Nursing Process Questions and Answers PDF

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A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care?

  • A. Patient will have one soft, formed bowel movement by end of shift.
  • B. Patient will walk unassisted to bathroom by the end of shift.
  • C. Patient will be offered laxatives or stool softeners this shift.
  • D. Patient will not take any pain medications this shift.
Correct Answer: A

Rationale: The correct answer is A. The most appropriate outcome for the nurse to include in the plan of care is for the patient to have one soft, formed bowel movement by the end of the shift. This outcome directly addresses the nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. By aiming for a soft, formed bowel movement, the nurse is working towards alleviating the constipation issue caused by the pain medications. This outcome is specific, measurable, achievable, relevant, and time-bound (SMART), making it an appropriate goal for the patient's care plan.

Choice B is incorrect because walking unassisted to the bathroom does not directly address the constipation issue. Choice C is incorrect as offering laxatives or stool softeners is a nursing intervention and not an outcome. Choice D is incorrect as withholding pain medications may not be in the best interest of the patient's overall care and does not directly target the constipation issue.

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A client undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction?

  • A. “Keep the stoma uncovered.”
  • B. “Keep the stoma dry.”
  • C. “Have a family member perform stoma care initially until you get used to the procedure.”
  • D. “Keep the stoma moist.”
Correct Answer: B

Rationale: The correct answer is B: "Keep the stoma dry." Keeping the stoma dry helps prevent infection and skin irritation. Moisture can lead to fungal growth and skin breakdown. Option A is incorrect because keeping the stoma uncovered can increase the risk of contamination and infection. Option C is incorrect as self-care promotes independence and allows the client to become familiar with the procedure. Option D is incorrect as moisture can lead to skin issues.

A client receiving chemotherapy has a nursing diagnosis of Deficient diversional activity related to decreased energy. Which statement indicates an accurate understanding of appropriate ways to deal with this deficit?

  • A. “I’ll play card games with my friends.”
  • B. “I’ll take a long trip to visit my aunt.”
  • C. “I’ll bowl with my team after discharge.”
  • D. “I’ll eat lunch in a restaurant everyday.”
Correct Answer: C

Rationale: The correct answer is C because bowling with the team after discharge promotes social interaction and physical activity, addressing both the diversional activity deficit and the decreased energy. Playing card games (A) may not involve physical activity. Taking a long trip (B) may be overwhelming and tiring. Eating in a restaurant daily (D) does not address the need for meaningful activities or social interaction.

The nurse is evaluating whether a patient’s turning schedule was effective in preventing the formation of pressure ulcers. Which finding indicates success of the turning schedule?

  • A. Staff documentation of turning the patient every 2 hours
  • B. Presence of redness only on the heels of the patient
  • C. Patient’s eating 100% of all meals NursingStoreRN
  • D. Absence of skin breakdown
Correct Answer: D

Rationale: The correct answer is D because the absence of skin breakdown indicates that the turning schedule was effective in preventing pressure ulcers. Skin breakdown is a key indicator of pressure ulcer development, so its absence suggests that the patient's skin integrity was maintained. Choice A is incorrect because documentation alone does not guarantee successful prevention. Choice B is incorrect as redness on the heels can still indicate the early stages of pressure ulcers. Choice C is unrelated to skin integrity and pressure ulcer prevention.

An adult has been diagnosed with some type of anemia. The results of his blood tests showed: decreased WBC, normal RBC, decreased HCT, decreased Hgb. Based on these data, which of the following nursing diagnosis should the nurse prioritize as the most important?

  • A. Potential for infection
  • B. Self care deficit
  • C. Alteration in infection
  • D. Fluid volume excess
Correct Answer: A

Rationale: The correct answer is A: Potential for infection. The decreased WBC count indicates reduced ability to fight off infections, making this the priority nursing diagnosis. Normal RBC count rules out anemia-related complications. Decreased HCT and Hgb indicate possible anemia but do not directly relate to infection risk. Choices B and C are not as critical as the potential for infection due to the significant impact on the individual's health and well-being. Choice D, fluid volume excess, is not directly related to the blood test results provided.

A nurse is conducting a nursing health history. Which component will the nurse address?

  • A. Nurse’s concerns
  • B. Patient expectations
  • C. Current treatment orders
  • D. Nurse’s goals for the patient
Correct Answer: B

Rationale: The correct answer is B: Patient expectations. During a nursing health history, the nurse focuses on gathering information about the patient's health concerns, medical history, lifestyle, and expectations for their care. Addressing patient expectations is crucial for providing patient-centered care and establishing a therapeutic relationship. The other choices are incorrect because:
A: Nurse's concerns are not the primary focus of a nursing health history.
C: Current treatment orders are important but are typically addressed during a physical assessment or when implementing care.
D: Nurse's goals for the patient are important but should be developed in collaboration with the patient based on their needs and preferences.

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