken 30 minutes before taking the medication to decrease flushing. Alcohol consumption needs to be avoided because it will enhance this side effect. The medication should be taken with meals; this will decrease gastrointestinal upset. Taking the medication with meals has no effect on the flushing. Clay-colored stools are a sign of hepatic dysfunction and should be immediately reported to the PHCP.

客户正在服用烟酸治疗高脂血症，护士会加强对客户的药物说明。客户的以下哪个陈述表明您对说明有所了解？ 1."没有必要避免使用酒精。" 2."药物应随餐服用，以减少潮红。" 3."黏土色的粪便是常见的副作用，不应引起关注。" 4."在烟酸前30分钟服用布洛芬应减少潮红。" 4 原理：潮红是这种药物的副作用。服用药物前30分钟可服用阿司匹林或非甾体抗炎药以减少潮红。需要避免饮酒，因为这会增加副作用。药物应随餐服用；这将减少肠胃不适。随餐服用药物对潮红没有影响。黏土色的粪便是肝功能障碍的征兆，应立即向PHCP报告。

A client is receiving digoxin daily. The nurse suspects digoxin toxicity after noting which signs and symptoms? Select all that apply. 1. Visual disturbances 2. Nausea and vomiting 3. Apical pulse rate of 63 beats per minute 4. Serum digoxin level of 2.3 ng/mL (2.93 nmol/L) 5. Serum potassium level of 3.9 mEq/L (3.9 mmol/L) 1, 2, 4 Rationale: Signs and symptoms of digoxin toxicity include gastrointestinal signs, bradycardia, visual disturbances, and hypokalemia. A therapeutic serum digoxin level ranges from 0.8 to 2.0 ng/mL (1.02 to 2.56 nmol/L). The serum potassium level should be between 3.5 mEq/L (3.5 mmol/L) and 5.0 mEq/L. The apical pulse must be greater than or equal to 60 beats per minute.

客户每天都在接受地高辛。护士注意到了哪些体征和症状后怀疑地高辛有毒性？选择所有符合条件的。 1.视觉障碍 2.恶心和呕吐 3.心尖搏动速率为每分钟63次 4.血清地高辛水平为2.3 ng / mL（2.93 nmol / L） 5.血清钾水平为3.9 mEq / L（3.9 mmol / L） 1 2 4 理由：地高辛毒性的体征和症状包括胃肠道体征，心动过缓，视力障碍和低钾血症。治疗性血清地高辛水平为0.8至2.0 ng / mL（1.02至2.56 nmol / L）。血清钾水平应在3.5 mEq / L（3.5 mmol / L）和5.0 mEq / L之间。心尖脉冲必须大于或等于每分钟60次。

The home health care nurse is visiting a client with elevated triglyceride levels and a serum cholesterol level of 398 mg/dL (9.95 mmol/L). The client is taking cholestyramine. Which statement made by the client indicates the need for further teaching? 1. "Constipation and bloating might be a problem." 2. "I'll continue to watch my diet and reduce my fats." 3. "Walking a mile each day will help the whole process." 4. "I'll continue my nicotinic acid from the health food store." 4 Rationale: Nicotinic acid, even an over-the-counter form, should be avoided because it may lead to liver abnormalities. All lipid-lowering medications can also cause liver abnormalities so a combination of nicotinic acid and cholestyramine resin is to be avoided. Constipation and bloating are the two most common side effects. Walking and the reduction of fats in the diet are therapeutic measures to reduce cholesterol and triglyceride levels.

家庭保健护士正在拜访一位甘油三酯水平升高且血清胆固醇水平为398 mg / dL（9.95 mmol / L）的客户。客户正在服用消胆胺。客户的哪项陈述表明需要进一步的教学？ 1."便秘和腹胀可能是一个问题。" 2."我将继续注意饮食并减少脂肪。" 3."每天走一英里将有助于整个过程。" 4."我将继续从保健食品商店购买烟酸。" 4 理由：烟酸，即使是非处方形式，也应避免，因为它可能导致肝脏异常。所有降脂药物也会引起肝脏异常，因此应避免烟酸和胆甾胺树脂的组合。便秘和腹胀是两种最常见的副作用。步行和减少饮食中的脂肪是降低胆固醇和甘油三酸酯水平的治疗措施。

A sulfonamide is prescribed for a client with a urinary tract infection. During review of the client's record, the nurse notes that the client is taking warfarin sodium daily. Which prescription should the nurse anticipate for this client? 1. Discontinuation of warfarin sodium 2. A decrease in the warfarin sodium dosage 3. An increase in the warfarin sodium dosage 4. A decrease in the usual dose of the sulfonamide 2 Rationale: Sulfonamides can potentiate the effects of warfarin sodium, phenytoin, and orally administered hypoglycemics such as tolbutamide. When an oral anticoagulant is combined with a sulfonamide, a decrease in the anticoagulant dosage may be needed.

对于患有尿路感染的患者，应开处方使用磺胺类药物。在查看服务对象的记录期间，护士注意到该服务对象每天服用华法林钠。护士应为此客户预期哪种处方？ 1.停用华法林钠 2.减少华法林钠的剂量 3.增加华法林钠剂量 4.减少磺胺类药物的常规剂量 2 理由：磺胺类药物可增强华法林钠，苯妥英钠和口服降血糖药（例如甲苯磺丁胺）的作用。当口服抗凝剂与磺胺类药物合用时，可能需要降低抗凝剂的剂量

Uremic Syndrome: A) Description: Systemic clinical and laboratory manifestations of severe and/or end-stage kidney disease as a result of accumulation of nitrogenous waste products in the blood caused by the kidneys' inability to filter out these waste products. B) Data collection 1. Oliguria 2. The presence of protein, red blood cells, and casts in the urine 3. Elevated levels of urea, uric acid, potassium, and magnesium in the urine 4. Hypotension or hypertension 5. Alterations in the level of consciousness 6. Electrolyte imbalances 7. Stomatitis 8. Nausea or vomiting 9. Diarrhea or constipation C) Interventions 1. Monitor vital signs for hypertension, tachycardia, and an irregular heart rate. 2. Monitor serum electrolyte levels. 3. Monitor intake and output and for oliguria. 4. Provide a limited, but high-quality, protein diet as prescribed. 5. Provide a limited sodium, nitrogen, potassium, and phosphate diet as prescribed.

尿毒症综合征： A）说明：严重的和/或晚期肾脏疾病的系统性临床和实验室表现，是由于肾脏无法滤除这些废物而导致血液中含氮废物积聚的结果。 B）数据收集 1.少尿 2.尿液中存在蛋白质，红细胞和铸型 3.尿液中尿素，尿酸，钾和镁的水平升高 4.低血压或高血压 5.意识水平的改变 6.电解质失衡 7.口腔炎 8.恶心或呕吐 9.腹泻或便秘 C）干预 1.监测高血压的生命体征， 心动过速和心律不齐。 2.监测血清电解质水平。 3.监测摄入量和输出量以及尿少。 4.按照规定提供有限但高质量的蛋白质饮食。 5.按规定提供有限的钠，氮，钾和磷酸盐饮食。

Refractive errors: 1. Description: a) Refraction is the bending of light rays. Any problem associated with either eye length or refraction can lead to refractive errors. b) Myopia (nearsightedness): Refractive ability of the eye is too strong for the eye length; images are bent and fall in front of, not on, the retina. c) Hyperopia (farsightedness): Refractive ability of the eye is too weak; images are focused behind the retina. d) Presbyopia: Loss of lens elasticity caused by aging; less able to focus the eye for close work, and images fall behind the retina. e) Astigmatism: Occurs because of the irregular curvature of the cornea; image does not focus on the retina. 2. Data collection: a) Refractive errors are diagnosed through a process called refraction. b) The client views an eye chart while various lenses of different strengths are systematically placed in front of the eye and is asked whether each lens sharpens or worsens the vision. 3. Nonsurgical interventions: Eyeglasses or contact lenses 4. Surgical interventions: a) Radial keratotomy: Incisions are made through the peripheral cornea to flatten the cornea, which allows the image to be focused closer to the retina; used to treat myopia. b) Photorefractive keratotomy: A laser beam is used to remove small portions of the corneal surface to reshape the cornea to focus an image properly on the retina; used to treat myopia and astigmatism. c) Laser in situ keratomileusis (LASIK): The superficial layers of the cornea are lifted as a flap, a laser reshapes the deeper corneal layers, and then the corneal flap is replaced; used to treat hyperopia, myopia, and astigmatism. d) Corneal ring: The shape of the cornea is changed by placing a flexible ring in the outer edges of the cornea; used to treat myopia.

屈光不正： 1.说明： a）折射是光线的弯曲。与眼睛长度或屈光有关的任何问题都可能导致屈光不正。 b）近视（近视）：眼睛的屈光能力对于眼睛的长度而言太强；图像弯曲并掉落在视网膜的前面而不是上面。 c）远视（远视）：眼睛的屈光能力太弱；图像聚焦在视网膜后面。 d）老花眼：由于老化导致晶状体弹性丧失；难以集中精力进行近距离工作，并且图像落在视网膜后面。 e）散光：由于角膜曲率不规则而发生；图像不聚焦于视网膜。 2.数据收集： a）屈光不正通过称为屈光的过程进行诊断。 b）客户在系统地将各种强度的各种镜片放置在眼前时查看视力表，并询问每个镜片是否会使视力锐化或恶化。 3.非手术干预：眼镜或隐形眼镜 4.手术干预： a）放射状角膜切开术：通过周边角膜切开切口以使角膜变平，从而使图像聚焦在距视网膜较近的位置；用于治疗近视。 b）屈光性角膜切开术：使用激光束去除角膜表面的一小部分以使角膜塑形，从而将图像正确聚焦在视网膜上；用于治疗近视和散光。 c）激光原位角膜磨镶术（LASIK）：将角膜表层抬高成皮瓣，激光重塑较深的角膜层，然后更换角膜瓣；用于治疗远视，近视和散光。 d）角膜环：通过在角膜的外边缘放置一个柔性环来改变角膜的形状；用于治疗近视。

A hemodialysis client with a left-arm fistula is at risk for arterial steal syndrome. The nurse monitors this client for which signs/symptoms of this disorder? 1. Edema and purpura of the left arm 2. Warmth, redness, and pain in the left hand 3. Aching pain, pallor, and edema of the left arm 4. Pallor, diminished pulse, and pain in the left hand 4 Rationale: Arterial steal syndrome results from vascular insufficiency after creation of a fistula. The client exhibits pallor and diminished pulse distal to the fistula and complains of pain distal to the fistula, which is caused by tissue ischemia. Warmth, redness, and pain should more likely characterize a problem with infection. Options 2 and 3 are not characteristics of steal syndrome.

左手臂瘘的血液透析患者处于动脉盗血综合征的风险中。护士会监视此服务对象的这种疾病的哪些体征/症状？ 1.左臂水肿和紫癜 2.左手有温暖，发红和疼痛 3.左臂疼痛，苍白和水肿 4.苍白，脉搏减弱和左手疼痛 4 理由：造瘘后的血管供血不足可导致动脉盗窃综合征。服务对象在瘘管远端表现出苍白和脉搏减弱，并抱怨由组织缺血引起的瘘管远端疼痛。温暖，发红和疼痛更可能是感染问题的特征。选项2和3不是盗窃综合症的特征。

Isosorbide mononitrate is prescribed for a client with angina pectoris. The client tells the nurse that the medication is causing a chronic headache. Which action should the nurse suggest to the client? 1. Cut the dose in half. 2. Discontinue the medication. 3. Take the medication with food. 4. Contact the primary health care provider (PHCP). 3 Rationale: Isosorbide mononitrate is an antianginal medication. Headache is a frequent side effect of isosorbide mononitrate and usually disappears during continued therapy. If a headache occurs during therapy, the client should be instructed to take the medication with food or meals. It is not necessary to contact the PHCP unless the headaches persist with therapy. It is not appropriate to instruct the client to discontinue therapy or adjust the dosages.

异山梨醇单硝酸盐适用于患有心绞痛的患者。服务对象告诉护士药物正在引起慢性头痛。护士应向服务对象建议什么措施？ 1.将剂量减半。 2.停药。 3.随食物一起服用药物。 4.与初级保健提供者（PHCP）联系。 3 理由：一硝酸异山梨酯是一种抗心绞痛药物。头痛是单硝酸异山梨酯的常见副作用，通常在继续治疗期间会消失。如果在治疗过程中出现头痛，应指导服务对象随食物或餐食服用药物。除非头痛持续治疗，否则不必联系PHCP。指示患者停止治疗或调整剂量是不合适的。

Foreign bodies: 1. Description: An object such as dust or dirt that enters the eye and causes irritation. 2. Interventions a) Have the client look upward, exposing the lower lid, wet a cotton-tipped applicator with sterile normal saline, and gently twist the swab over the particle, and remove it. b) If the particle cannot be seen, have the client look downward, place a cotton applicator horizontally on the outer surface of the upper eyelid, grasp the lashes, and pull the upper lid outward and over the cotton applicator. If the particle is seen, gently twist a swab over it to remove it.

异物： 1.说明：诸如灰尘或污垢的物体进入眼睛并引起刺激。 2.干预 a）让服务对象抬起头，露出下盖，用无菌生理盐水湿润带棉的涂抹器，然后轻轻地将棉签拧到颗粒上，然后将其取出。 b）如果看不见颗粒，请服务对象向下看，将棉签水平地放在上眼睑的外表面，抓住睫毛，然后将上眼睑向外拉到棉签上方。 如果看到颗粒，则将棉签轻轻拧在其上以将其除去。

Cardiac Glycosides: 1. Cardiac glycosides inhibit the sodium- potassium pump, thus increasing intracellular calcium which causes the heart muscle fibers to contract more efficiently. 2. Cardiac glycosides produce a positive inotropic action, which increases the force of myocardial contractions. 3. Cardiac glycosides produce a negative chronotropic action which slows the heart rate. 4. Cardiac glycosides produce a negative dromotropic action that slows conduction velocity through the atrioventricular (AV) node. 5. The increase in myocardial contractility increases cardiac, peripheral, and kidney function by increasing cardiac output, decreasing preload, improving blood flow to the periphery and kidneys, decreasing edema, and increasing fluid excretion. As a result, fluid retention in the lungs and extremities is decreased. 6. Cardiac glycosides are used second-line for heart failure (medications affecting the renin-angiotensin-aldosterone system are used more often) and cardiogenic shock, atrial tachycardia, atrial fibrillation, and atrial flutter; used less frequently for rate control in atrial dysrhythmia (β-blockers and calcium channel blockers are used more often). 7. These medications are contraindicated in those with ventricular dysrhythmia and second- or third-degree heart block and should be used with caution in clients with renal disease, hypothyroidism, and hypokalemia. 8. A common cardiac glycoside is digoxin. 9. Bleeding is the primary concern for a client taking an anticoagulant, thrombolytic, or antiplatelet medication. 10. Early signs of digoxin toxicity present as gastrointestinal manifestations (anorexia, nausea, vomiting, diarrhea); then heart rate abnormalities and visual disturbances appear. 11. The therapeutic digoxin range is 0.8 to 2.0 ng/mL (1.02 to 2.56 nmol/L).

心脏糖苷： 1.心脏苷抑制钠钾泵，从而增加细胞内钙，导致心肌纤维更有效地收缩。 2.强心苷产生正性肌力作用，增加心肌收缩力。 3.强心苷产生负变时性作用，减慢心律。 4.心脏苷产生负的同营养作用，从而减慢了通过房室（AV）结的传导速度。 5.心肌收缩力的增加通过增加心输出量，减少预负荷，改善流向周围和肾脏的血液，减少水肿和增加液体排泄而增加心脏，外周和肾脏的功能。结果，减少了在肺和四肢中的液体滞留。 6.心脏苷用于心力衰竭的二线治疗（影响肾素-血管紧张素-醛固酮系统的药物的使用频率更高）和心源性休克，房性心动过速，房颤和房扑。减少心律失常的心率控制频率（β受体阻滞剂和钙通道阻滞剂使用频率更高）。 7.这些药物禁止用于室性心律不齐和二级或三级心脏传导阻滞，对于肾病，甲状腺功能减退和低钾血症的患者应谨慎使用。 8.常见的强心苷是地高辛。 9.出血是服用抗凝剂，溶栓剂或抗血小板药物的患者的主要担忧。 10.地高辛毒性的早期迹象表现为 胃肠道表现（厌食，恶心，呕吐，腹泻）；然后出现心率异常和视觉障碍。 11.治疗性地高辛的范围是0.8至2.0 ng / mL（1.02至2.56 nmol / L）。

Phases of Acute Kidney Injury (AKI) and interventions: 1. Onset: Begins with precipitating event 2. Oliguric phase: a) For some clients, oliguria does not occur and the urine output is normal; otherwise, the duration of oliguria is 8 to 15 days; the longer the duration, the less chance of recovery. b) Sudden decrease in urine output. Urine output is less than 400 mL/day. c) Signs of excess fluid volume: hypertension, edema, pleural and pericardial effusions, dysrhythmia, heart failure (HF), and pulmonary edema d) Signs of uremia: anorexia, nausea, vomiting, and pruritus e) Signs of metabolic acidosis: Kussmaul's respirations f) Signs of neurological changes: tingling of extremities, drowsiness progressing to disorientation, and then coma g) Signs of pericarditis: friction rub, chest pain with inspiration, and low-grade fever h) With early recognition or potential for AKI, client may be treated with fluid challenges (IV boluses of 500- 1000 mL over 1 hour) i) Fluid intake may be restricted. If hypertension is present, daily fluid allowances may be 400 mL to 1000 mL plus the measured urinary output. j) Assist with the administration of medications as prescribed, such as diuretics (furosemide) to increase renal blood flow and diuresis.

急性肾损伤（AKI）的阶段和干预措施： 1.发作：始于突发事件 2.尿酸期： a）对于某些客户，不会出现少尿并且尿量正常；否则，少尿持续时间为8至15天；持续时间越长，恢复的机会就越少。 b）尿量突然减少。尿量少于400毫升/天。 c）体液过多的迹象：高血压，水肿，胸膜和心包积液，心律不齐，心力衰竭（HF）和肺水肿 d）尿毒症的迹象：厌食，恶心，呕吐和瘙痒 e）代谢性酸中毒的迹象：库斯马尔的呼吸 f）神经系统改变的迹象：四肢发麻，嗜睡发展到迷失方向，然后昏迷 g）心包炎的迹象：摩擦擦，胸痛伴有吸气和低烧 h）尽早发现或具有潜在的AKI可能会给患者治疗体液挑战（在1小时内静脉内推注500-1000 mL） i）液体摄入可能受到限制。如果存在高血压，则每日体液摄入量应为400 mL至1000 mL加上测得的尿量。 j）协助按规定使用药物，例如利尿剂（速尿）以增加肾脏血流量和利尿作用。

A client with chronic kidney disease has been on dialysis for 3 years. The client is receiving the usual combination of medications for the disease, including aluminum hydroxide as a phosphate-binding agent. The client now has mental cloudiness, dementia, and complaints of bone pain. Which does this data indicate? 1. Advancing uremia 2. Phosphate overdose 3. Folic acid deficiency 4. Aluminum intoxication 4 Rationale: Aluminum intoxication may occur when there is an accumulation of aluminum, an ingredient in many phosphate-binding antacids. It results in mental cloudiness, dementia, and bone pain from infiltration of the bone with aluminum. This condition was formerly known as dialysis dementia. It may be treated with aluminum-chelating agents, which make aluminum available to be dialyzed from the body. It can be prevented by avoiding or limiting the use of phosphate-binding agents that contain aluminum.

患有慢性肾脏疾病的客户已经接受透析3年了。客户正在接受针对该疾病的常用药物组合，包括氢氧化铝作为磷酸盐结合剂。现在，服务对象患有精神混浊，痴呆症和骨痛症状。该数据表明了什么？ 1.进行尿毒症 2.磷酸盐过量 3.叶酸缺乏 4.铝中毒 4 理由：铝的积累可能会引起铝中毒，铝是许多与磷酸盐结合的抗酸剂中的一种成分。铝渗入骨头会导致精神模糊，痴呆和骨头疼痛。这种情况以前称为透析性痴呆。可以用铝螯合剂处理，这可以使铝从人体中透析出来。可以通过避免或限制使用含铝的磷酸盐结合剂来预防。

A client with chronic kidney disease is receiving epoetin alfa. Which laboratory result would indicate a therapeutic effect of the medication? 1. Hematocrit of 33% (0.33) 2. Platelet count of 400,000 mm3 (400 × 109/L) 3. White blood cell count of 6000 mm3 (6.0 × 109/L) 4. Blood urea nitrogen level of 15 mg/dL (5.25 mmol/L) 1 Rationale: Epoetin alfa is synthetic erythropoietin, which the kidneys produce to stimulate red blood cell production in the bone marrow. It is used to treat anemia associated with chronic kidney disease. The normal hematocrit level is Male: 42% to 52% (0.42 to 0.52); Female: 37% to 47% (0.37 to 0.47). Therapeutic effect is seen when the hematocrit reaches between 30% and 33% (0.30 and 0.33). The normal platelet count is 150,000 to 400,000 mm3 (150 to 400 × 109/L). The normal blood urea nitrogen level is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). The normal white blood cell count is 5000 to 10,000 mm3 (5- 10 × 109/L). Platelet production, white blood cell production, and blood urea nitrogen do not respond to erythropoietin.

患有慢性肾脏疾病的客户正在接受埃泊汀阿尔法。哪个实验室结果表明该药物具有治疗效果？ 1.血细胞比容为33％（0.33） 2.血小板计数为400,000 mm3（400×109 / L） 3.白细胞计数为6000 mm3（6.0×109 / L） 4.血液尿素氮含量为15 mg / dL（5.25 mmol / L） 1个 原理：埃泊汀是合成的促红细胞生成素，肾脏产生该物质以刺激骨髓中红细胞的产生。它用于治疗与慢性肾脏疾病相关的贫血。正常的血细胞比容水平是男性：42％至52％（0.42至0.52）；女性：37％至47％（0.37至0.47）。当血细胞比容达到30％至33％（0.30至0.33）时，可以看到治疗效果。正常血小板计数为150,000至400,000 mm3（150至400×109 / L）。正常的血液尿素氮水平为10至20 mg / dL（3.6至7.1 mmol / L）。正常白细胞计数为5000至10,000 mm3（5-10×109 / L）。血小板生成，白细胞生成和血液尿素氮对促红细胞生成素无反应。

A client with benign prostatic hypertrophy (BPH) undergoes a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigations postoperatively. Which are the signs/symptoms of transurethral resection (TUR) syndrome? 1. Tachycardia and diarrhea 2. Bradycardia and confusion 3. Increased urinary output and anemia 4. Decreased urinary output and bladder spasms 2 Rationale: TUR syndrome is caused by increased absorption of nonelectrolyte irrigating fluid used during surgery. The client may show signs of cerebral edema and increased intracranial pressure, such as increased blood pressure, bradycardia, confusion, disorientation, muscle twitching, visual disturbances, and nausea and vomiting.

患有良性前列腺肥大（BPH）的患者接受经尿道前列腺电切术（TURP），并且术后接受连续膀胱冲洗。经尿道切除（TUR）综合征的体征/症状是什么？ 1.心动过速和腹泻 2.心动过缓和混乱 3.尿量增加和贫血 4.尿量减少和膀胱痉挛 2 理由：TUR综合征是由于手术期间使用的非电解质冲洗液吸收增加所致。服务对象可能显示出脑水肿和颅内压升高的迹象，例如血压升高，心动过缓，意识模糊，神志不清，肌肉抽搐，视觉障碍以及恶心和呕吐。

Sensorineural hearing loss: 1. Description a) Sensorineural hearing loss is a pathological process of the inner ear or of the sensory fibers that lead to the cerebral cortex. b) Sensorineural hearing loss is often permanent, and measures must be taken to reduce further damage. 2. Causes: a) Damage to the inner ear structures b) Damage to the eighth cranial nerve or the brain itself c) Prolonged exposure to loud noise d) Medications e) Trauma f) Inherited disorders g) Metabolic and circulatory disorders h) Infections i) Surgery j) Ménière's syndrome k) Diabetes mellitus l) Myxedema

感音神经性听力损失： 1.说明 a）感音神经性听力丧失是内耳或导致大脑皮层的感觉纤维的病理过程。 b）感音神经性听力损失通常是永久性的，必须采取措施减少进一步的损害。 2.原因： a）损害内耳结构 b）对第八颅神经或大脑本身的损害 c）长时间暴露于大噪音 d）药物 e）创伤 f）遗传性疾病 g）代谢和循环系统疾病 h）感染 i）手术 j）梅尼尔综合症 k）糖尿病 l）黏液水肿

Chronic Kidney Disease: A) Description 1. Chronic kidney disease (CKD) is a slow, progressive, and irreversible loss of kidney function with a GFR less than or equal to 60 mL/minute for 3 months or longer. 2. Occurs in stages (with loss of 75% of functioning nephrons, the client becomes symptomatic) and eventually results in uremia or end-stage kidney disease(with loss of 90%- 95% of functioning nephrons). 3. Hypervolemia can occur because of the kidneys' inability to excrete sodium and water, or hypovolemia can occur because of the kidneys' inability to conserve sodium and water. 4. Chronic kidney disease affects all major body systems and may require dialysis or kidney transplantation to maintain life. B. Interventions 1. Same as the interventions for AKI 2. Administer prescribed diet, usually moderate- protein (to decrease the workload on the kidneys), high-carbohydrate, low-potassium, and low-phosphorus. 3. Provide oral care to prevent stomatitis and reduce discomfort from mouth sores. 4. Provide skin-care to prevent pruritus. 5. Teach the client about fluid, dietary restrictions, and the importance of daily weight measurements.

慢性肾病： 说明 1.慢性肾脏病（CKD）是一种缓慢，进行性且不可逆的肾功能丧失，其GFR小于或等于60 mL / min持续3个月或更长时间。 2.分阶段发生（功能肾功能丧失75％，服务对象有症状），最终导致尿毒症或终末期肾脏疾病（功能肾功能丧失90％至95％）。 3.高血容量的发生可能是由于肾脏无法排泄钠和水，或者低血容量的发生可能是由于肾脏无法保留钠和水。 4.慢性肾脏病影响所有主要身体 系统，可能需要透析或肾脏移植以维持生命。 B.干预 1.与AKI的干预措施相同 2.按规定饮食，通常为中蛋白（以减少肾脏的工作量），高碳水化合物，低钾和低磷饮食。 3.提供口腔护理，以预防口腔炎和减轻口疮带来的不适。 4.提供皮肤护理以防止瘙痒。 5.教客户有关体液，饮食限制以及每日体重测量的重要性的信息。

Antilipemic Medications: A. Description 1. Antilipemic medications reduce serum levels of cholesterol, triglycerides, or low-density lipoprotein. 2. When cholesterol, triglyceride, and low-density lipoprotein levels are elevated, the client is at increased risk for coronary artery disease. 3. In many cases, diet alone will not lower blood lipid levels; therefore, antilipemic medications will be prescribed. B) Bile sequestrants: 1. Description a) Bind with acids in the intestines which prevents reabsorption of cholesterol b) Should not be used as the only therapy in clients with elevated triglyceride levels because they may raise triglyceride levels. 2. Side and adverse effects a) Constipation b) Gastrointestinal disturbances: Heartburn, nausea, belching, bloating 3. Interventions a) Cholestyramine comes in a gritty powder that must be mixed thoroughly in juice or water before administration. b) Monitor the client for early signs of peptic ulcer such as nausea and abdominal discomfort followed by abdominal pain and distention. c) Reinforce instructions to the client that the medication must be taken with and followed by sufficient fluids.

抗血脂药物： 说明 1.抗血脂药物可降低血清胆固醇，甘油三酸酯或低密度脂蛋白的水平。 2.当胆固醇，甘油三酸酯和低密度脂蛋白水平升高时，服务对象罹患冠心病的风险增加。 3.在许多情况下，单靠饮食并不能降低血脂水平。因此，将开出降血脂药物。 B）胆汁螯合剂： 1.说明 a）与肠酸结合，防止胆固醇重新吸收 b）不应将甘油三酸酯水平升高的患者用作唯一疗法，因为它们可能会升高甘油三酸酯水平。 2.副作用 a）便秘 b）胃肠道不适：胃灼热，恶心，气，腹胀 3.干预 a）胆甾醇胺为粗粒粉末，给药前必须在汁液或水中充分混合。 b）监测服务对象是否有消化性溃疡的早期迹象，例如恶心和腹部不适，然后是腹痛和腹胀。 c）加强对委托人的指示，即必须与足够的药液一起服用药物。

The nurse reinforces discharge instructions to a postoperative client who is taking warfarin sodium. Which statement made by the client reflects the need for further teaching? 1. "I will take my pills every day at the same time." 2. "I will be certain to avoid alcohol consumption." 3. "I have already called my family to pick up a MedicAlert bracelet." 4. "I will take enteric-coated aspirin for my headaches because it is coated." 4 Rationale: Aspirin-containing products should be avoided while taking this medication. Alcohol consumption should be avoided by a client taking warfarin sodium. Taking prescribed medication at the same time each day increases client compliance. The MedicAlert bracelet provides health care personnel with emergency information.

护士加强了对服用华法林钠的术后病人的出院指导。客户的哪项陈述反映了进一步教学的需要？ 1."我每天都会在同一时间服药。" 2."我一定会避免饮酒。" 3."我已经打电话给家人来拿起MedicAlert手镯。" 4."我会因肠溶而服用肠溶阿司匹林，因为它是包膜的。" 4 理由：服用这种药物时应避免含有阿司匹林的产品。服用华法林钠的食用者应避免饮酒。每天在同一时间服用处方药可以提高服务对象的依从性。 MedicAlert手镯可为医护人员提供紧急信息。

The nurse is preparing to reinforce a teaching plan for a client who is undergoing cataract extraction with an intraocular implant. Which home care measures should the nurse include in the plan? Select all that apply. 1. To avoid activities that require bending over 2. To contact the surgeon if eye scratchiness occurs 3. To take acetaminophen for minor eye discomfort 4. To place an eye shield on the surgical eye at bedtime 5. That episode of sudden severe pain in the eye is expected 6. To contact the surgeon if a decrease in visual acuity occurs 1, 3, 4, 6 Rationale: After eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and is usually relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse would also instruct the client to notify the surgeon of purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure such as bending over.

护士正准备加强针对使用眼内植入物进行白内障摘除的服务对象的教学计划。护士应在计划中包括哪些家庭护理措施？选择所有符合条件的。 1.避免需要弯腰的活动 2.如果出现眼抓伤情况，请联系外科医生 3.服用对乙酰氨基酚可减轻眼部不适 4.睡前在手术用的眼睛上放置护目镜 5.预计眼睛会突然出现剧烈疼痛 6.如果视力下降，请联系外科医生 1 3 4 6 基本原理：眼科手术后，手术眼可能会出现一些scratch痒和轻度的不适感，通常可以通过轻度的止痛药缓解。如果眼痛加剧，服务对象应通知医生，因为这可能表示出血，感染或眼内压升高。护士还将指示服务对象告知外科医生化脓性引流，发红增加或视力下降。指示服务对象在就寝时在手术眼上戴上眼罩，以保护眼睛在睡眠中免受伤害，并避免增加眼内压的活动，例如弯腰.

The nurse is collecting data from a client who has had benign prostatic hyperplasia (BPH) in the past. To determine whether the client is currently experiencing an exacerbation of BPH, the nurse should ask the client about the presence of which early symptom? 1. Nocturia 2. Urinary retention 3. Urge incontinence 4. Decreased force in the stream of urine 4 Rationale: Decreased force in the stream of urine is an early sign of BPH. The stream later becomes weak and dribbling. The client may then develop hematuria, frequency, urgency, urge incontinence, and nocturia. If untreated, complete obstruction and urinary retention can occur.

护士正在从过去有良性前列腺增生（BPH）的客户那里收集数据。为了确定服务对象当前是否正在加重BPH，护士应向服务对象询问出现哪种早期症状？ 1.夜尿 2.尿retention留 3.敦促失禁 4.尿流中的力量减少 4 理由：尿流中的力量减少是BPH的早期征兆。后来溪流变得微弱而盘流。然后客户可能会出现血尿，频率，尿急，急迫性尿失禁和夜尿症。如果不及时治疗，可能会发生完全阻塞和尿retention留。

The nurse is reinforcing discharge instructions to a client receiving sulfadiazine. Which should be included in the list of instructions? 1. Restrict fluid intake. 2. Maintain a high fluid intake. 3. Decrease the dosage when symptoms are improving to prevent an allergic response. 4. If the urine turns dark brown, call the primary health care provider (PHCP) immediately. 2 Rationale: Each dose of sulfadiazine should be administered with a full glass of water, and the client should maintain a high fluid intake. The medication is more soluble in alkaline urine. The client should not be instructed to taper or discontinue the dose. Some forms of sulfadiazine cause urine to turn dark brown or red. This does not indicate the need to notify the PHCP.

护士正在加强对接受磺胺嘧啶的服务对象的出院指导。 说明列表中应包括哪些内容？ 1.限制液体摄入。 2.保持高液体摄入量。 3.症状改善时应减少剂量，以防止过敏反应。 4.如果尿液变成深褐色，请立即致电初级卫生保健提供者（PHCP）。 2 理由：每剂磺胺嘧啶应与一整杯水一起服用，服务对象应保持高液体摄入量。 该药物更易溶于碱性尿。 不应指示服务对象逐渐减少剂量或停止剂量。 某些形式的磺胺嘧啶会导致尿液变成深棕色或红色。 这并不表示需要通知PHCP。

The nurse is assisting with developing a teaching plan for the client with glaucoma. Which instruction should the nurse suggest to include in the plan of care? 1. Decrease the amount of salt in the diet. 2. Decrease fluid intake to control the intraocular pressure. 3. Avoid reading the newspaper and watching television. 4. Eye medications may need to be administered for the rest of your life. 4 Rationale: The administration of eyedrops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications may need to be taken for the rest of his or her life. Limiting fluids and reducing salt will not decrease intraocular pressure. Option 3 is not necessary.

护士正在协助制定青光眼患者的教学计划。护士建议在护理计划中包括哪些指示？ 1.减少饮食中的盐含量。 2.减少液体摄入量以控制眼压。 3.避免阅读报纸和看电视。 4.在您的余生中，可能需要服用眼药。 4 理由：滴眼剂的治疗是青光眼患者治疗计划的重要组成部分。需要指示服务对象在余生中可能需要服用药物。限制体液和减少盐分不会降低眼压。选项3是不必要的。

The nurse is reviewing the client's record and notes that the primary health care provider (PHCP) has documented that the client has a renal disorder. Which laboratory results would indicate a decrease in renal function? Select all that apply. 1. Elevated serum creatinine level 2. Elevated thrombocyte cell count 3. Decreased red blood cell (RBC) count 4. Decreased white blood cell (WBC) count 5. Elevated blood urea nitrogen (BUN) level 1, 3, 5 Rationale: BUN testing is a frequently used laboratory test to determine renal function. The BUN and serum creatinine levels start to rise when the glomerular filtration rate falls below 40% to 60%. A decreased RBC count may be noted if erythropoietic function by the kidney is impaired. An increased WBC is most likely to be noted in renal disease. Thrombocyte cell counts do not indicate decreased renal function.

护士正在审查客户的记录，并指出初级保健提供者（PHCP）已证明该客户患有肾脏疾病。哪些实验室结果表明肾功能下降？选择所有符合条件的。 1.血清肌酐水平升高 2.血小板细胞计数升高 3.红细胞（RBC）数量减少 4.白细胞（WBC）数量减少 5.血尿素氮（BUN）升高 1 3 5 理由：BUN测试是一种用于确定肾功能的常用实验室测试。当肾小球滤过率低于40％至60％时，BUN和血清肌酐水平开始升高。如果肾脏的红细胞生成功能受损，则应注意减少RBC计数。在肾脏疾病中最有可能发现白细胞增加。血小板计数并不表示肾功能下降。

The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for dialysis because of the risk of which complication? 1. Peritonitis 2. Hyperglycemia 3. Hyperphosphatemia 4. Disequilibrium syndrome 2 Rationale: An extended dwell time increases the risk of hyperglycemia in the client with diabetes mellitus as a result of absorption of glucose from the dialysate and electrolyte changes. Diabetic clients may require extra insulin when receiving peritoneal dialysis. Peritonitis is a risk associated with breaks in aseptic technique. Hyperphosphatemia is an electrolyte imbalance that occurs with renal dysfunction. Disequilibrium syndrome is a complication associated with hemodialysis.

护士正在指导糖尿病患者进行腹膜透析。护士告诉服务对象，保持透析规定的停留时间很重要，因为这可能会引起并发症？ 1.腹膜炎 2.高血糖 3.高磷血症 4.不平衡综合症 2 理由：由于透析液中葡萄糖的吸收和电解质的变化，延长住院时间会增加患有糖尿病的患者高血糖的风险。糖尿病患者接受腹膜透析时可能需要额外的胰岛素。腹膜炎是与无菌技术中断相关的风险。高磷酸盐血症是一种电解质失衡，并伴有肾功能不全。不平衡综合征是与血液透析有关的并发症。

The nurse is reviewing the medical record of a client with a diagnosis of pyelonephritis. Which disorder noted on the client's record should the nurse identify as a risk factor for this diagnosis? 1. Hypoglycemia 2. Diabetes mellitus 3. Coronary artery disease 4. Orthostatic hypotension 2 Rationale: Risk factors associated with pyelonephritis include diabetes mellitus, hypertension, chronic renal calculi, chronic cystitis, structural abnormalities of the urinary tract, presence of urinary stones, and indwelling or frequent urinary catheterization.

护士正在检查诊断为肾盂肾炎的服务对象的病历。服务对象记录中应指出哪种疾病应被护士确定为诊断的危险因素？ 1.低血糖 2.糖尿病 3.冠状动脉疾病 4.体位性低血压 2 理由：与肾盂肾炎相关的危险因素包括糖尿病，高血压，慢性肾结石，慢性膀胱炎，泌尿道结构异常，泌尿系结石的存在以及留置或频繁导尿。

The nurse is caring for the client with epididymitis. Which treatment modalities should be implemented? Select all that apply. 1. Bed rest 2. Sitz bath 3. Antibiotics 4. Heating pad 5. Scrotal elevation 1, 2, 3, 5 Rationale: Common interventions used in the treatment of epididymitis include bed rest, elevation of the scrotum, ice packs, sitz baths, analgesics, and antibiotics. A heating pad should not be used because direct application of heat could increase blood flow to the area and increase the swelling.

护士正在照顾附睾炎的病人。应采用哪种治疗方式？选择所有符合条件的。 1.卧床休息 2.坐浴 3.抗生素 4.加热垫 5.阴囊抬高 1 2 3 5 理由：用于治疗附睾炎的常见干预措施包括卧床休息，阴囊升高，冰袋，sitz浴，止痛药和抗生素。不应使用加热垫，因为直接加热会增加流向该部位的血液并增加肿胀。

The nurse is monitoring a client who is taking propranolol. Which data collection finding would indicate a potential serious complication associated with propranolol? 1. The development of complaints of insomnia 2. The development of audible expiratory wheezes 3. A baseline resting heart rate of 88 beats/min followed by a resting heart rate of 72 beats/min after two doses of the medication 4. A baseline blood pressure of 150/80 mm Hg followed by a blood pressure of 138/72 mm Hg after two doses of the medication 2 Rationale: Audible expiratory wheezes may indicate a serious adverse reaction: bronchospasm. β-blockers may induce this reaction particularly in clients with chronic obstructive pulmonary disease or asthma. Normal decreases in blood pressure and heart rate are expected. Insomnia is a frequent mild side effect and should be monitored.

护士正在监视服用普萘洛尔的服务对象。哪个数据收集结果表明可能存在普萘洛尔潜在的严重并发症？ 1.失眠症的发展 2.可听见的呼气喘息的发展 3.服用两剂药物后的基线静息心率是88次/分钟，然后静息心率是72次/分钟 4.服用两剂药物后，基线血压为150/80 mm Hg，然后血压为138/72 mm Hg 2 理由：呼气可闻的喘息声可能表示严重的不良反应：支气管痉挛。 β受体阻滞剂可能会引起这种反应，特别是在患有慢性阻塞性肺疾病或哮喘的患者中。预期血压和心率会正常下降。失眠是一种常见的轻度副作用，应加以监测。

The nurse is planning to administer hydrochlorothiazide to a client. Which are concerns related to the administration of this medication? 1. Hypouricemia, hyperkalemia 2. Hypokalemia, hyperglycemia, sulfa allergy 3. Hypokalemia, increased risk of osteoporosis 4. Hyperkalemia, hypoglycemia, penicillin allergy 2 Rationale: Thiazide diuretics such as hydrochlorothiazide are sulfa-based medications, and a client with a sulfa allergy is at risk for an allergic reaction. Also, clients are at risk for hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia, and hyperuricemia.

护士正计划向委托人服用氢氯噻嗪。 与该药物的给药有关的问题有哪些？ 1.低钾血症，高钾血症 2.低钾血症，高血糖症，磺胺过敏 3.低钾血症，增加骨质疏松症的风险 4.高钾血症，低血糖，青霉素过敏 2 理由：噻嗪类利尿剂如氢氯噻嗪是基于磺胺类的药物，对磺胺类过敏的患者有发生过敏反应的风险。 此外，服务对象有低血钾，高血糖，高血钙，高血脂和高尿酸血症的风险。

The nurse is assigned to care for a client with a diagnosis of a detached retina. Which findings would indicate that bleeding has occurred as a result of retinal detachment? Select all that apply. 1. Total loss of vision 2. Vision may be cloudy 3. A reddened conjunctiva 4. A sudden sharp pain in the eye 5. Complaints of a burst of black spots or floaters 6. Vision is clear straight ahead but not to the right 2, 5 Rationale: Complaints of a sudden burst of black spots or floaters indicate that bleeding has occurred as a result of the detachment. Vision may also be cloudy.

护士被分配为诊断患有视网膜脱离的服务对象。哪些发现表明视网膜脱离导致出血？选择所有符合条件的。 1.完全丧失视力 2.视线可能多云 3.结膜变红 4.眼睛突然剧烈疼痛 5.出现黑点或浮标的投诉 6.愿景直截了当，但并不正确 2 5 理由：关于黑点或浮子突然爆炸的投诉表明，由于分离而发生了出血。视力也可能是阴天。 570.客户在车祸后到达急诊室。服务对象的额头碰到方向盘，并诊断出一种前房积血。护士应准备将其放置在哪个位置

Air Embolism in a Client Receiving Hemodialysis: 1. Stop hemodialysis. 2. Turn the client on the left side with the head down (Trendelenburg's). 3. Notify the registered nurse (RN) and primary health care provider (PHCP) and nephrologist. 4. Administer oxygen. 5. Check vital signs and pulse oximetry. 6. Document the event, actions taken, and the client's response. 7. Air embolism occurs when air enters the catheter system and is a complication of hemodialysis. The signs of air embolism include dyspnea, tachypnea, chest pain, hypotension, reduced oxygen saturation, cyanosis, anxiety, and any change in sensorium.

接受血液透析的患者中的空气栓塞： 1.停止血液透析。 2.头部向下（特伦德伦堡的），将客户转向左侧。 3.通知注册护士（RN），基层医疗服务提供者（PHCP）和肾科医生。 4.补充氧气。 5.检查生命体征和脉搏血氧饱和度。 6.记录事件，采取的措施以及客户的反应。 7.空气进入导管系统时会发生空气栓塞，是血液透析的并发症。空气栓塞的迹象包括呼吸困难，呼吸急促，胸痛，低血压，血氧饱和度降低，发，焦虑和感觉觉改变。

Client Education Regarding a Hearing Aid: 1. Begin using the hearing aid slowly to adjust to the device. 2. Adjust the volume to the minimal hearing level to prevent feedback squeaking. 3. Concentrate on the sounds that are to be heard and filter out background noise. 4. Clean the ear mold and cannula per manufacturer's instructions. 5. Keep the hearing aid dry. 6. Turn off the hearing aid before removing from the ear to prevent squealing feedback. 7. Remove the battery when not in use. 8. Keep extra batteries on hand. 9. Keep the hearing aid in a safe place. 10. Prevent hair sprays, oils, or other hair and face products from coming in contact with the receiver of the hearing aid. 11. Instruct the client to keep the hearing aid in the proper environmental climate, as recommended by the manufacturer, in order to prolong the life of the device.

有关助听器的客户教育： 1.慢慢开始使用助听器以适应设备。 2.将音量调节到最小的听觉水平，以防止产生反馈声。 3.专注于要听到的声音并滤除背景噪音。 4.按照制造商的说明清洁耳模和套管。 5.保持助听器干燥。 6.从耳朵上移开助听器之前，请先关闭助听器，以防止产生尖叫声。 7.不用时取出电池。 8.备有备用电池。 9.将助听器放在安全的地方。 10.防止发胶，油或其他头发和脸部产品与助听器的接收器接触。 11.指导客户按照制造商的建议将助听器放在适当的环境中，以延长设备的使用寿命。

A client sustains a contusion of the eyeball after a traumatic injury with a blunt object. The nurse should take which immediate action? 1. Apply ice to the affected eye. 2. Irrigate the eye with cool water. 3. Notify the primary health care provider (PHCP). 4. Accompany the client to the emergency department. 1 Rationale: Treatment for a contusion begins at the time of injury. Ice is applied immediately. The client should receive a thorough eye examination to rule out the presence of other eye injuries. Eye irrigation is not indicated in a contusion. Options 3 and 4 will delay immediate treatment. After the application of ice, the PHCP would be notified.

服务对象在用钝物造成外伤后维持眼球挫伤。护士应立即采取哪些行动？ 1.在受感染的眼睛上涂冰块。 2.用凉水冲洗眼睛。 3.通知初级卫生保健提供者（PHCP）。 4.陪伴客户到急诊室。 1个 理由：在受伤时开始治疗挫伤。立即加冰。服务对象应接受彻底的眼睛检查，以排除其他眼睛受伤的情况。挫伤时未进行眼冲洗。选项3和4将延迟立即治疗。结冰后，将通知PHCP。

The nurse who is administering bethanechol chloride is monitoring for acute toxicity associated with the medication. The nurse should check the client for which sign of toxicity? 1. Dry skin 2. Dry mouth 3. Bradycardia 4. Signs of dehydration 3 Rationale: Toxicity (overdose) produces manifestations of excessive muscarinic stimulation such as salivation, sweating, involuntary urination and defecation, bradycardia, and severe hypotension. Treatment includes supportive measures and the administration of atropine sulfate subcutaneously or intravenously.

服用乙酰氯的护士正在监测与药物有关的急性毒性。护士应检查服务对象有哪些中毒迹象？ 1.皮肤干燥 2.口干 3.心动过缓 4.脱水迹象 3 理由：毒性（过量）会产生毒蕈碱过多刺激的表现，例如流涎，出汗，不随意排尿和排便，心动过缓和严重低血压。治疗包括支持性措施以及皮下或静脉内给予硫酸阿托品。

Oxybutynin chloride is prescribed for a client with neurogenic bladder. Which sign would indicate a possible toxic effect related to this medication? 1. Pallor 2. Drowsiness 3. Bradycardia 4. Restlessness 4 Rationale: Toxicity (overdose) of this medication produces central nervous system excitation, such as nervousness, restlessness, hallucinations, and irritability. Other signs of toxicity include hypotension or hypertension, confusion, tachycardia, flushed or red face, and signs of respiratory depression. Drowsiness is a frequent side effect of the medication but does not indicate overdose.

氯化奥昔布宁用于患有神经源性膀胱的患者。哪个迹象表明该药物可能有毒性作用？ 1.苍白 2.睡意 3.心动过缓 4.躁动 4 理由：这种药物的毒性（过量）会引起中枢神经系统兴奋，例如神经质，躁动不安，幻觉和易怒。其他毒性迹象包括低血压或高血压，意识模糊，心动过速，脸红或发红，以及呼吸抑制的迹象。嗜睡是药物的常见副作用，但并不表示服用过量。

Homeostasis of water: 1. The antidiuretic hormone (ADH) is primarily responsible for the reabsorption of water by the kidneys. 2. ADH is produced by the hypothalamus and secreted from the posterior lobe of the pituitary gland. 3. Secretion of ADH is stimulated by dehydration or high sodium intake and by a decrease in blood volume. 4. ADH makes the DCTs and collecting duct permeable to water. 5. Water is drawn out of the tubules by osmosis and returns to the blood. Concentrated urine remains in the tubule to be excreted. 6. When ADH is lacking, the client develops diabetes insipidus (DI). 7. Clients with DI produce large amounts of dilute urine; treatment is necessary because the client cannot drink sufficient water to survive.

水的体内平衡： 1.抗利尿激素（ADH）主要负责肾脏对水的重吸收。 2. ADH由下丘脑产生，并从垂体后叶分泌。 3.脱水或高钠摄入以及血容量减少会刺激ADH的分泌。 4. ADH使DCT和收集管可以透水。 5.水通过渗透作用从小管中抽出并返回血液。 浓缩尿液残留在肾小管中以排出体外。 6.缺乏ADH时，服务对象会患上尿崩症（DI）。 7. DI病人产生大量稀尿； 治疗是必要的，因为服务对象不能喝足够的水来生存。

Legal blindness: 1. Description: The best visual acuity with corrective lenses in the better eye of 20/200 or less or the visual field is no greater than 20 degrees in its widest diameter in the better eye. 2. Interventions a) When speaking to the client who has limited sight or is blind, the nurse uses a normal tone of voice. b) Allow the client to touch objects in the room. f) Use the clock placement of foods on the meal tray to orient the client. g) Promote independence as much as possible. h) Provide radios, televisions, and clocks that give the time orally, or provide a Braille watch. i) When ambulating, allow the client to grasp the nurse's arm at the elbow. The nurse keeps his or her arm close to the body so that the client can detect the direction of movement.

法律失明： 1.说明：矫正眼镜的最佳视力在20/200或以下的最佳眼睛中，或者在最佳眼睛的最大直径范围内，视野不大于20度。 2.干预 a）当与视力不佳或失明的服务对象通话时，护士会使用正常的语调。 b）允许服务对象触摸房间内的物体。 f）使用时钟将食物放置在餐盘上，以调整服务对象的方向。 g）尽可能促进独立。 h）提供广播时间的收音机，电视和时钟，或提供盲文手表。 i）行走时，让服务对象抓住护士的胳膊肘。护士将他或她的手臂靠近身体，以便服务对象可以检测到运动的方向。

Trimethoprim-sulfamethoxazole is prescribed for a client. The nurse should instruct the client to report which symptom if it developed during the course of this medication therapy? 1. Nausea 2. Diarrhea 3. Headache 4. Sore throat 4 Rationale: Clients taking trimethoprim-sulfamethoxazole should be informed about early signs of blood disorders that can occur from this medication. These include sore throat, fever, and pallor, and the client should be instructed to notify the PHCP if these symptoms occur. The other options do not require PHCP notification.

甲氧苄啶-磺胺甲恶唑是为客户开处方的。护士应指示服务对象报告在此药物治疗过程中是否出现了哪种症状？ 1.恶心 2.腹泻 3.头痛 4.喉咙痛 4 理由：服用甲氧苄氨嘧啶磺胺甲基恶唑的客户应被告知这种药物可能引起的血液疾病的早期迹象。这些包括喉咙痛，发烧和面色苍白，如果出现这些症状，应指示服务对象告知PHCP。其他选项不需要PHCP通知。

A male client has a tentative diagnosis of urethritis. The nurse should assess the client for which manifestation of the disorder? 1. Hematuria and pyuria 2. Dysuria and proteinuria 3. Hematuria and urgency 4. Dysuria and penile discharge 4 Rationale: Urethritis in the male client often results from chlamydial infection and is characterized by dysuria, which is accompanied by a clear to mucopurulent discharge. Because this disorder often coexists with gonorrhea, diagnostic tests are done for both and include culture and rapid assays. Hematuria is not associated with urethritis. Proteinuria is associated with kidney dysfunction.

男性患者初步诊断为尿道炎。 护士应评估服务对象的哪种疾病表现？ 1.血尿和脓尿 2.排尿困难和蛋白尿 3.血尿和尿急 4.排尿困难和阴茎排出 4 理由：男性患者的尿道炎通常是由衣原体感染引起的，其特征是排尿困难，伴有明显的粘液尿排出。 由于这种疾病通常与淋病共存，因此对两者都进行了诊断测试，包括培养和快速检测。 血尿与尿道炎无关。 蛋白尿与肾功能不全有关。

Anatomy and Physiology of the Eye: A) Vitreous body 1. Contains a gelatinous substance that occupies the vitreous chamber, which is the space between the lens and the retina/ 2. The vitreous body transmits light and gives shape to the posterior eye. B) Vitreous 1. Gel-like substance that maintains the shape of the eye. 2. Provides additional physical support to the retina C) Rods and cones 1. Rods are responsible for peripheral vision and function at reduced levels of illumination. 2. Cones function at bright levels of illumination and are responsible for color vision and central vision.

眼睛的解剖和生理学： A）玻璃体 1.含有占据玻璃体腔的胶状物质，玻璃体腔是晶状体与视网膜/ 2.玻璃体透射光线并为后眼赋予形状。 B）玻璃体 1.保持形状的凝胶状物质 眼。 2.为视网膜提供额外的身体支撑 C）杆和锥 1.杆负责降低照明水平下的周边视觉和功能。 2.圆锥体在明亮的照明水平下起作用，并负责彩色视觉和中央视觉。

Cataracts: 1. Description: a) A cataract is an opacity of the lens that distorts the image projected onto the retina and that can progress to blindness. b) Causes include the aging process (senile cataracts), heredity (congenital cataracts), and injury (traumatic cataracts). Cataracts can also result from another eye disease (secondary cataracts). c) Causes of secondary cataracts include diabetes mellitus, maternal rubella, severe myopia, ultraviolet light exposure, and medications such as corticosteroids. d) Intervention is indicated when visual acuity has been reduced to a level that the client finds to be unacceptable or adversely affects lifestyle. 2. Data collection: a) Blurred vision and decreased color perception are early signs. b) Diplopia, reduced visual acuity, absence of the red reflex, and the presence of a white pupil are late signs. c) Pain or eye redness is associated with age-related cataract formation. d) Loss of vision is gradual.

白内障： 1.说明： a）白内障是晶状体的不透明性，会使投影到视网膜上的图像变形，并可能发展为失明。 b）原因包括衰老过程（老年性白内障），遗传（先天性白内障）和伤害（外伤性白内障）。白内障也可能由另一种眼疾（继发性白内障）引起。 c）继发性白内障的原因包括糖尿病，产妇风疹，严重的近视，紫外线照射以及皮质类固醇等药物。 d）当视力降低到服务对象认为不可接受或对生活方式造成不利影响的水平时，应进行干预。 2.数据收集： a）视力模糊和色觉下降是早期症状。 b）复视，视力下降，红色反射消失和白色瞳孔出现是晚期症状。 c）疼痛或眼睛发红与年龄相关的白内障形成有关。 d）视力丧失是逐渐的。

Phenazopyridine hydrochloride is prescribed for a client for symptomatic relief of pain resulting from a lower urinary tract infection. Which should the nurse reinforce to the client? 1. Take the medication at bedtime. 2. Take the medication before meals. 3. Discontinue the medication if a headache occurs. 4. A reddish-orange discoloration of the urine may occur. 4 Rationale: The nurse should instruct the client that a reddish-orange discoloration of urine may occur. The nurse also should instruct the client that this discoloration can stain fabric. The medication should be taken after meals to reduce the possibility of gastrointestinal upset. A headache is an occasional side effect of the medication and does not warrant discontinuation of the medication.

盐酸苯并吡啶被指定用于治疗对象，以减轻下尿路感染引起的疼痛。护士应该向服务对象加强什么？ 1.睡前服用药物。 2.饭前服药。 3.如果发生头痛，请中止用药。 4.尿液可能会发生红橙色的变色。 4 理由：护士应指示服务对象，尿液可能会发生红橙色的变色。护士还应指示服务对象该变色会弄脏织物。饭后应服用药物，以减少胃肠道不适的可能性。头痛是药物的偶发副作用，不能保证停药。

The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. The nurse should take which actions? Select all that apply. 1. Contact the nephrologist. 2. Check the level of the drainage bag. 3. Reposition the client to his or her side. 4. Place the client in good body alignment. 5. Check the peritoneal dialysis system for kinks. 6. Increase the flow rate of the peritoneal dialysis solution. 2, 3, 4, 5 Rationale: If outflow drainage is inadequate, the nurse attempts to stimulate outflow by changing the client's position. Turning the client to the other side or making sure that the client is in good body alignment may assist with outflow drainage. The drainage bag needs to be lower than the client's abdomen to enhance gravity drainage. The connecting tubing on the peritoneal dialysis system is also checked for kinks or twisting, and the clamps on the system are checked to ensure that they are open. There is no reason to contact the nephrologist. Increasing the flow rate is an inappropriate action and is unassociated with the amount of outflow solution.

监视接受腹膜透析的病人的护士注意到，病人的流出量少于流入量。护士应该采取哪些行动？选择所有符合条件的。 1.联系肾脏科医生。 2.检查排水袋的高度。 3.将客户重新安置在他或她的身边。 4.使服务对象保持良好的身体姿势。 5.检查腹膜透析系统是否有扭结。 6.增加腹膜透析液的流速。 2 3 4 5 理由：如果流出排水不充分，护士会尝试通过改变服务对象的位置来刺激流出。将服务对象转向另一侧或确保服务对象身体对准良好，可能有助于流出排水。引流袋的高度必须低于服务对象的腹部，以增强重力引流能力。还检查腹膜透析系统上的连接管是否扭结或扭曲，并检查系统上的夹子以确保其打开。没有理由联系肾脏科医生。增加流速是不适当的操作，并且与流出溶液的量无关。

Direct-Acting Arteriolar Vasodilators: 1. Direct-acting vasodilators relax the smooth muscles of the blood vessels, mainly the arteries, causing vasodilation; with vasodilation, the BP drops and sodium and water are retained, resulting in peripheral edema (diuretics may be given to decrease the edema). 2. Direct-acting vasodilators promote an increase in blood flow to the brain and kidneys. 3. These medications are used in the client with moderate to severe hypertension and for acute hypertensive emergencies.

直接作用的小动脉血管扩张剂： 1.直接作用的血管舒张剂使血管（主要是动脉）的平滑肌松弛，引起血管舒张； 血管舒张时，血压下降，钠和水被保留，导致周围水肿（利尿剂可减轻水肿）。 2.直接作用的血管扩张剂促进流向大脑和肾脏的血流量增加。 3.这些药物用于中度至重度高血压患者以及急性高血压紧急情况。

Layers of the eye: 1. External layer: a) The fibrous coat that supports the eye. b) Contains the sclera, an opaque white tissue; "the white of the eye". c) Contains the cornea, a dense transparent layer. 2. Middle layer: a) Called the uveal tract. b) Consists of the choroid, the ciliary body, and the iris. c) The choroid is the dark brown membrane located between the sclera and the retina that has dark pigmentation to prevent light from reflecting internally. d) The choroid lines most of the sclera and is attached to the retina but can detach easily from the sclera. e) The choroid contains many blood vessels and supplies nutrients to the retina. f) The ciliary body connects the choroid with the iris and secretes aqueous humor that helps give the eye its shape. The muscles of the ciliary body control the thickness of the lens. g) The iris is the colored portion of the eye, is located in front of the lens, and has a central circular opening called the pupil. The pupil controls the amount of light (darkness produces dilation and light produces constriction) admitted into the retina. 3. Internal layer a. Consists of the retina, a thin, delicate structure in which the fibers of the optic nerve are distributed b. The retina is bordered externally by the choroid and sclera and internally by the vitreous. c. The retina is the visual receptive layer of the eye in which light waves are changed into nerve impulses and contains blood vessels and photoreceptors called rods and cones.

眼睛的层次： 1.外层： a）支撑眼睛的纤维涂层。 b）含有巩膜，一种不透明的白色组织； "眼白"。 c）包含角膜，致密的透明层。 2.中间层： a）称为葡萄膜。 b）由脉络膜，睫状体和虹膜组成。 c）脉络膜是位于巩膜和视网膜之间的深棕色膜，具有深色的色素沉着以防止光在内部反射。 d）脉络膜位于巩膜的大部分区域，并附着在视网膜上，但很容易与巩膜分离。 e）脉络膜包含许多血管，并为视网膜提供营养。 f）睫状体将脉络膜与虹膜相连，并分泌房水，有助于使眼睛成形。睫状体的肌肉控制晶状体的厚度。 g）虹膜是眼睛的有色部分，位于晶状体的前面，并有一个称为瞳孔的中心圆形开口。瞳孔控制进入视网膜的光量（黑暗会产生扩张，光会产生收缩）。 3.内部层 a）由视网膜组成，视网膜是一种薄而细腻的结构，视神经纤维分布在其中 b）视网膜的外部是脉络膜和巩膜，玻璃体是内部。 c）视网膜是眼睛的视觉感受层，其中光波变成神经冲动，并包含血管和称为杆和锥的感光器。

Penetrating objects: 1. Description: An injury that occurs to the eye in which an object penetrates the eye 2. Interventions a) Never remove the object because it may be holding ocular structures in place. The object must be removed by the PHCP. b) Cover the object with a cup (paper or plastic) and tape in place. c) Do not allow the client to bend over or lie flat as these positions may move the object. d) Do not place pressure on the eye. e) The client must be seen by a PHCP immediately. f) X-rays and computed tomography (CT) scans of the orbit are usually performed. g) Magnetic resonance imaging (MRI) is contraindicated because of the possibility of metal-containing projectile movement during the procedure.

穿透对象： 1.描述：物体穿透眼睛对眼睛造成的伤害 2.干预 a）切勿移开物体，因为它可能会将眼部结构固定到位。 该对象必须由PHCP移除。 b）用杯子（纸或塑料）盖住物体，并用胶带粘好。 c）请勿让服务对象弯腰或平躺，因为这些位置可能会移动物体。 d）不要对眼睛施加压力。 e）PHCP必须立即与客户见面。 f）通常对轨道进行X射线和计算机断层扫描（CT）扫描。 g）磁共振成像（MRI）是禁忌的，因为在手术过程中可能会产生含金属的弹丸运动。

Presbycusis: 1. Description a) Presbycusis is a sensorineural hearing loss associated with aging. b) Presbycusis leads to degeneration or atrophy of the ganglion cells in the cochlea and a loss of elasticity of the basilar membranes. c) Presbycusis leads to compromise of the vascular supply to the inner ear with changes in several areas of the ear structure. 2. Data collection a) Hearing loss is gradual and bilateral. b) The client states that he or she has no problem with hearing but that they cannot understand what the words are. c) The client thinks that the speaker is mumbling. d) Reinforce instructions to the client that cotton-tipped applicators should not be used to dry ears because their use can lead to trauma to the canal and puncture the tympanic membrane.

老年性耳聋： 1.说明 a）老花眼是与衰老相关的感觉神经性听力损失。 b）老年性耳聋会导致耳蜗中神经节细胞的变性或萎缩，以及基底膜的弹性丧失。 c）老年性耳聋会导致耳朵结构的多个区域发生变化，从而损害内耳的血管供应。 2.数据收集 a）听力损失是逐渐的和双向的。 b）当事人说他或她的听力没有问题，但是他们听不懂这些词是什么。 c）客户认为说话者正在喃喃自语。 d）加强对客户的指示，不要使用带有棉签的涂抹器擦干耳朵，因为使用它们可能会导致耳道受伤并刺破鼓膜。

Cerumen and foreign bodies 1. Description: a) Cerumen or wax is the most common cause of impacted canals. b) Foreign bodies can include vegetables, beads, pencil erasers, insects, or other objects. 2. Data collection: a) Sensation of fullness in the ear with or without hearing loss b) Pain, itching, or bleeding 3. Cerumen: a) Removal of wax by irrigation may be a slow process. b) Irrigation is contraindicated in clients with a history of tympanic membrane perforation or otitis media. c) If prescribed to soften cerumen, glycerin or mineral oil is placed in the ear at bedtime; hydrogen peroxide may also be prescribed. d) After several days, the ear is irrigated. e) The maximal amount of solution that should be used for irrigation is 50 mL to 70 mL. f) Inform the client that ear candles should never be used to remove cerumen. Their use can cause burns and a vacuum effect causing a perforation in the tympanic membrane.

耳垢和异物 1.说明： a）陶瓷或蜡是影响运河的最常见原因。 b）异物可以包括蔬菜，珠子，橡皮，昆虫或其他物体。 2.数据收集： a）有或没有听力损失的耳朵饱满感 b）疼痛，瘙痒或出血 3.耵聍： a）通过灌溉去除蜡可能是一个缓慢的过程。 b）有鼓膜穿孔或中耳炎病史的患者禁忌灌溉。 c）如果规定要软化皮肤，可在睡前将甘油或矿物油放在耳朵里； 也可以规定过氧化氢。 d）几天后，对耳朵进行灌溉。 e）应用于灌溉的最大溶液量为50 mL至70 mL。 f）告知服务对象切勿使用耳烛来去除耳垢。 它们的使用会引起灼伤，并产生真空效应，从而导致鼓膜穿孔。

Anatomy and Physiology of the Ear : A) Functions 1. Hearing 2. Maintenance of balance B) External ear (pinna) 1. The external ear is embedded in the temporal bone bilaterally at the level of the eyes. 2. The external ear extends from the auricle through the external canal to the tympanic membrane or eardrum, and includes the mastoid process, which is the bony ridge located over the temporal bone. C) Middle ear 1. The middle ear consists of the medial side of the tympanic membrane. 2. The middle ear contains 3 bony ossicles. a) Malleus b) Incus c) Stapes 3. Functions of the middle ear a) Conduct sound vibrations from the outer ear to the central hearing apparatus in the inner ear b) Protect the inner ear by reducing the amplitude of loud sounds. c) The eustachian tube (auditory canal) allows equalization of air pressure on each side of the tympanic membrane so that the membrane does not rupture. D) Inner ear 1. The inner ear contains the semicircular canals, the cochlea, and the distal end of the eighth cranial nerve. 2. The semicircular canals contain fluid and hair cells connected to sensory nerve fibers of the vestibular portion of the eighth cranial nerve. 3. The inner ear maintains sense of balance or equilibrium. 4. The cochlea is the spiral-shaped organ of hearing. 5. The organ of Corti (within the cochlea) is the receptor and organ of hearing.

耳朵的解剖和生理学： A）功能 1.听证会 2.维持平衡 B）外耳（耳廓） 1.外耳在眼睛的水平两侧嵌入颞骨。 2.外耳从耳廓穿过外耳道延伸到鼓膜或鼓膜，并包括乳突，这是位于颞骨上的骨。 C）中耳 1.中耳由鼓膜的内侧组成。 2.中耳包含3个骨小骨。 a）马略斯 b）砧骨 c）钉 3.中耳的功能 a）将声音振动从外耳传导到内耳的中央听力设备 b）通过降低声音的振幅来保护内耳。 c）咽鼓管（听道）可均衡鼓膜两侧的气压，以使膜不会破裂。 D）内耳 1.内耳包含半圆管，耳蜗和第八个的远端 颅神经。 2.半圆形管包含与第八颅神经的前庭部分的感觉神经纤维相连的体液和毛细胞。 3.内耳保持平衡或平衡感。 4.耳蜗是螺旋形的听觉器官。 5. Corti的器官（在耳蜗内）是听觉的受体和器官。

Diagnostic Tests for the Ear: A) Tomography 1. Description: a) Tomography may be performed with or without contrast medium. b) Tomography assesses the mastoid, middle ear, and inner ear structures. c) Multiple radiographs of the head are obtained. d) Tomography is especially helpful in the diagnosis of acoustic tumors. 2. Interventions: a) All jewelry is removed. b) Lead eye shields are used to cover the cornea to diminish the radiation dose to the eyes. c) The client must remain still in a supine position. d) No follow-up care is required. e) If contrast is to be used, assess for allergies or previous response to contrast.

耳朵的诊断测试： A）断层扫描 1.说明： a）断层扫描可以在有或没有造影剂的情况下进行。 b）断层扫描评估乳突，中耳和内耳的结构。 c）获得头部的多个射线照片。 d）断层扫描对声学肿瘤的诊断特别有帮助。 2.干预措施： a）所有珠宝都被移走。 b）铅眼罩用于覆盖角膜以减少对眼睛的辐射剂量。 c）服务对象必须保持仰卧姿势。 d）不需要后续护理。 e）如果要使用对比，请评估过敏或以前对对比的反应。

Cochlear implantation: 1. Cochlear implants are used for sensorineural hearing loss. 2. A small computer converts sound waves into electrical impulses. 3. Electrodes are placed by the internal ear with a computer device attached to the external ear. 4. Electronic impulses directly stimulate nerve fibers. Hearing aids: 1. Hearing aids are used for the client with conductive hearing loss. 2. Hearing aids have limited value for the client with sensorineural hearing loss because they only make sounds louder and not clearer. 3. A difficulty that exists in the use of hearing aids is the amplification of background noise and voices. 4. Hearing aids are costly and often not covered by insurance. Some clients can obtain hearing aids through a rehabilitation facility or through other resources.

耳蜗植入： 1.人工耳蜗用于感觉神经性听力损失。 2.小型计算机将声波转换为电脉冲。 3.电极由内耳放置，并将计算机设备连接到外耳。 4.电子脉冲直接刺激神经纤维。 助听器： 1.助听器用于患有传导性听力损失的客户。 2.助听器对于感觉神经性听力损失的服务对象的价值有限，因为它们只会使声音变大而不清晰。 3.使用助听器存在的困难是背景噪音和声音的放大。 4.助听器价格昂贵，通常不在保险范围内。 一些客户可以通过康复设施或其他资源获得助听器。

Heparin sodium is prescribed for the client. Which laboratory result indicates that the heparin is prescribed at a therapeutic level? 1. Thrombocyte count of 100,000 mm3 2. Prothrombin time (PT) of 21 seconds 3. International normalized ratio (INR) of 2.3 4. Activated partial thromboplastin time (aPTT) of 55 seconds 4 Rationale: The aPTT will assess the therapeutic effect of heparin sodium. The normal aPTT is 30 to 40 sec. To maintain a therapeutic level, the aPTT should be 1.5 to 2.5 times the normal value. The PT and INR will assess for the therapeutic effect of warfarin sodium. A decreased thrombocyte count can cause bleeding.

肝素钠为客户开处方。哪个实验室结果表明以治疗水平开具了肝素处方？ 1.血小板计数为100,000 mm3 2.凝血酶原时间（PT）为21秒 3.国际标准化比率（INR）为2.3 4.激活的部分凝血活酶时间（aPTT）为55秒 4 理由：aPTT将评估肝素钠的治疗效果。正常的aPTT为30到40秒。为了维持治疗水平，aPTT应该为正常值的1.5到2.5倍。 PT和INR将评估华法林钠的治疗效果。血小板计数减少会导致出血。

Heparin sodium: 1. Description a) Heparin prevents thrombin from converting fibrinogen to fibrin. b) Heparin prevents thromboembolism. c) The therapeutic dose does not dissolve clots but prevents new thrombus formation. 2. Blood levels a) The normal activated partial thromboplastin time (aPTT) is 30 to 40 seconds (conventional and SI units) in most laboratories (values depend on reagent and instrumentation used). b) To maintain a therapeutic level of anticoagulation when the client is receiving a continuous infusion of heparin, the aPTT should be 1.5 to 2.5 times the normal value. Some agencies use 2 different protocols, such as a low-intensity protocol for acute coronary situation, and a low-intensity protocol for venous thromboembolism, and the dosages and recommended aPTT ranges are slightly different for the different protocols. c) Activated partial thromboplastin time therapy should be measured every 4 to 6 hours during initial continuous infusion therapy and then daily per agency policy. d) If the aPTT is too long, (level based on agency protocol), the dosage should be lowered. e) If aPTT is too short, (level based on agency protocol), the dosage should be increased. 3. Interventions a) Monitor aPTT. b) Monitor platelet count. c) Observe for bleeding gums, bruises, nosebleeds, hematuria, hematemesis, occult blood in the stool, and petechiae. d) When heparin is administered subcutaneously, it is injected into the abdomen with a 5⁄8- inch (16 mm) needle (25-28 gauge) at a 90-degree angle; the injection site should not be aspirated or rubbed. e) Continuous infusions must be delivered through an infusion pump and the infusion pump should be preprogrammed to ensure a precise rate of delivery.

肝素钠： 1.说明 a）肝素可防止凝血酶将纤维蛋白原转化为纤维蛋白。 b）肝素可预防血栓栓塞。 c）治疗剂量不能溶解血凝块，但可以防止新的血栓形成。 2.血液水平 a）在大多数实验室中，正常的活化部分凝血活酶时间（aPTT）为30到40秒（常规和SI单位）（值取决于所用试剂和仪器）。 b）为了在患者连续输注肝素时保持治疗性抗凝水平，aPTT应为正常值的1.5至2.5倍。一些机构使用2种不同的方案，例如针对急性冠脉情况的低强度方案和针对静脉血栓栓塞的低强度方案，并且针对不同方案，剂量和推荐的aPTT范围略有不同。 c）在初始连续输注治疗期间，应每4至6小时测量一次活化的部分凝血活酶时间疗法，然后根据代理商政策每天进行一次测量。 d）如果aPTT太长（根据代理协议的水平），则应降低剂量。 e）如果aPTT太短（根据代理协议的水平），则应增加剂量。 3.干预 a）监视aPTT。 b）监测血小板计数。 c）观察牙龈，瘀伤，流鼻血，血尿，呕血，大便隐血和瘀点是否出血。 d）皮下注射肝素时，用5⁄8英寸（16毫米）针头（25-28号）以90度角将其注射到腹部；不得抽吸或摩擦注射部位。 e）连续输液必须通过输液泵进行，并且应对输液泵进行预编程以确保精确的输液速度。

Hydronephrosis: A) Description 1. The distention of the renal pelvis and calices caused by an obstruction of normal urine flow 2. The urine becomes trapped proximal to the obstruction. 3. The causes include calculus, a tumor, scar tissue, ureter obstruction, and hypertrophy of the prostate. B) Data collection 1. Hypertension 2. Headache 3. Colicky or dull flank pain that radiates to the groin C. Interventions 1. Monitor vital signs frequently. 2. Monitor for fluid and electrolyte imbalances, including dehydration after the obstruction is relieved. 3. Monitor for diuresis, which can lead to fluid depletion. 4. Monitor weight daily. 5. Monitor urine for specific gravity, albumin, and glucose levels. 6. Assist with the administration of fluid replacement as prescribed. 7. Assist with preparing the client for insertion of a nephrostomy tube or a surgical procedure to relieve the obstruction if prescribed.

肾积水： 说明 1.正常尿流阻塞引起的肾盂和肾盂扩张 2.尿液被阻塞处阻塞。 3.原因包括结石，肿瘤，疤痕组织，输尿管阻塞和前列腺肥大。 B）数据收集 1.高血压 2.头痛 3.放射到腹股沟的腹痛或钝痛 C.干预 1.经常监测生命体征。 2.监测液体和电解质的不平衡情况，包括阻塞解除后的脱水情况。 3.监测利尿情况，这可能导致液体消耗。 4.每天监控体重。 5.监测尿液的比重，白蛋白和葡萄糖水平。 6.协助按规定进行补液管理。 7.协助服务对象准备插入肾造口术管或进行手术以减轻阻塞（如果有规定）。

Treatment Options for Renal Calculi: A) Cystoscopy: 1. Cystoscopy may be done for stones located in the bladder or lower ureter. 2. No incision is made. 3. One or two ureteral catheters are inserted past the stone. 4. The catheters are left in place for 24 hours to drain the urine trapped proximal to the stone and to dilate the ureter. 5. A continuous chemical irrigation may be prescribed to dissolve the stone. B) Extracorporeal shock wave lithotripsy (ESWL) 1. A noninvasive mechanical procedure for breaking up stones located in the kidney or upper ureter so that they can pass spontaneously or be removed by other methods 2. No incision is made and no drains are placed. A stent may be placed to facilitate passing stone fragments. 3. Fluoroscopy is used to visualize the stone and ultrasonic waves are delivered to the areas of the stone to disintegrate it. 4. The stones are passed in the urine within a few days. 5. The client is taught to watch for signs of urinary obstruction, bleeding, or hematoma formation.

肾结石的治疗选择： A）膀胱镜检查： 1.膀胱镜检查可用于膀胱或下输尿管中的结石。 2.不做切口。 3.将一或两个输尿管导管插入结​​石旁。 4.将导管留在原处24小时，以排出结石附近捕获的尿液并扩张输尿管。 5.可以要求进行连续化学冲洗以溶解石头。 B）体外冲击波碎石术（ESWL） 1.破坏位于肾脏或输尿管上的结石的一种非侵入性机械方法，使结石可以自发通过或通过其他方法清除 2.不做切口，也不放置引流管。可以放置支架以利于石头碎片的通过。 3.荧光检查法用于观察结石，并将超声波传送到 用石头将其分解。 4.结石会在几天内进入尿液。 5.指导服务对象注意尿路阻塞，出血或血肿的迹象 编队。

Following kidney transplantation, cyclosporine is prescribed for a client. Which laboratory result would indicate an adverse effect from the use of this medication? 1. Hemoglobin level of 14.0 g/dL (140 g/L) 2. Creatinine level of 0.6 mg/dL (53 mcmol/L) 3. Blood urea nitrogen level of 25 mg/dL (8.8 mmol/L) 4. Fasting blood glucose level of 99 mg/dL (5.5 mmol/L) 3 Rationale: Cyclosporine is an immunosuppressant. Nephrotoxicity can occur from the use of cyclosporine. Nephrotoxicity is evaluated by monitoring for elevated blood urea nitrogen and serum creatinine levels. The normal blood urea nitrogen level is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). The normal creatinine level for a male is 0.6 to 1.2 mg/dL (53 to 106 mcmol/L) and for a female 0.5 tō.1 mg/dL (44 to 97 mcmol/L). Cyclosporine can lower complete blood cell count levels. A normal hemoglobin is Male: 14 to 18 g/dL (140 to 180 mmol/L); Female: 12 to 16 g/dL (120 to 160 mmol/L). A normal hemoglobin is not an adverse effect. Cyclosporine does affect the glucose level. The normal fasting glucose is 70 to 110 mg/dL (4 to 6 mmol/L).

肾脏移植后，为客户开具环孢霉素。哪个实验室结果表明使用这种药物会有不良影响？ 1.血红蛋白水平为14.0 g / dL（140 g / L） 2.肌酐水平为0.6 mg / dL（53 mcmol / L） 3.血液尿素氮含量为25 mg / dL（8.8 mmol / L） 4.空腹血糖水平为99 mg / dL（5.5 mmol / L） 3 理由：环孢菌素是一种免疫抑制剂。使用环孢菌素会产生肾毒性。通过监测血液尿素氮和血清肌酐水平的升高来评估肾毒性。正常的血液尿素氮水平为10至20 mg / dL（3.6至7.1 mmol / L）。男性的正常肌酐水平为0.6至1.2 mg / dL（53至106 mcmol / L），女性为0.5至1.1 mg / dL（44至97 mcmol / L）。环孢霉素可降低全血细胞计数水平。正常的血红蛋白是男性：14至18 g / dL（140至180 mmol / L）；女：12至16 g / dL（120至160 mmol / L）。正常的血红蛋白不是副作用。环孢菌素确实会影响葡萄糖水平。正常的空腹血糖为70至110 mg / dL（4至6 mmol / L）。

Benign Prostatic Hypertrophy (Hyperplasia): A) Description 1. Benign prostatic hypertrophy (benign prostatic hyperplasia; BPH) is a slow enlargement of the prostate gland with hypertrophy and hyperplasia of normal tissue. 2. Enlargement compresses the urethra resulting in partial or complete obstruction. 3. Usually occurs in men older than 50 years B) Data collection 1. Diminished size and force of urinary stream (an early sign of BPH) 2. Urinary urgency and frequency 3. Nocturia 4. Inability to start (hesitancy) or continue a urinary stream 5. Feelings of incomplete bladder emptying 6. Postvoid dribbling from overflow incontinence (later sign) 7. Urinary retention and bladder distention 8. Hematuria 9. Urinary stasis and UTIs 10. Dysuria and bladder pain C) Interventions 1. Encourage fluid intake of up to 2000 mL/day to 3000 mL/day unless contraindicated. 2. Prepare for urinary catheterization to drain the bladder and prevent distention. 3. Avoid administering medications that cause urinary retention, such as anticholinergics, antihistamines, decongestants, and antidepressants. 4. Assist with the administration of medications, as prescribed, to shrink the prostate gland and improve urine flow. 5. Assist with the administration of medications, as prescribed, to relax prostatic smooth muscle and improve urine flow. 6. Reinforce instructions to the client to decrease the intake of caffeine and artificial sweeteners and limit spicy or acidic foods.

良性前列腺肥大（增生）： 说明 1.前列腺增生症（BPH）是前列腺增生缓慢并伴正常组织增生的一种缓慢增生。 2.肿大会压迫尿道，导致部分或完全阻塞。 3.通常发生在50岁以上的男性中 B）数据收集 1.尿流的大小和力量减小（BPH的早期迹象） 2.尿急和尿频 3.夜尿症 4.无法开始（保持性）或继续排尿 5.膀胱排空不完全的感觉 6.避免因溢尿失禁而盘带（后征） 7.尿retention留和膀胱bladder肿 8.血尿 9.尿瘀和尿路感染 10.排尿困难和膀胱疼痛 C）干预 1.除非有禁忌症，否则鼓励每天摄入高达2000 mL /天至3000 mL /天的液体。 2.为导尿做好准备，以排干膀胱并防止膨胀。 3.避免服用引起尿retention留的药物，例如抗胆碱能药，抗组胺药，减充血药和抗抑郁药。 4.按照规定协助药物治疗，以缩小前列腺并改善尿流。 5.按照规定协助药物治疗，以放松前列腺平滑肌并改善尿流。 6.加强对客户的指示，以减少咖啡因和人造甜味剂的摄入，并限制辛辣或酸性食物。

Hemodialysis: A) Description 1. Hemodialysis is an intermittent renal replacement therapy involving the process of cleansing the client's blood. 2. It involves the diffusion of dissolved particles from one fluid compartment into another across a semipermeable membrane. The client's blood flows through one fluid compartment of a dialysis filter, and the dialysate is in another fluid compartment. B) Functions of hemodialysis 1. Cleanses the blood of accumulated waste products 2. Removes the byproducts of protein metabolism such as urea, creatinine, and uric acid from the blood 3. Removes excess body fluids 4. Maintains or restores the buffer system of the body 5. Maintains or restores electrolyte levels in the body

血液透析： 说明 1.血液透析是一种间断性肾脏替代疗法，涉及到清洁服务对象血液的过程。 2.它涉及溶解的颗粒从一个流体隔室到半透膜的扩散。服务对象的血液流过透析过滤器的一个液体隔室，而透析液在另一个液体隔室中。 B）血液透析的功能 1.清除血液中累积的废物 2.从血液中去除蛋白质代谢的副产物，例如尿素，肌酐和尿酸 3.清除多余的体液 4.维持或恢复身体的缓冲系统 5.维持或恢复体内电解质水平

Angiotensin-Converting Enzyme (ACE) Inhibitors and Angiotensin II Receptor Blockers (ARBs): 1. ACE inhibitors prevent peripheral vasoconstriction by blocking the conversion of angiotensin I to angiotensin II (AII). 2. ARBs prevent peripheral vasoconstriction and secretion of aldosterone and block the binding of AII to type 1 AII receptors. 3. These medications are used to treat hypertension and heart failure. ACE inhibitors are also administered for their cardioprotective effect after myocardial infarction. 4. Use with potassium supplements and potassium-retaining diuretics is avoided.

血管紧张素转换酶（ACE）抑制剂和血管紧张素II受体阻滞剂（ARB）： 1. ACE抑制剂可通过阻止血管紧张素I向血管紧张素II（AII）的转化来防止外周血管收缩。 2. ARB阻止外周血管收缩和醛固酮的分泌，并阻止AII与1型AII受体的结合。 3.这些药物用于治疗高血压和心力衰竭。 ACE抑制剂还因心肌梗塞后的心脏保护作用而给药。 4.避免与补钾剂和保钾利尿剂一起使用。

Retinal detachment: 1. Description a) Detachment or separation of the retina from the epithelium. b) Retinal detachment occurs when the layers of the retina separate because of the accumulation of fluid between them or when both retinal layers elevate away from the choroid as a result of a tumor. c) Partial detachment becomes complete if untreated. d) When detachment becomes complete, blindness occurs. 2. Data collection a) Flashes of light b) Floaters or black spots (signs of bleeding) c) Increase in blurred vision d) Sense of a curtain being drawn over the eye e) Loss of a portion of the visual field; painless loss of central or peripheral vision. 3. Immediate interventions: a) Provide bed rest. b) Cover both eyes with patches, as prescribed, to prevent further detachment. c) Speak to the client before approaching. d) Position the client's head as prescribed. e) Protect the client from injury. f) Avoid jerky head movements. g) Minimize eye stress. h) Assist to prepare the client for a surgical procedure as prescribed.

视网膜脱离： 1.说明 a）视网膜与上皮的分离或分离。 b）当视网膜层由于它们之间的积聚而分离时，或者当两个视网膜层由于肿瘤而从脉络膜抬高时，就会发生视网膜脱离。 c）如果不治疗，部分脱离会完全。 d）脱离完成后，就会发生失明。 2.数据收集 a）闪光 b）漂浮物或黑点（出血迹象） c）视物模糊 d）眼帘被拉到眼睛上的感觉 e）视野的一部分丧失；无痛的中央或周围视力丧失。 3.立即干预： a）提供卧床休息。 b）按规定用补丁遮盖两只眼睛，以防止进一步脱离。 c）在接近之前与客户交谈。 d）按照规定放置服务对象的头部。 e）保护服务对象免受伤害。 f）避免头部晃动。 g）最小化眼睛压力。 h）协助客户按照规定进行外科手术。

After a renal biopsy, the client complains of pain at the biopsy site that radiates to the front of the abdomen. Which would this indicate? 1. Bleeding 2. Infection 3. Renal colic 4. Normal, expected pain 1 Rationale: If pain originates at the biopsy site and begins to radiate to the flank area and around the front of the abdomen, bleeding should be suspected. Hypotension, a decreasing hematocrit, and gross or microscopic hematuria should also indicate bleeding. Signs of infection should not appear immediately after a biopsy. Pain of this nature is not normal. There are no data to support the presence of renal colic.

进行肾脏活检后，服务对象抱怨放射至腹部前部的活检部位疼痛。这表示什么？ 1.出血 2.感染 3.肾绞痛 4.正常的预期疼痛 1个 理由：如果疼痛起源于活检部位并开始辐射到腹侧面和腹部前部，则应怀疑出血。低血压，血细胞比容下降以及肉眼或镜下血尿也应指示出血。活检后不应立即出现感染迹象。这种性质的疼痛是不正常的。没有数据支持肾绞痛的存在。

Homeostasis of acidity (pH) 2193 1. Blood pH is controlled by maintaining the concentration of buffer systems. 2. Carbonic acid and sodium bicarbonate form the most important buffers for neutralizing acids in the plasma. 3. The concentration of carbonic acid is controlled by the respiratory system. 4. The concentration of sodium bicarbonate is controlled by the kidneys. 5. Normal arterial pH is 7.35 to 7.45, maintained by keeping the ratio of concentrations of sodium bicarbonate to carbon dioxide constant at 20:1. 6. Strong acids are neutralized by sodium bicarbonate to produce carbonic acid and the sodium salts of the strong acid; this process quickly restores the ratio and thus blood pH. 7. The carbonic acid dissociates into carbon dioxide and water; because the concentration of carbon dioxide is maintained at a constant level by the respiratory system, the excess carbonic acid is rapidly excreted. 8. Sodium combined with the strong acid is actively reabsorbed in the DCTs in exchange for hydrogen or potassium ions. The strong acid is neutralized by ammonia and excreted as ammonia or potassium salts.

酸度（pH）的稳态 1.通过维持缓冲液系统的浓度来控制血液的pH值。 2.碳酸和碳酸氢钠是中和血浆中酸的最重要的缓冲剂。 3.碳酸的浓度由呼吸系统控制。 4.碳酸氢钠的浓度由肾脏控制。 5.通过保持碳酸氢钠与二氧化碳的浓度比恒定在20：1来维持正常动脉的pH为7.35至7.45。 6.用碳酸氢钠中和强酸，生成碳酸和强酸的钠盐；这个过程很快恢复了比例，从而恢复了血液的pH值。 7.碳酸分解成二氧化碳和水；因为通过呼吸系统将二氧化碳的浓度保持在恒定水平，所以过量的碳酸会迅速排出。 8.与强酸结合的钠会在DCT中重新吸收，以交换氢或钾离子。强酸被氨中和，并以氨或钾盐的形式排出。

Calcium Channel Blockers: 1. Calcium channel blockers decrease cardiac contractility (negative inotropic effect by relaxing smooth muscle) and the workload of the heart thus decreasing the need for oxygen. 2. Calcium channel blockers promote vasodilation of the coronary and peripheral vessels. 3. Used for angina, dysrhythmia, or hypertension 4. Should be used with caution in the client with heart failure, bradycardia, or atrioventricular block.

钙通道阻滞剂： 1.钙通道阻滞剂可减少心脏 收缩力（放松平滑肌产生负性肌力作用）和心脏的工作量，从而减少了对氧气的需求。 2.钙通道阻滞剂促进冠状动脉和周围血管的血管舒张。 3.用于心绞痛，心律不齐或高血压。4.对于有心力衰竭，心动过缓或房室传导阻滞的患者，应谨慎使用。

Antihypertensive Medications: Diuretics A) Thiazide diuretics: 1. Description a) Thiazide diuretics increase sodium and water excretion by inhibiting sodium reabsorption in the distal tubule of the kidney. b) Used for hypertension and peripheral edema c) Not effective for immediate diuresis d) Used in clients with normal renal function (contraindicated in clients with renal failure) e) Thiazide diuretics should be used with caution in the client taking lithium because lithium toxicity can occur in the client taking digoxin, corticosteroids, or hypoglycemic medications.

降压药：利尿剂 A）噻嗪类利尿剂： 1.说明 a）噻嗪类利尿剂通过抑制肾脏远端小管中钠的重吸收而增加钠和水的排泄。 b）用于高血压和周围水肿 c）对立即利尿无效 d）用于肾功能正常的患者（禁忌于肾功能衰竭的患者） e）服用锂的患者应谨慎使用噻嗪类利尿剂，因为服用地高辛，糖皮质激素或降糖药的患者可能会发生锂中毒。

Glaucoma: 1. Description a) A group of ocular diseases resulting in increased IOP. b) Intraocular pressure is the fluid (aqueous humor) pressure within the eye. (Normal intraocular pressure is 10-21 mm Hg.) c) Increased IOP results from inadequate drainage of aqueous humor from the canal of Schlemm or overproduction of aqueous humor. d) The condition damages the optic nerve and can result in 2. Types a) Primary open-angle glaucoma (POAG) results from obstruction to outflow of aqueous humor, and is the most common type. b) Primary angle-closure glaucoma (PACG) results from blocking the outflow of aqueous humor into the trabecular meshwork; causes include lens or pupil dilation from medications or sympathetic stimulation.

青光眼： 1.说明 a）导致IOP增加的一组眼部疾病。 b）眼内压是指眼内的液体（房水）压力。 （正常眼压为10-21毫米汞柱。） c）IOP增加是由于Schlemm管的房水排出不足或房水生产过剩所致。 d）疾病损害视神经并可能导致 2.类型 a）原发性开角型青光眼（POAG）由房水阻塞至流出引起，是最常见的类型。 b）原发性闭角型青光眼（PACG）是由于房水流出到小梁网中而引起的；原因包括药物或交感神经刺激引起的晶状体或瞳孔散大。

Teaching for Prevention of Cystitis: 1. Use good perineal care, wiping front to back. 2. Avoid bubble baths, tub baths, and vaginal deodorants or sprays. 3. Void every 2 to 3 hours. 4. Wear cotton pants and avoid wearing tight clothes or pantyhose with slacks. 5. Avoid sitting in a wet bathing suit for prolonged periods. 6. If pregnant, void every 2 hours. 7. If menopausal, use estrogen vaginal creams to restore pH. 8. Use water-soluble lubricants for intercourse, especially after menopause. 9. Void and drink a glass of water after intercourse.

预防膀胱炎的教学： 1.使用会阴部护理，前后擦拭。 2.避免使用泡泡浴，浴缸浴和阴道除臭剂或喷雾剂。 3.每2至3个小时无效一次。 4.穿棉质裤子，避免穿宽松的衣服或连裤袜。 5.避免长时间坐在湿泳衣中。 6.如果怀孕，则每2小时排空一次。 7.如果更年期，使用雌激素阴道霜恢复pH值。 8.使用水溶性润滑剂进行性交，尤其是在更年期之后。 9.性交后虚脱并喝一杯水。