Fundamentals Nursing Process Questions

Fundamentals Nursing Process Questions Related

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A nurse determines that the patient’s condition has improved and has met expected outcomes. Which step of the nursing process is the nurse exhibiting?

  • A. Assessment
  • B. Planning
  • C. Implementation NursingStoreRN
  • D. Evaluation
Correct Answer: D

Rationale: The correct answer is D: Evaluation. In the nursing process, evaluation involves determining if the patient's condition has improved and if the expected outcomes have been met. The nurse assesses the patient's progress, compares it to the expected outcomes set during planning, and determines the effectiveness of the interventions implemented. This step ensures that the care provided is meeting the patient's needs and helps in making any necessary adjustments to the care plan.

Incorrect choices:
A: Assessment - This step involves gathering information about the patient's condition and needs at the beginning of the nursing process.
B: Planning - Involves setting goals and developing a plan of care based on the assessment data.
C: Implementation - Involves carrying out the interventions outlined in the care plan to meet the patient's goals.

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A client is admitted to the hospital with a bleeding ulcer and is to receive 4 units of packed cells. Which nursing intervention is of primary importance in the administration of blood?

  • A. Checking the flow rate
  • B. Monitoring the vital signs
  • C. Identifying the client
  • D. Maintaining blood temperature
Correct Answer: C

Rationale: Step 1: Identifying the client is crucial for correct blood transfusion to avoid errors.
Step 2: Client identification includes verifying name, date of birth, and unique identifiers.
Step 3: Ensuring correct patient prevents transfusion reactions and improves patient safety.
Step 4: Monitoring vital signs and flow rate are important but secondary to client identification.
Step 5: Maintaining blood temperature is not a primary concern during blood transfusion.

Mrs. Santos, a 75-year old patient with type II diabetes is in emergency department with signs of hyperglycemic, hyperosmolar nonketotic (HHNK) coma. What assessment finding should the nurse expect?

  • A. Fruity odor of the breath
  • B. shallow, deep respirations
  • C. severe dehydration
  • D. profuse sweating
Correct Answer: C

Rationale: The correct answer is C: severe dehydration. In HHNK coma, the body tries to eliminate excess glucose through frequent urination, leading to dehydration. This results in decreased blood volume, causing hypotension and tachycardia. Signs include dry mucous membranes, poor skin turgor, and concentrated urine output. Fruity odor of the breath (A) is associated with diabetic ketoacidosis, not HHNK coma. Shallow, deep respirations (B) and profuse sweating (D) are not typically associated with HHNK coma.

A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data?

  • A. The patient can now perform the dressing changes without help.
  • B. The patient can begin retaking all of the previous medications.
  • C. The patient is apprehensive about discharge.
  • D. The patient’s surgery was not successful.
Correct Answer: C

Rationale: The correct answer is C. The nurse can infer that the patient is apprehensive about discharge based on the subjective data of the patient expressing fear of going home and being alone. This indicates the patient may not feel ready to leave the hospital setting. Choice A is incorrect because the patient's fear of going home suggests they may not be comfortable performing dressing changes alone. Choice B is incorrect because there is no information provided to support that the patient can begin retaking all previous medications. Choice D is incorrect as there is no indication that the fear of going home is related to the success of the surgery.

The nursing care for the client in addisonian crisis should include which of the following interventions?

  • A. Encouraging independence with activities of daily living (ADL)
  • B. Allowing ambulation as tolerated
  • C. Offering extra blankets and raising the heat in the room to keep the client warm
  • D. Placing the client in a private room
Correct Answer: C

Rationale: The correct answer is C because in Addisonian crisis, the client experiences adrenal insufficiency leading to decreased cortisol levels and impaired stress response. Offering extra blankets and raising room temperature helps prevent hypothermia, as clients in crisis are unable to regulate body temperature. Encouraging independence with ADLs (choice A) and ambulation (choice B) are not priorities as the client is in a critical state. Placing the client in a private room (choice D) is not directly related to managing Addisonian crisis.

A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data?

  • A. The patient can now perform the dressing changes without help.
  • B. The patient can begin retaking all of the previous medications.
  • C. The patient is apprehensive about discharge.
  • D. The patient’s surgery was not successful.
Correct Answer: C

Rationale: The correct answer is C because the patient expressing fear of going home and being alone indicates apprehension about discharge. This inference is supported by the subjective data provided. Choice A is incorrect because fear of being alone does not necessarily mean the patient can perform dressing changes independently. Choice B is incorrect as resuming all previous medications is not related to the patient's fear of going home. Choice D is incorrect as the subjective data does not provide any information about the success of the surgery.

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