Nursing Process Test Questions

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Aling Loida, who was admitted for acute pancreatitis, starts complaining of acute abdominal pain, which of the following would be an appropriate nursing interventions by Nurse Norma?

  • A. administer morphine sulfate as ordered
  • B. obtain daily weights
  • C. maintain Aling Loida on high calorie, high protein diet
  • D. place her on supine position
Correct Answer: A

Rationale: The correct answer is A: administer morphine sulfate as ordered. This is the appropriate nursing intervention because acute abdominal pain is a common symptom of acute pancreatitis, and morphine sulfate is a commonly used medication to relieve severe abdominal pain. Administering morphine sulfate will help alleviate Aling Loida's discomfort and improve her overall well-being.

Choice B is incorrect because obtaining daily weights is not directly related to managing acute abdominal pain in this scenario. Choice C is incorrect as maintaining Aling Loida on a high calorie, high protein diet may exacerbate her symptoms due to the acute pancreatitis. Choice D is incorrect as placing her on a supine position may not address the underlying cause of the abdominal pain and could potentially worsen her condition.

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A registered nurse administers pain medication to a patient suffering from fractured ribs. Which type of nursing intervention is this nurse implementing?

  • A. Collaborative
  • B. Independent
  • C. Interdependent
  • D. Dependent
Correct Answer: D

Rationale: The correct answer is D: Dependent. In this scenario, the nurse is administering pain medication based on a healthcare provider's prescription, which demonstrates a dependent nursing intervention. The nurse is reliant on the provider's order to carry out this action. Collaborative interventions involve working with other healthcare professionals, independent interventions are actions that nurses can initiate without supervision, and interdependent interventions involve mutual goal-setting and decision-making among healthcare team members.

Why are older adults with heart and blood vessel diseases susceptible to thrombophlebitis?

  • A. Choose all that apply
  • B. IV drugs and chemicals
  • C. Impaired mobility
  • D. Compromised circulation
Correct Answer: B

Rationale: The correct answer is B: IV drugs and chemicals. Thrombophlebitis is inflammation of a vein with blood clot formation, commonly caused by irritants like IV drugs. Impaired mobility (C) and compromised circulation (D) are risk factors for thrombophlebitis, but not specific to older adults with heart and blood vessel diseases. A is incorrect as not all choices apply in this scenario.

A nurse performs an assessment on a patient. Which assessment data will the nurse use as an etiology for Acute pain?

  • A. Discomfort while changing position
  • B. Reports pain as a 7 on a 0 to 10 scale
  • C. Disruption of tissue integrity
  • D. Dull headache
Correct Answer: C

Rationale: The correct answer is C: Disruption of tissue integrity. Acute pain is typically caused by tissue damage or injury, such as a cut or a burn. The nurse would use this assessment data as an etiology for acute pain because it directly relates to the source of the pain. Discomfort while changing position (A) is a symptom of pain but does not provide the underlying cause. Reports pain as a 7 on a 0 to 10 scale (B) is a pain intensity rating and does not explain the cause of the pain. Dull headache (D) is a specific type of pain but is not relevant to the given scenario of tissue disruption.

Which of the following communication methods is not an option for a patient following laryngectomy surgery?

  • A. Placing a finger over the stoma
  • B. Using a picture board
  • C. Using a special valve that diverts air into
  • D. Learning esophageal speech the oesophagus
Correct Answer: D

Rationale: The correct answer is D because learning esophageal speech involves creating sound by pushing air from the mouth into the esophagus and then releasing it. Following laryngectomy surgery, the patient's larynx is removed, making it impossible to produce sound in this manner. Placing a finger over the stoma (A) allows the patient to redirect air through the mouth for speech, using a picture board (B) enables communication through written or visual cues, and using a special valve that diverts air into the trachea (C) allows for voice rehabilitation. In summary, options A, B, and C are valid communication methods post-laryngectomy surgery, while option D is not feasible due to the absence of the larynx.

Which of the ff. statements does the nurse understand is true concerning air conduction of sound in the ear?

  • A. It is caused by the vibration of bones in the skull.
  • B. It is less efficient than bone conduction.
  • C. It is heard longer than bone conduction.
  • D. It is caused by transmission of heat through the air.
Correct Answer: B

Rationale: The correct answer is B because air conduction is less efficient than bone conduction due to the sound waves traveling through the air in the ear canal, which can be hindered by factors like blockages or obstructions. This results in a weaker and less clear sound transmission compared to bone conduction, where sound waves are transmitted directly through the bones of the skull, bypassing any potential obstructions in the ear canal.

Incorrect choices:
A: This statement is incorrect as air conduction of sound in the ear is not caused by the vibration of bones in the skull.
C: This statement is incorrect as air conduction is typically heard for a shorter duration than bone conduction.
D: This statement is incorrect as air conduction of sound in the ear is not caused by the transmission of heat through the air, but rather by sound waves traveling through the ear canal.

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