Nursing Process Quizlet Questions

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A nurse is assisting with lunch at a nursing home. Suddenly, one of the residents begins to choke and is unable to breathe. The nurse assesses the resident’s ability to breathe and then begins CPR. Why did the nurse assess respiratory status?

  • A. To identify a life-threatening problem
  • B. To establish a database for medical care
  • C. To practice respiratory assessment skills
  • D. To facilitate the resident’s ability to breathe
Correct Answer: A

Rationale: Step-by-step rationale for why answer A is correct:
1. Assessing respiratory status is crucial during a choking incident to identify if the resident is unable to breathe.
2. In this scenario, the resident's inability to breathe indicates a life-threatening problem requiring immediate intervention.
3. CPR is initiated based on the assessment of the resident's breathing difficulty, emphasizing the critical nature of identifying a life-threatening issue.
4. The assessment of respiratory status directly informs the nurse's actions to address the immediate danger of choking.

Summary:
- Choice A is correct as assessing respiratory status helps identify life-threatening issues like choking.
- Choice B is incorrect as the primary focus is on immediate intervention, not establishing a database.
- Choice C is incorrect as the assessment is not for skill practice but for identifying a critical situation.
- Choice D is incorrect as the goal is not to facilitate breathing but to address the immediate life-threatening problem.

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Which of the following is the medication of choice for anaphylaxis that the nurse should anticipate would be ordered?

  • A. Epinephrine
  • B. Digoxin (Lanoxin)
  • C. Theophylline (Theo-Dur)
  • D. Furosemide (Lasix)
Correct Answer: A

Rationale: The correct answer is A: Epinephrine. In anaphylaxis, epinephrine is the medication of choice due to its rapid onset of action and ability to reverse severe allergic reactions. It acts by constricting blood vessels, increasing heart rate, and opening airways. This helps counteract the dangerous drop in blood pressure and airway constriction seen in anaphylaxis. Digoxin, theophylline, and furosemide are not appropriate for anaphylaxis as they do not address the immediate life-threatening symptoms of anaphylaxis.

Several days before admission, a client reports finding a small lump in the left breast near the nipple. What should the nurse tell the client to do?

  • A. Inform the physician immediately
  • B. Squeeze the nipple to check for drainage
  • C. Check the area after the next menstrual period
  • D. Put a heating pad on the area to reduce inflammation
Correct Answer: A

Rationale: The correct answer is A: Inform the physician immediately. This is because finding a lump in the breast could be a sign of breast cancer, and early detection is crucial for effective treatment. The nurse should advise the client to seek medical evaluation promptly for further assessment, such as a mammogram or biopsy.

Choice B is incorrect because squeezing the nipple could potentially worsen the condition or spread cancerous cells if present. Choice C is incorrect as waiting until after the next menstrual period may delay necessary medical attention. Choice D is incorrect as using a heating pad could mask symptoms and delay proper diagnosis and treatment.

The nurse is preparing to administer a unit of blood to a client’s who’s anemic. After its removal from the refrigerator, the blood should be administered within:

  • A. 1 hour
  • B. 4 hours
  • C. 2 hours
  • D. 6 hours
Correct Answer: C

Rationale: The correct answer is C: 2 hours. Blood should be administered within 30 minutes to 4 hours after removal from the refrigerator to prevent bacterial growth and maintain its efficacy. Option C falls within this timeframe, ensuring safety and effectiveness. Option A (1 hour) is too short, while option B (4 hours) and option D (6 hours) exceed the recommended timeframe, increasing the risk of bacterial contamination and compromising the quality of the blood product.

A patient has been prescribed bumetanide (Bumex) every morning for control of hypertension. Which of the ff. statements indicates correct knowledge of the treatment regimen?

  • A. “I can travel to Florida and sunbathe all day.”
  • B. “Now I can eat whatever I want, whenever I want.”
  • C. “I’ll take my medication in the morning, every morning.”
  • D. “I won’t need medication once my pressure goes down.”
Correct Answer: C

Rationale: The correct answer is C: “I’ll take my medication in the morning, every morning.” This statement reflects understanding of the treatment regimen by indicating consistency in taking bumetanide for hypertension control. Taking the medication as prescribed is crucial for its effectiveness in managing blood pressure.

Choice A is incorrect because sunbathing all day may not be advisable, especially if the patient is on medication. Choice B is incorrect as it implies no consideration for dietary restrictions that may be necessary with the medication. Choice D is incorrect as stopping medication once blood pressure decreases is not recommended and can lead to rebound hypertension.

A patient has chronic respiratory acidosis related to long-standing lung disease. Which of the following problems is the cause?

  • A. Hyperventilation
  • B. Loss of acid by kidneys
  • C. Hypoventilation
  • D. Loss of base by kidneys CARING FOR CLIENTS REQUIRING INTRAVENOUS THERAPY
Correct Answer: C

Rationale: The correct answer is C: Hypoventilation. In chronic respiratory acidosis, the lungs cannot effectively eliminate carbon dioxide, leading to an accumulation of CO2 in the blood, causing acidosis. Hypoventilation results in decreased removal of CO2, exacerbating the acidosis.

A: Hyperventilation would lead to respiratory alkalosis, not acidosis.
B: Loss of acid by kidneys would result in metabolic alkalosis, not respiratory acidosis.
D: Loss of base by kidneys would lead to metabolic acidosis, not respiratory acidosis.

In summary, the main issue in chronic respiratory acidosis is inadequate elimination of CO2 due to hypoventilation, leading to acidosis.

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