Nursing Process Test Bank

Nursing Process Test Bank Related

Review Nursing Process Test Bank related questions and content

A patient was rushed to the ER because of difficulty in urination. He was diagnosed then as a cse of benign prostate hyperthropy (BPH) and was advised by the doctor to undego transurethral resection of prostate (TURP). Based on the urgency of the surgery, the nurse classifies this condition as:

  • A. emergency
  • B. C.urgent
  • C. elective
  • D. required
Correct Answer: A

Rationale: The correct answer is A: emergency. In this scenario, the patient is experiencing difficulty in urination due to benign prostate hyperplasia (BPH), a condition that can lead to serious complications like acute urinary retention. Transurethral resection of the prostate (TURP) is a surgical procedure that is used to relieve the obstruction caused by BPH. Given the urgency of the situation and the potential for acute complications, the surgery needs to be performed immediately to prevent further harm to the patient's health. Classifying this condition as an emergency ensures prompt intervention and prioritizes the patient's well-being.

Summary:
- B: C.urgent (not correct): While the surgery is time-sensitive, it does not require immediate intervention like in an emergency situation.
- C: elective (not correct): Elective surgeries are planned in advance and are not typically performed in urgent situations like this one.
- D: required (not correct): While the surgery is necessary for the patient's condition

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A 78 year old male has been working on his lawn for two days, although the temperature has been above 90 degree F. he has been on thiazide diuretics for hypertension. His lab values are K 3.7 mEq/L, Na 129 mEq/L, Ca 9 mg/dl, and Cl 95 mEq/L. What would be a priority action for this man?

  • A. Make sure he drinks 8 glasses of water a day.
  • B. Monitor for fatigue, muscle weakness, restlessness, and flushed skin
  • C. Look for signs of hyperchloremia
  • D. Observe for neurologic changes
Correct Answer: B

Rationale: The correct answer is B: Monitor for fatigue, muscle weakness, restlessness, and flushed skin. The patient is at risk for dehydration due to the combination of high temperature, age, and thiazide diuretic use. Thiazide diuretics can lead to electrolyte imbalances, including hypokalemia, which can cause symptoms such as muscle weakness and fatigue. Monitoring for signs of dehydration and electrolyte imbalances is crucial in this scenario to prevent complications.

A: Making sure he drinks 8 glasses of water a day is not the priority as he is already at risk for dehydration and electrolyte imbalances.
C: Hyperchloremia is not a common concern in this scenario based on the given lab values.
D: Neurologic changes may occur in severe cases of electrolyte imbalances but monitoring for physical symptoms such as fatigue and muscle weakness is more relevant at this stage.

The nurse provides care for a client with deep partial-thickness burns. What could cause a reduced hematocrit (Hct) in this client?

  • A. Hypoalbuminemia with hemoconcentration
  • B. Volume overload with hemodilution
  • C. Metabolic acidosis
  • D. Lack of erythropoeitin factor
Correct Answer: B

Rationale: The correct answer is B: Volume overload with hemodilution. In deep partial-thickness burns, there can be fluid shifts leading to volume overload. This excess fluid in the intravascular space can dilute the blood, resulting in a decreased hematocrit (Hct). Reduced Hct indicates lower concentration of red blood cells in the blood. Other choices are incorrect because hypoalbuminemia would lead to hemoconcentration, metabolic acidosis would not directly cause a reduced Hct, and lack of erythropoietin factor would primarily affect erythropoiesis but not directly lead to decreased Hct.

A client who reports increasing difficulty swallowing, weight loss, and fatigue is diagnosed with esophageal cancer. Because this client has difficulty swallowing, the nurse should assign highest priority to:

  • A. Helping the client cope with body image
  • B. Maintaining a patent airway.
  • C. Preventing injury.
  • D. Ensuring adequate nutrition.
Correct Answer: B

Rationale: The correct answer is B: Maintaining a patent airway. This is the highest priority because the client with esophageal cancer is at risk for airway obstruction due to difficulty swallowing. Maintaining a patent airway ensures adequate oxygenation and ventilation, which are vital for the client's survival. Without a clear airway, the client may experience respiratory distress or failure. Body image, preventing injury, and ensuring adequate nutrition are important aspects of care but do not take precedence over maintaining a patent airway in this situation.

The nurse has given medication instruction to the client receiving phenyton (Dilantin). The nurse determines that the client has an adequate understanding if the client states that:

  • A. “Alcohol is not contraindicated while taking this medication.”
  • B. “Good oral hygiene is needed, including brushing and flossing.”
  • C. “The medication dose may be self-adjusted depending on side effects.”
  • D. “The morning dose of the medication should be taken before a serum drug level is drawn.”
Correct Answer: B

Rationale: The correct answer is B: "Good oral hygiene is needed, including brushing and flossing." This is because phenytoin (Dilantin) can cause gingival hyperplasia, a side effect that leads to overgrowth of gum tissue. Good oral hygiene practices, such as regular brushing and flossing, can help prevent or minimize this side effect.

Choice A is incorrect because alcohol is contraindicated while taking phenytoin as it can increase the risk of side effects and decrease the effectiveness of the medication.

Choice C is incorrect because medication doses should never be self-adjusted without consulting a healthcare provider, as this can lead to ineffective treatment or potential harm.

Choice D is incorrect because the timing of the morning dose in relation to drawing a serum drug level is not relevant to the client's understanding of medication instructions and does not address the specific side effect of gingival hyperplasia associated with phenytoin.

Laboratory studies indicate a client’s blood pressure level is 185mg/dl. Two hours have passed since the client ate breakfast. Which test would yield the most occlusive diagnostic information about the client’s glucose utilization?

  • A. A fasting blood glucose test
  • B. A test of serum glycosylated hemoglobin (HbA1c)
  • C. A 6-hour glucose tolerance test
  • D. A test for urine ketones
Correct Answer: C

Rationale: The correct answer is C: A 6-hour glucose tolerance test. This test involves measuring blood glucose levels at specific intervals after consuming a glucose solution, providing a comprehensive assessment of glucose utilization over time. This test is particularly useful in evaluating how the body processes glucose after a meal and can help diagnose conditions such as diabetes.

A: A fasting blood glucose test would not provide a comprehensive picture of glucose utilization over time since it only measures glucose levels in a fasted state.
B: A test of serum glycosylated hemoglobin (HbA1c) reflects average blood glucose levels over the past 2-3 months but does not directly assess glucose utilization after a meal.
D: A test for urine ketones is used to detect ketones in the urine, which can indicate diabetic ketoacidosis but does not directly measure glucose utilization.

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