Nursing Process Exam Questions

Nursing Process Exam Questions Related

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A nurse changes a client’s wound dressing according to the protocol outlined by the health care agency. What type of nursing intervention is this?

  • A. Independent intervention
  • B. Dependent intervention
  • C. Interdependent intervention
  • D. Collaborative intervention
Correct Answer: C

Rationale: The correct answer is C: Interdependent intervention. This type of nursing intervention involves collaboration with other healthcare professionals to provide holistic care. In this scenario, the nurse is following a protocol set by the health care agency, which likely involves input and guidance from various team members. The nurse's actions require coordination and communication with others to ensure the best outcome for the client.

Choice A (Independent intervention) would involve actions that the nurse can perform autonomously without requiring direction from others. Choice B (Dependent intervention) would require an order or prescription from a healthcare provider for the nurse to carry out. Choice D (Collaborative intervention) involves working together with other healthcare professionals on a specific aspect of care, but in this case, the nurse is primarily following a set protocol without necessarily actively collaborating with others during the task.

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While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?

  • A. Consider cultural differences during this assessment.
  • B. Ask the patient to make eye contact to determine her affect.
  • C. Continue with the interview and document that the patient is depressed.
  • D. Notify the health care provider to recommend a psychological evaluation.
Correct Answer: A

Rationale: Step 1: Recognize cultural differences in communication styles. In many Asian cultures, avoiding direct eye contact is a sign of respect, humility, or shyness.
Step 2: Understand that the patient's behavior may not indicate depression but rather a cultural norm.
Step 3: Adjust communication approach by respecting the patient's cultural preferences.
Step 4: Building trust and rapport by acknowledging and accommodating cultural differences.
Summary: Choice A is correct as it acknowledges and respects cultural differences. Choices B, C, and D are incorrect as they do not consider cultural aspects and may lead to misinterpretation and inappropriate actions.

The physician orders propranolol (Inderal) for a client's angina. The effect of this drug is to:

  • A. Act as a vasoconstrictor
  • B. Block beta stimulation in the heart
  • C. Act as a vasodilator
  • D. Increase the heart rate
Correct Answer: B

Rationale: The correct answer is B: Block beta stimulation in the heart. Propranolol is a beta-blocker that works by blocking the beta receptors in the heart, which reduces the heart's workload and oxygen demand, making it an effective treatment for angina. By blocking beta stimulation, propranolol helps to decrease heart rate, blood pressure, and myocardial contractility. This ultimately improves oxygen supply to the heart muscle.

Explanation for other choices:
A: Act as a vasoconstrictor - Propranolol does not act as a vasoconstrictor; it actually can cause vasodilation in some cases.
C: Act as a vasodilator - Propranolol is not primarily a vasodilator; its main action is to block beta stimulation in the heart.
D: Increase the heart rate - Propranolol actually decreases heart rate by blocking beta receptors in the heart.

When administering oxygen to a client, under which of the ff situations should the nurse discontinue the administration and notify the physician?

  • A. When the client’s color does not improve
  • B. When the client level of consciousness decreases
  • C. When the client is in a state of respiratory arrest
  • D. When the client cannot effectively use the diaphragm
Correct Answer: C

Rationale: The correct answer is C. When the client is in a state of respiratory arrest, immediate medical intervention is required. Discontinuing oxygen administration and notifying the physician is crucial to address the life-threatening situation. A: Improving color is a positive sign. B: Decreased consciousness may indicate a need for further assessment but does not require immediate discontinuation of oxygen. D: Inability to use the diaphragm may require intervention but does not indicate an immediate threat as respiratory arrest does.

A client in the terminal stage of cancer is receiving continuous infusion of morphine (Duramorph) for pain management. Which assessment finding suggests that the client is experiencing an adverse effect of this drug?

  • A. Voiding of 350mL of concentrated urine in
  • B. Irregular heart rate of 82 beats/min
  • C. Pupils constricted and equal
  • D. Respiratory rate of 8breaths/min
Correct Answer: D

Rationale: The correct answer is D because a respiratory rate of 8 breaths/min indicates respiratory depression, a serious adverse effect of morphine. Morphine is a central nervous system depressant that can suppress the respiratory drive, leading to hypoventilation and potentially respiratory failure. This is a life-threatening complication that requires immediate intervention.

A: Voiding of 350mL of concentrated urine is not typically associated with morphine use.
B: An irregular heart rate of 82 beats/min is within a normal range and not a common adverse effect of morphine.
C: Pupils constricted and equal is a common side effect of morphine due to its action on the central nervous system, not necessarily indicating an adverse effect.

Of the following types of nursing diagnoses, which one is validated by the presence of major defining characteristics?

  • A. Risk nursing diagnosis
  • B. Actual nursing diagnosis
  • C. Possible nursing diagnosis
  • D. Wellness diagnosis
Correct Answer: B

Rationale: The correct answer is B: Actual nursing diagnosis. An actual nursing diagnosis is validated by the presence of major defining characteristics, such as signs and symptoms exhibited by the patient. This helps in identifying the specific health issues that the patient is currently experiencing. In contrast, a risk nursing diagnosis is focused on potential health problems that the patient may develop in the future. Possible nursing diagnosis involves uncertain or unclear health issues that require further assessment. Wellness diagnosis is aimed at enhancing health and promoting well-being, rather than addressing existing health problems. Therefore, the presence of major defining characteristics is crucial in confirming an actual nursing diagnosis.

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