Nursing Process Practice Questions

Nursing Process Practice Questions Related

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After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse’s actions?

  • A. To form a language that can be encoded only by nurses
  • B. To distinguish the nurse’s role from the physician’s role
  • C. To develop clinical judgment based on other’s intuition
  • D. To help nurses focus on the scope of medical practice
Correct Answer: D

Rationale: The correct answer is D: To help nurses focus on the scope of medical practice. Developing a standard formal nursing diagnosis helps nurses to identify and focus on the patient's specific health issues within the nursing scope of practice. This enables nurses to provide targeted and effective care interventions.

A: To form a language that can be encoded only by nurses - This choice is incorrect because the purpose of a nursing diagnosis is not exclusive to nurses and should be comprehensible to all healthcare professionals caring for the patient.

B: To distinguish the nurse’s role from the physician’s role - While this distinction is important, the main purpose of developing a nursing diagnosis is to guide nursing interventions based on the patient's nursing care needs, rather than solely differentiating roles.

C: To develop clinical judgment based on other’s intuition - This choice is incorrect as clinical judgment should be based on evidence-based practice and critical thinking, rather than solely relying on intuition or others' opinions.

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Which of the ff interventions is implemented for a client with empyema?

  • A. Teach the client breathing exercises
  • B. Offer assurance that empyema takes less time to resolve
  • C. Recommend that the client eat a balanced but light diet
  • D. Emphasize the completion of the entire course of drug therapy
Correct Answer: D

Rationale: The correct answer is D: Emphasize the completion of the entire course of drug therapy. Empyema is a serious condition that requires antibiotic treatment. Emphasizing the completion of the entire course of drug therapy is crucial to ensure that the infection is completely eradicated and to prevent the development of drug-resistant strains. Teaching breathing exercises (choice A) may help improve lung function but is not the primary intervention for empyema. Offering assurance that empyema takes less time to resolve (choice B) is incorrect as it can mislead the client about the seriousness of the condition. Recommending a balanced but light diet (choice C) may be beneficial for overall health but is not directly related to treating empyema.

An adult is on a clear liquid diet. Which food item can be offered/

  • A. Milk
  • B. Orange juice
  • C. Jello
  • D. Ice cream
Correct Answer: C

Rationale: The correct answer is C: Jello. A clear liquid diet includes transparent liquids that do not contain any solid particles, providing easily digestible nutrients. Jello meets these criteria as it is a clear, gelatin-based dessert that melts into a liquid form at room temperature.

Rationale:
1. Jello is a clear liquid that does not contain solid particles, making it suitable for a clear liquid diet.
2. Milk (A) and ice cream (D) are not considered clear liquids as they contain fats and proteins, which are not allowed on a clear liquid diet.
3. Orange juice (B) contains pulp and fibers, making it unsuitable for a clear liquid diet.

Summary:
Jello is the correct choice because it meets the criteria of being a clear liquid without solid particles. Milk, orange juice, and ice cream are not appropriate choices for a clear liquid diet due to their composition.

Halfway through the administration of a unit of blood, a client complains of lumbar pain. The nurse should:

  • A. Obtain vita! Signs
  • B. Assess the pain further
  • C. Stop the transfusion
  • D. Increase the flow of normal saline SITUATION: James, A 27 basketball player sustained inhalation burn that required him to have tracheostomy due to massive upper airway edema.
Correct Answer: C

Rationale: The correct answer is C: Stop the transfusion. Lumbar pain during blood administration could indicate a transfusion reaction, such as a hemolytic reaction or fluid overload. Stopping the transfusion is crucial to prevent further harm to the client. Obtaining vital signs (A) is important but not the priority when a transfusion reaction is suspected. Assessing the pain further (B) may delay necessary intervention. Increasing the flow of normal saline (D) is not indicated and may worsen fluid overload. In this situation, stopping the transfusion is the most appropriate action to ensure client safety.

A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?

  • A. Complete the questions in chronological order.
  • B. Focus on the patient’s presenting situation.
  • C. Make accurate interpretations of the data.
  • D. Conduct an observational overview.
Correct Answer: B

Rationale: The correct answer is B: Focus on the patient’s presenting situation. In the problem-oriented approach, the nurse prioritizes the patient's immediate concerns to address them effectively. By focusing on the presenting situation first, the nurse can gather relevant data and identify key issues. This step ensures that the nurse addresses the most pressing problems promptly.

A: Completing questions in chronological order may not be necessary and could delay addressing the immediate concern.
C: Making accurate interpretations of data should come after gathering relevant information about the presenting situation.
D: Conducting an observational overview is important but should come after focusing on the patient's presenting situation to gather specific data.

A patient is having difficulty swallowing following a stroke, and a swallowing evaluation is ordered. The ff. nursing interventions might be recommended to help prevent aspiration during eating except:

  • A. Provide clear liquids only until the patient can swallow solid foods.
  • B. Have the patient swallow twice after each bite
  • C. Place food on the unaffected side of the patient’s mouth
  • D. Check if the patient’s mouth for pocketing of food
Correct Answer: A

Rationale: The correct answer is A because providing clear liquids only until the patient can swallow solid foods is not a recommended nursing intervention to prevent aspiration. Clear liquids do not require the same level of swallowing coordination as solid foods, so it may not help improve swallowing ability.

B: Having the patient swallow twice after each bite can help clear the throat and reduce the risk of aspiration.
C: Placing food on the unaffected side of the mouth can help direct the food towards the stronger side for swallowing.
D: Checking the patient's mouth for pocketing of food is important to ensure that food is not being retained in the mouth, which could lead to aspiration.

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