Nursing Process Practice Questions Quizlet

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Clients will go through operations and who have undergone surgery need the proper observation, treatment, and care. Implementing the nursing process to these patients will help reduce complications. Nurse Maria is preparing Mr. Sy for surgery. Which of the following statements by the client would indicate he is well-informed about his imminent surgery?

  • A. “ Right after the operation, I will wear the pneumatic compression device while sitting on the chair.”
  • B. “I will not eat anything after 12 pm the night befire my operation, but I sure can drink.”
  • C. “The skin preparation site is longer and wider than the actual incision site.”
  • D. “I will need to sign the consent from after I get to the operating table.”
Correct Answer: B

Rationale: The correct answer is B. Mr. Sy's statement indicates he understands the pre-operative fasting instructions, which is crucial to prevent aspiration during surgery. Not eating after midnight reduces the risk of complications.

A: Incorrect. Wearing a pneumatic compression device post-surgery is important, but this statement does not demonstrate understanding of pre-surgery preparations.
C: Incorrect. Knowing the skin preparation site size does not indicate understanding of the surgery process.
D: Incorrect. Signing the consent form at the operating table may indicate lack of understanding of the consent process and timing.

In summary, choice B is correct as it shows Mr. Sy's awareness of the fasting requirement before surgery, which is crucial for a safe operation.

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A patient is being given penicillin via IV piggyback and develops an anaphylactic reaction. Which of the following should be the nurse’s first action?

  • A. Call the doctor
  • B. Maintain the antibiotic
  • C. Call for help
  • D. Turn off the antibiotic
Correct Answer: D

Rationale: The correct answer is D: Turn off the antibiotic. This should be the nurse's first action because in an anaphylactic reaction, stopping the administration of the causative agent is crucial to prevent further harm. Continuing the antibiotic (Choice B) can worsen the reaction. Calling the doctor (Choice A) may cause a delay in the immediate intervention needed. Calling for help (Choice C) is important but turning off the antibiotic takes precedence to stop the allergen.

Which organ(s) is/are most at risk for dysfunction in a patient with a potassium level of 6.3 mEq/L?

  • A. Lungs
  • B. Liver
  • C. Kidneys
  • D. Heart
Correct Answer: D

Rationale: The correct answer is D: Heart. A potassium level of 6.3 mEq/L indicates hyperkalemia, which can lead to cardiac arrhythmias and even cardiac arrest. The heart is highly sensitive to potassium levels, as it plays a crucial role in regulating the heart's electrical activity. Elevated potassium levels can disrupt this balance, leading to serious cardiac complications.

Summary:
A: Lungs - Not directly affected by potassium levels.
B: Liver - Not directly affected by potassium levels.
C: Kidneys - Kidneys regulate potassium levels but are not the most at risk for dysfunction in this scenario.

Hypernatremia is associated with a:

  • A. Serum osmolality of 245mOsm/kg
  • B. Urine specific gravity below 1.003
  • C. Serum sodium of 150mEq/L
  • D. Combination of all of the above
Correct Answer: D

Rationale: Step 1: Hypernatremia is defined by elevated serum sodium levels (>145mEq/L).
Step 2: Serum osmolality of 245mOsm/kg is high, consistent with hypernatremia.
Step 3: Urine specific gravity below 1.003 indicates dilute urine, a common finding in hypernatremia.
Step 4: The combination of elevated serum sodium, high serum osmolality, and low urine specific gravity confirms hypernatremia.
Summary:
A: Incorrect, as high serum osmolality (not 245mOsm/kg) is associated with hypernatremia.
B: Incorrect, as low urine specific gravity (not below 1.003) is seen in hypernatremia.
C: Incorrect, as serum sodium needs to be >145mEq/L to indicate hypernatremia.

Which of the ff is a sign or symptom of asthma?

  • A. Production of abnormally thick, sticky mucus in lungs
  • B. Faulty transport of sodium in lung cells
  • C. Paroxysms or shortness of breath
  • D. Altered electrolyte balance in the sweat glands
Correct Answer: C

Rationale: The correct answer is C: Paroxysms or shortness of breath. Asthma is characterized by episodes of wheezing, coughing, chest tightness, and shortness of breath, known as paroxysms. This symptom is caused by inflammation and constriction of the airways in response to triggers such as allergens or irritants.

A: Production of abnormally thick, sticky mucus in lungs is more indicative of conditions like cystic fibrosis, not asthma.
B: Faulty transport of sodium in lung cells is associated with conditions like cystic fibrosis, not asthma.
D: Altered electrolyte balance in the sweat glands is a symptom of cystic fibrosis, not asthma.

In summary, paroxysms or shortness of breath is a key sign of asthma due to airway inflammation and constriction, distinguishing it from the other choices that are more indicative of cystic fibrosis.

An adult suffered a diving accident and is being brought in by an ambulance intubated and on backboard with a cervical collar. What is the first action the nurse would take on arrival in the hospital?

  • A. Take the client vital signs
  • B. Insert a large bore IV line
  • C. Check the lungs for equal breath sounds bilaterally
  • D. Perform a neurologic check using the Glasgow scale
Correct Answer: C

Rationale: Upon arrival, checking the lungs for equal breath sounds bilaterally is the first action. This is crucial to assess airway patency and breathing effectiveness in a patient with a history of diving accident and intubation. Ensuring proper oxygenation takes precedence over other actions. Taking vital signs, inserting an IV line, and performing a neurologic check can wait until airway and breathing are adequately assessed.

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