Nursing Process Exam Questions

Nursing Process Exam Questions Related

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The nurse has been asked to prepare an intervention plan for a client, age 70, admitted for treatment of renal calculi. He complains of frequent pain due to increased pressure in the renal pelvis and is frightened of the excruciating pain. Which of the ff measures can the nurse include in the client’s nursing care plan? Choose all that apply

  • A. Administer prescribed nephrotoxic drugs
  • B. Encourage ambulation and liberal fluid
  • C. Observe aseptic principles when changing intake
  • D. Provide a comfortable position
Correct Answer: B

Rationale: The correct answer is B: Encourage ambulation and liberal fluid. Encouraging ambulation can help in the movement of kidney stones and alleviate pain. Liberal fluid intake helps in flushing out kidney stones and preventing further stone formation.

Incorrect options:
A: Administering prescribed nephrotoxic drugs can worsen kidney function and exacerbate the pain.
C: Observing aseptic principles when changing intake is important for infection prevention but not directly related to pain management for renal calculi.
D: Providing a comfortable position can offer temporary relief but does not address the underlying cause of kidney stone pain.

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For a patient who is being discharged on digoxin, the nurse should include which of the ff. in an explanation to the patient on the signs and symptoms of digoxin toxicity?

  • A. Poor appetite
  • B. Halos around lights
  • C. Constipation
  • D. Tachycardia
Correct Answer: B

Rationale: The correct answer is B: Halos around lights. Digoxin toxicity can cause visual disturbances like seeing halos around lights, which is a common symptom. This is due to its effect on the eyes. Poor appetite (choice A) is a common side effect but not specific to toxicity. Constipation (choice C) is not a typical sign of digoxin toxicity. Tachycardia (choice D) is more commonly associated with digoxin toxicity, but visual disturbances like halos around lights are more specific and should be explained to the patient.

The patient asks the nurse, “What is hypertension?” Which of the following is the best response to explain hypertension?

  • A. “It is measured as the heart pumps blood into the arteries.”
  • B. “It is higher than normal on two separate occasions.”
  • C. “It is regulated by stress, activity, and emotions.”
  • D. “It is determined by peripheral vascular resistance.”
Correct Answer: D

Rationale: The correct answer is D because hypertension is primarily determined by peripheral vascular resistance, which refers to the resistance in the blood vessels that the heart must overcome to pump blood effectively. This is a key factor in the development of high blood pressure. Choice A is incorrect as it simplifies the concept to just the pumping action of the heart. Choice B is incorrect because hypertension is not just about having high readings on separate occasions but rather a sustained elevation in blood pressure. Choice C is incorrect as stress, activity, and emotions can influence blood pressure but are not the sole determinants of hypertension.

An adult has a Hickman type central venous catheter and needs to have blood drawn from it. Which of the following should the nurse do first?

  • A. Use sterile technique to assemble supplies needed
  • B. Aspirate and discard the first 10 ml of the blood
  • C. First flush the catheter with heparinized solution, then withdraw the blood
  • D. Remove the cap of the catheter and replace it with a new one
Correct Answer: C

Rationale: The correct answer is C because flushing the central venous catheter with a heparinized solution before blood withdrawal is essential to maintain catheter patency and prevent clot formation. This step ensures the catheter is clear of any blockages, allowing for accurate blood sampling. Choice A is incorrect because assembling supplies should come after preparing the catheter. Choice B is incorrect as discarding blood before flushing the catheter may lead to inaccurate test results. Choice D is incorrect as replacing the catheter cap without flushing may lead to clot formation and catheter malfunction.

A 19 y.o. student develops trigeminal neuralgia. Which of the ff. actions will most likely aggravate her pain?

  • A. Sleeping
  • B. Reading
  • C. Eating
  • D. Cooking
Correct Answer: C

Rationale: The correct answer is C: Eating. Chewing food can trigger trigeminal nerve pain due to the movement and pressure applied on the nerve. The other choices (A: Sleeping, B: Reading, D: Cooking) do not involve the same level of jaw movement and pressure on the trigeminal nerve, thus are less likely to aggravate the pain. Therefore, eating is the most likely action to worsen trigeminal neuralgia symptoms in this scenario.

A nursing assessment for a patient with a spinal cord injury leads to several pertinent nursing diagnoses. Which nursing diagnosis is the highest priority for this patient?

  • A. Risk for impaired skin integrity
  • B. Risk for infection
  • C. Spiritual distress
  • D. Reflex urinary incontinence
Correct Answer: A

Rationale: The correct answer is A: Risk for impaired skin integrity. This is the highest priority as patients with spinal cord injuries are at high risk for pressure ulcers due to immobility. Preventing skin breakdown is crucial to avoid complications. Choices B, C, and D are not as urgent. Choice B may be a concern but preventing skin breakdown takes precedence. Choices C and D are important but not life-threatening like potential skin issues in this patient population.

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