Nursing Process Questions and Answers PDF

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Olympic gymnast Ms. Slovenski sufferd a great fall and suffered a great fall and fractured her femur. Approximately after 20 hours in the hospital she became dyspneic, tachypneic, and with scattered crackles in her lung fields. She is coughing up large amounts of thick, white sputum. The nurse correctly interprets this as:

  • A. respiratory compromise related to inhalation of smoke
  • B. pneumonia related to prolonged bedrest
  • C. fat embolism syndrome related to femur fracture
  • D. hypovolemic shock related to multiple trauma
Correct Answer: C

Rationale: The correct answer is C: fat embolism syndrome related to femur fracture. Fat embolism syndrome occurs when fat globules enter the bloodstream and travel to the lungs, causing respiratory distress. In this case, the patient's femur fracture likely led to fat embolism, explaining her dyspnea, tachypnea, crackles, and thick sputum. Choices A, B, and D do not align with the patient's presentation and history, making them incorrect. Choice A suggests smoke inhalation, which is not supported by the scenario. Choice B mentions pneumonia from bedrest, which is not a common complication of immobility. Choice D proposes hypovolemic shock from multiple trauma, which does not explain the respiratory symptoms and sputum production observed in the patient.

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A client who suffered a vehicular accident a few days ago is in skeletal traction. Which nursing action would BESt promote INDEPENDENCE for this patient?

  • A. tell the client to call for an analgesic before the pain felt becomes severe
  • B. encourage the patient to do leg exercises within the limits of his traction
  • C. provide an overhead trapeze for client use on the Balkan frame
  • D. provide skin care to prevent skin breakdown
Correct Answer: B

Rationale: The correct answer is B because encouraging the patient to do leg exercises within the limits of his traction promotes independence by maintaining muscle strength and mobility. This helps prevent muscle atrophy and promotes circulation. Choice A focuses on pain management but does not directly promote independence. Choice C provides assistance but does not actively involve the patient in self-care. Choice D is important for overall care but does not directly promote independence through active patient involvement.

Under which of the ff situations should a nurse notify the physician when caring for a client with lymphangitis? Choose all that apply

  • A. Affected area appears to enlarge
  • B. Red streaks extend up the arm or leg
  • C. Additional lymph nodes become
  • D. Liver and spleen become enlarged
Correct Answer: A

Rationale: Correct Answer: A

Rationale:
1. Lymphangitis is an inflammation of lymphatic vessels.
2. If the affected area appears to enlarge, it indicates possible worsening or spreading of the infection.
3. Nurse should notify the physician for further evaluation and treatment.
4. Red streaks extending up the arm or leg (B) are common signs of lymphangitis, not necessarily requiring immediate physician notification.
5. Additional lymph nodes becoming (C) is a normal response to infection and may not warrant immediate physician notification.
6. Liver and spleen enlargement (D) are not directly related to lymphangitis and do not require immediate notification.

Which of the ff suggestions should a nurse give breastfeeding mothers to prevent or eliminate mastitis and breast abscess? Choose all that apply

  • A. Offer the opposite breast at each feeding to their
  • B. Avoid frequent nursing of the infants
  • C. Avoid breastfeeding
  • D. Ensure that their hands and breasts are clean
Correct Answer: D

Rationale: Rationale:
D is correct because cleanliness helps prevent infections. Washing hands and keeping breasts clean reduces the risk of mastitis and abscesses.
A is incorrect because alternating breasts is a common practice in breastfeeding.
B is incorrect as frequent nursing helps maintain milk supply and prevent engorgement, reducing the risk of mastitis.
C is incorrect as breastfeeding itself is not a cause of mastitis or abscess; stopping abruptly can lead to further complications like engorgement.

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.

Which of the ff. problems during the immediate postoperative course ff. lumbar microdiskectomy should be reported to the physician immediately?

  • A. Incisional pain
  • B. Inability to move affected leg
  • C. Two-inch area of bleeding on dressing
  • D. Muscle spasm of affected
Correct Answer: B

Rationale: The correct answer is B because the inability to move the affected leg post lumbar microdiskectomy could indicate a serious complication like nerve damage or blood clot. This would require immediate medical attention to prevent further complications. Incisional pain (A) is common and can be managed with pain medication. A two-inch area of bleeding on the dressing (C) is concerning but can be managed with proper wound care unless it is excessive. Muscle spasm (D) is also common postoperatively and can be managed with medications or physical therapy.

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