Nursing Process Questions

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A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?

  • A. Ineffective breathing pattern related to pneumonia
  • B. Risk for infection related to chest x-ray procedure NursingStoreRN
  • C. Risk for deficient fluid volume related to dehydration
  • D. Impaired gas exchange related to alveolar-capillary membrane changes
Correct Answer: D

Rationale: The correct answer is D: Impaired gas exchange related to alveolar-capillary membrane changes. This nursing diagnosis is appropriate for a patient with pneumonia and lower lobe infiltrates because pneumonia causes inflammation and fluid accumulation in the alveoli, leading to impaired gas exchange. The nurse correctly identified the underlying respiratory issue.

A: Ineffective breathing pattern related to pneumonia is incorrect as it focuses on the pattern of breathing rather than the physiological problem causing the breathing difficulty.
B: Risk for infection related to chest x-ray procedure is incorrect as the patient already has a diagnosis of pneumonia, so the focus should be on managing the existing condition.
C: Risk for deficient fluid volume related to dehydration is incorrect as there is no indication of dehydration in the question stem.

In summary, the nurse's diagnosis of Impaired gas exchange related to alveolar-capillary membrane changes is the most appropriate as it addresses the respiratory issue caused by pneumonia and lower lobe infiltrates.

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To treat cervical cancer, a client has had an applicator of radioactive material placed in the vagina. Which observation by the nurse indicates a radiation hazard?

  • A. The client is maintained on strict bed rest
  • B. The head of the bed is at 30-degree angle
  • C. The client receives a complete bed bath each morning
  • D. The nurse checks the applicator’s position every 4 hours
Correct Answer: B

Rationale: The correct answer is B because having the head of the bed at a 30-degree angle can cause the radioactive material to shift, potentially leading to an uneven distribution of radiation. This could result in harmful exposure to surrounding tissues.

A: Maintaining the client on strict bed rest is important to prevent displacement of the radioactive applicator.
C: Providing a complete bed bath each morning is necessary for hygiene and does not pose a radiation hazard.
D: Checking the applicator's position every 4 hours is essential to ensure proper placement and does not indicate a radiation hazard.

Which nursing actions will the nurse perform in the evaluation phase of the nursing process? (Select all that apply.)

  • A. Set priorities for patient care.
  • B. Determine whether outcomes or standards are met.
  • C. Ambulate patient 25 feet in the hallway.
  • D. Document results of goal achievement.
Correct Answer: A

Rationale: In the evaluation phase of the nursing process, the nurse sets priorities for patient care to determine the effectiveness of nursing interventions. This involves comparing achieved outcomes with established goals. Choices B and D are related to evaluation as they involve determining whether outcomes or standards are met and documenting results of goal achievement, respectively. However, choice C, ambulating the patient, is an intervention that would typically occur in the implementation phase, not the evaluation phase. Therefore, the correct answer is A because setting priorities for patient care is a key component of the evaluation phase.

The nurse caring for an adult client. The nurse will need to monitor for which of the following metabolic complications?

  • A. hypoglycemia and hypercalcemia
  • B. hyperglycemia and hyperkalemia
  • C. hyperglycemia and Hypokalemia
  • D. hyperkalemia and hypercalcemia
Correct Answer: C

Rationale: The correct answer is C, hyperglycemia and hypokalemia. Hyperglycemia can occur in adult clients due to various factors such as diabetes or stress. Hypokalemia can be a consequence of hyperglycemia or other conditions leading to potassium loss. Monitoring for these metabolic complications is essential to ensure the client's well-being. Other choices are incorrect because hypoglycemia and hypercalcemia (choice A) are less likely to occur concurrently in adult clients. Hyperglycemia and hyperkalemia (choice B) are less common as hyperkalemia is usually associated with renal dysfunction. Hyperkalemia and hypercalcemia (choice D) are less likely to be monitored together as they are not commonly seen in the same clinical context.

A client suspected of having colorectal cancer will require which diagnostic study to confirm the diagnosis?

  • A. Stool hematest
  • B. Abdominal computed tomography (CT)
  • C. Carcinoembryonic antigen (CEA) scan
  • D. Sigmoidoscopy
Correct Answer: D

Rationale: The correct answer is D: Sigmoidoscopy. Sigmoidoscopy is a direct visualization procedure that allows for examination of the lower part of the colon and rectum, where colorectal cancer commonly occurs. This procedure can help identify any abnormal growths or polyps that may indicate cancer. Stool hematest (A) detects blood in stool but does not confirm colorectal cancer. Abdominal CT (B) provides imaging of the abdomen but may not definitively diagnose colorectal cancer. CEA scan (C) measures a tumor marker associated with colorectal cancer but is not a definitive diagnostic test. Thus, sigmoidoscopy is the most appropriate diagnostic study for confirming colorectal cancer.

Which of the ff is a critical task of a nurse during the uterosigmoidostomy procedure for treating a malignant tumor?

  • A. Inspecting for bleeding or cyanosis
  • B. Inspecting for symptoms of peritonitis
  • C. Assessing the clients allergy to iodine
  • D. Checking for signs of electrolyte losses
Correct Answer: A

Rationale: The correct answer is A: Inspecting for bleeding or cyanosis. During uterosigmoidostomy, the nurse's critical task is to monitor for any signs of bleeding or cyanosis, which are indicators of potential complications such as hemorrhage or impaired blood flow. This involves observing the surgical site for any abnormal bleeding and assessing the skin color for signs of inadequate oxygenation. Inspecting for symptoms of peritonitis (B) is not directly related to this surgical procedure. Assessing the client's allergy to iodine (C) is important but not a critical task during the procedure. Checking for signs of electrolyte losses (D) is important but not as critical as monitoring for immediate postoperative complications like bleeding or cyanosis.

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