Nursing Process Practice Questions Quizlet

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A client is hospitalized with oat cell carcinoma of the lung. To manage severe pain, the physician prescribes a continuous I.V. infusion of morphine. Which formula should the nurse use to check that the morphine dose is appropriate for the client?

  • A. 1 mg/kg of body weight
  • B. 5 mg/70kg of body weight
  • C. 5 mg/kg of body weight
  • D. 10mg/70kg of body weight
Correct Answer: C

Rationale: The correct formula to calculate the appropriate morphine dose for the client is 5 mg/kg of body weight. This is the most suitable formula because morphine dosing is typically based on weight to ensure appropriate pain management and to prevent adverse effects. By using this formula, the nurse can calculate the exact dose based on the client's weight, providing personalized care.

Choice A (1 mg/kg of body weight) is too low of a dose and may not effectively manage severe pain. Choice B (5 mg/70kg of body weight) is not ideal as it does not account for variations in weight among individuals. Choice D (10mg/70kg of body weight) would result in an overdose for most patients, potentially causing serious harm.

Therefore, by using the formula of 5 mg/kg of body weight, the nurse can ensure that the morphine dose is appropriate and safe for the client.

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The nurse is caring for a client who is HIV positive. To prevent the spread of the HIV virus, what do the Centers for Disease Control and Prevention recommend?

  • A. Universal blood and body fluid precautions
  • B. Body systems isolation
  • C. Laminar flow room during active infection
  • D. Needle and syringe precautions
Correct Answer: A

Rationale: The correct answer is A: Universal blood and body fluid precautions. This is recommended by the CDC to prevent the spread of HIV because the virus can be present in blood and certain body fluids. Universal precautions involve treating all blood and body fluids as potentially infectious.

Incorrect choices:
B: Body systems isolation - This is not specific to preventing the spread of HIV and is not recommended by the CDC.
C: Laminar flow room during active infection - This is not a standard recommendation for preventing the spread of HIV.
D: Needle and syringe precautions - While important in preventing needlestick injuries, it is not the primary method recommended by the CDC for preventing the spread of HIV.

Which of the ff is a sign or symptom of asthma?

  • A. Production of abnormally thick, sticky mucus in lungs
  • B. Faulty transport of sodium in lung cells
  • C. Paroxysms or shortness of breath
  • D. Altered electrolyte balance in the sweat glands
Correct Answer: C

Rationale: The correct answer is C: Paroxysms or shortness of breath. Asthma is characterized by episodes of wheezing, coughing, chest tightness, and shortness of breath, known as paroxysms. This symptom is caused by inflammation and constriction of the airways in response to triggers such as allergens or irritants.

A: Production of abnormally thick, sticky mucus in lungs is more indicative of conditions like cystic fibrosis, not asthma.
B: Faulty transport of sodium in lung cells is associated with conditions like cystic fibrosis, not asthma.
D: Altered electrolyte balance in the sweat glands is a symptom of cystic fibrosis, not asthma.

In summary, paroxysms or shortness of breath is a key sign of asthma due to airway inflammation and constriction, distinguishing it from the other choices that are more indicative of cystic fibrosis.

What is a critical component of the evaluation phase in the nursing process?

  • A. Determine if client outcomes have been achieved
  • B. Revise the client’s health history
  • C. Establish priorities for care
  • D. Formulate new nursing diagnoses
Correct Answer: A

Rationale: Step 1: Evaluation phase assesses if client outcomes have been achieved.
Step 2: Determines effectiveness of nursing interventions.
Step 3: Validates if goals are met or adjustments are needed.
Step 4: Reflects on the success of the care plan.
Step 5: Choice A is correct as it directly relates to evaluating the effectiveness of nursing care.
Summary:
- Choice B is incorrect as revising health history is part of assessment.
- Choice C is incorrect as establishing priorities is part of the planning phase.
- Choice D is incorrect as formulating new nursing diagnoses is part of the diagnosis phase.

A client with primary diabetes insipidus is ready for discharge on desmopressin (DDAVP). Which instruction should the nurse provide?

  • A. “Administer desmopressin while the suspension is cold.”
  • B. “Your condition isn’t chronic, so you won’t need to wear a medical identification bracelet.”
  • C. “You may not be able to use desmopressin nasally if you have nasal discharge or blockage.”
  • D. “You won’t need to monitor your fluid intake and output after you start taking desmopressin.”
Correct Answer: C

Rationale: The correct answer is C: “You may not be able to use desmopressin nasally if you have nasal discharge or blockage.”

Rationale:
1. Desmopressin is available in intranasal form for diabetes insipidus.
2. Nasal discharge or blockage may prevent proper absorption of the medication.
3. Instructing the client about this potential issue ensures optimal drug effectiveness.

Summary:
A: Incorrect. Temperature of desmopressin suspension doesn't affect its efficacy.
B: Incorrect. A medical identification bracelet is necessary for chronic conditions like diabetes insipidus.
D: Incorrect. Monitoring fluid intake and output is crucial when taking desmopressin.

A female client with lymphedema expresses her anxiety about the abnormal enlargement of an arm. Which of the ff suggestions should a nurse give to support the clients self image?

  • A. Place the arm in the sling
  • B. Apply cold soaks to the affected arm
  • C. Introduce variations in styles of clothing
  • D. Tie a tight bandage to the arm
Correct Answer: C

Rationale: The correct answer is C: Introduce variations in styles of clothing. This suggestion promotes the client's self-image by helping her feel more comfortable and confident in her appearance despite the lymphedema. It allows her to express her personal style while accommodating the enlarged arm.

A: Placing the arm in a sling does not address the client's self-image concerns and may further highlight the abnormality.
B: Applying cold soaks may help with swelling but does not directly address the client's self-image.
D: Tying a tight bandage can worsen lymphedema and does not address the client's self-image concerns.

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