Nursing Process Practice Questions

Nursing Process Practice Questions Related

Review Nursing Process Practice Questions related questions and content

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will prescribe diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client does not comply with the recommended treatment, which complication may arise?

  • A. Cerebral edema
  • B. Severe hyperkalemia
  • C. Hypovolemic shock
  • D. Tetany
Correct Answer: A

Rationale: Correct Answer: A - Cerebral edema

Rationale:
1. SIADH leads to water retention and dilutional hyponatremia.
2. Diuretic therapy aims to increase urine output and correct fluid imbalance.
3. If the client does not comply, excessive water retention can lead to cerebral edema.
4. Cerebral edema is a serious complication that can cause neurological deficits.

Summary:
- B: Severe hyperkalemia is unlikely as diuretics would help excrete excess potassium.
- C: Hypovolemic shock is not expected as fluid restriction may prevent rapid volume loss.
- D: Tetany is not a direct consequence of non-compliance with treatment for SIADH.

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What does a nurse assess postoperatively in a client with a nasal fracture?

  • A. Allergic reaction
  • B. Extreme sense of smell
  • C. Airway obstruction
  • D. Stridor
Correct Answer: C

Rationale: The correct answer is C: Airway obstruction. Postoperatively, a nurse must assess for airway patency in a client with a nasal fracture to ensure proper breathing. Any swelling or bleeding in the nasal area can lead to airway obstruction, which is a critical concern that needs immediate intervention. Choices A, B, and D are incorrect because an allergic reaction, extreme sense of smell, and stridor are not typically associated with postoperative assessment of a nasal fracture. It is crucial to prioritize airway assessment to prevent any complications related to breathing difficulties in this situation.

During a breast examination, which finding most strongly suggests that the client has breast cancer?

  • A. Slight asymmetry of the breasts
  • B. A fixed nodular mass with dimpling of the overlying skin
  • C. Bloody discharge from the nipple
  • D. Multiple firm, round, freely movable masses that change with the menstrual cycle
Correct Answer: B

Rationale: The correct answer is B because a fixed nodular mass with dimpling of the overlying skin is highly indicative of breast cancer. This finding suggests an invasive tumor pulling on the skin, causing dimpling. Other choices are incorrect because slight breast asymmetry (A) is common, bloody nipple discharge (C) can be benign or due to other conditions, and multiple freely movable masses (D) are more indicative of benign breast conditions like fibrocystic changes.

The nurse assesses a client shortly after kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?

  • A. Serum potassium level of 4.9mEq/L
  • B. Temperature of 99.2F (37.3C)
  • C. Serum sodium level of 135mEq/L
  • D. Urine output of 20mL/hour
Correct Answer: D

Rationale: The correct answer is D: Urine output of 20mL/hour. This is a critical finding after kidney transplant surgery as it indicates potential kidney dysfunction or acute kidney injury. Decreased urine output can lead to fluid and electrolyte imbalances, which can be life-threatening. Immediate physician notification is crucial for prompt intervention. Choices A, B, and C are within normal ranges and do not indicate immediate danger. Serum potassium level of 4.9mEq/L is slightly elevated but not critical. Temperature of 99.2F (37.3C) is within normal limits for postoperative care. Serum sodium level of 135mEq/L is also normal and does not warrant immediate physician notification.

Which finding will alert the nurse that the goal has been met?

  • A. Heart rate 78 beats/min on 12/3
  • B. Heart rate 78 beats/min on 12/4
  • C. Heart rate 80 beats/min on 12/3
  • D. Heart rate 80 beats/min on 12/4
Correct Answer: A

Rationale: The correct answer is A because it meets the goal of maintaining a heart rate of 78 beats/min. This specific date ensures the consistency of the heart rate within the desired range. Choices B, C, and D do not align with the goal as they either have a different heart rate or occur on a different date. Therefore, A is the only option that accurately reflects the goal being met on the specified date.

The knows that a positive diagnosis for HIV infection is made based on; a.A history of high-risk sexual behaviors

  • A. Positive ELISA and Western blot tests
  • B. Evidence of extreme weight loss and high fever
  • C. Identification of an associated opportunistic infection
Correct Answer: A

Rationale: The correct answer is A because a positive diagnosis for HIV infection is confirmed through laboratory testing, specifically the ELISA and Western blot tests. These tests detect the presence of HIV antibodies in the blood, providing definitive evidence of the infection. Choice B is incorrect as weight loss and fever are symptoms but not diagnostic criteria. Choice C is incorrect as opportunistic infections are a consequence of HIV, not the diagnostic criteria. Choice D is incomplete and irrelevant. In summary, the key to diagnosing HIV is through positive laboratory tests, not just based on symptoms or associated infections.

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