Nursing Process Questions and Answers PDF

Nursing Process Questions and Answers PDF Related

Review Nursing Process Questions and Answers PDF related questions and content

A 62-year old client diagnosed with pyelonephritis and possible septicemia has had five urinary tract infections over the past 2 years. She’s fatigued from lack of sleep; urinates frequently, even during the night, and has lost weight recently. Tests reveal the following: sodium level 152mEq/L, osmolarity 340mOsm/L, glucose level 125mg/dl, and potassium level of 3.8mEq/L. Which of the following nursing diagnoses is most appropriate for this client?

  • A. Deficient fluid volume related to inability to conserve water
  • B. Imbalanced nutrition: Less than body requirements related to hypermetabolic state
  • C. Deficient fluid volume related to osmotic diuresis induced by hypernatremia
  • D. Imbalanced nutrition: Less than body requirements related to catabolic effects of insulin deficiency
Correct Answer: C

Rationale: The most appropriate nursing diagnosis for this client is C: Deficient fluid volume related to osmotic diuresis induced by hypernatremia. The client's elevated sodium level of 152mEq/L indicates hypernatremia, which leads to osmotic diuresis and subsequent fluid loss. This results in deficient fluid volume, causing the client to urinate frequently and experience fatigue from lack of sleep. The other choices are incorrect because:

A: Deficient fluid volume related to inability to conserve water is not the most appropriate diagnosis as the primary issue is the osmotic diuresis induced by hypernatremia, not the client's inability to conserve water.

B: Imbalanced nutrition: Less than body requirements related to hypermetabolic state is not the most appropriate diagnosis as the client's weight loss is likely due to fluid loss from osmotic diuresis, not a hypermetabolic state.

D: Imbalanced nutrition: Less than body requirements related to catab

You may also like to solve these questions

Which of the ff would help a client with an allergic skin reaction to reduce itching and maintain skin intact? Choose all that apply

  • A. Humidifying the environment
  • B. Avoiding a skin lubricant
  • C. Bathing with a bar soap that contains lye
  • D. Wearing cotton gloves, esp during sleep
Correct Answer: D

Rationale: The correct answer is D. Wearing cotton gloves, especially during sleep, helps reduce itching by preventing scratching, which can further irritate the skin. Cotton is a breathable fabric that reduces friction and irritation.

A: Humidifying the environment may help in some cases, but it doesn't directly address the itching or maintaining skin integrity.
B: Avoiding a skin lubricant is not recommended as it can help moisturize the skin and reduce itching.
C: Bathing with a bar soap that contains lye can be harsh and drying, exacerbating the skin reaction.

A client who suffered a vehicular accident a few days ago is in skeletal traction. Which nursing action would BESt promote INDEPENDENCE for this patient?

  • A. tell the client to call for an analgesic before the pain felt becomes severe
  • B. encourage the patient to do leg exercises within the limits of his traction
  • C. provide an overhead trapeze for client use on the Balkan frame
  • D. provide skin care to prevent skin breakdown
Correct Answer: B

Rationale: The correct answer is B because encouraging the patient to do leg exercises within the limits of his traction promotes independence by maintaining muscle strength and mobility. This helps prevent muscle atrophy and promotes circulation. Choice A focuses on pain management but does not directly promote independence. Choice C provides assistance but does not actively involve the patient in self-care. Choice D is important for overall care but does not directly promote independence through active patient involvement.

Mr. RR is to have a brain scanning. Nursing intervention in preparation for this test includes:

  • A. Discontinuing any anticonvulsant therapy
  • B. Obtaining consent for the treatment
  • C. Explaining to Mr. RR that although his head will be supported in place for a period of time, the test will not be painful.
  • D. Informing Mr. RR that nausea and headache are frequent following this test
Correct Answer: C

Rationale: The correct answer is C because it addresses the specific nursing intervention needed to prepare Mr. RR for the brain scanning test. By explaining to Mr. RR that the test will not be painful and that his head will be supported in place, the nurse helps alleviate any potential anxiety or fear he may have. This information reassures the patient and ensures his cooperation during the procedure.

Choice A is incorrect because discontinuing anticonvulsant therapy without medical approval could have serious consequences for Mr. RR's health. Choice B is also incorrect as obtaining consent is important, but it is not directly related to preparing Mr. RR for the test. Choice D is incorrect as it introduces potential negative outcomes without providing necessary information to prepare the patient for the test.

Considering Mr. Franco’s conditions, which of the following is most important to include in preparing Franco’s bedside equipment?

  • A. Hand bell and extra bed linen
  • B. Footboard and splint
  • C. Sandbag and trochanter rolls
  • D. Suction machine and gloves
Correct Answer: C

Rationale: Step 1: Mr. Franco's condition suggests he may need support and positioning.
Step 2: Sandbags provide stability and trochanter rolls prevent hip rotation.
Step 3: These help prevent pressure ulcers and maintain proper body alignment.
Step 4: Hand bell and bed linen are not essential for Mr. Franco's immediate care.
Step 5: Footboard and splint may not be relevant to his specific condition.
Step 6: Suction machine and gloves are important but not as crucial as positioning aids for Mr. Franco.
Summary: Choice C is correct as it directly addresses Mr. Franco's needs for support and positioning, while the other choices are less relevant or not as essential in this context.

If a patient has elevated pulmonary vascular pressures, the nurse understands that the patient is most likely to develop which of the ff. physiological cardiac changes?

  • A. Left atrial atrophy
  • B. Left ventricular hypertrophy
  • C. Right atrial atrophy
  • D. Right ventricular hypertrophy
Correct Answer: D

Rationale: The correct answer is D: Right ventricular hypertrophy. Elevated pulmonary vascular pressures lead to increased resistance in the pulmonary circulation, causing the right ventricle to work harder to pump blood to the lungs. Over time, this can result in hypertrophy of the right ventricle as it adapts to the increased workload. Left atrial atrophy (A) and right atrial atrophy (C) are unlikely as the atria are not directly affected by elevated pulmonary pressures. Left ventricular hypertrophy (B) is not the correct choice as it typically occurs in response to systemic hypertension, not pulmonary hypertension.

Copyright © 2025 Nokea. All rights reserved.