Nursing Process Test Bank

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Patients with Guillain-Barre Syndrome should be closely monitored. Which of the ff. parameters is most important to be checked regularly for acute complications?

  • A. BUN and creatinine
  • B. Hgb and Hct
  • C. ABG
  • D. Serum potassium
Correct Answer: C

Rationale: The correct answer is C: ABG. Monitoring ABG in Guillain-Barre Syndrome patients is crucial as they are at risk for respiratory complications like respiratory failure due to muscle weakness. ABG provides information on oxygenation, ventilation, and acid-base balance. Regular monitoring helps detect early signs of respiratory distress and guide appropriate interventions.

A: BUN and creatinine are important for assessing renal function, but they do not directly relate to acute complications in Guillain-Barre Syndrome.
B: Hgb and Hct are markers for anemia, which is not a common acute complication in Guillain-Barre Syndrome.
D: Serum potassium levels are important, but ABG monitoring takes precedence in patients with Guillain-Barre Syndrome due to the risk of respiratory issues.

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Which of the ff should the nurse identify as the earliest symptom of heart failure in many older clients?

  • A. Increased urine output
  • B. Dyspnea on exertion
  • C. Swollen joints
  • D. Nausea and vomiting
Correct Answer: B

Rationale: The correct answer is B: Dyspnea on exertion. In older clients, dyspnea on exertion is often the earliest symptom of heart failure due to decreased cardiac reserve. This occurs when the heart cannot pump enough blood to meet the body's demands during physical activity. Increased urine output (A) is not typically an early symptom of heart failure. Swollen joints (C) are more indicative of arthritis or inflammation, not necessarily heart failure. Nausea and vomiting (D) are not typical early symptoms of heart failure and are more commonly associated with gastrointestinal issues.

An African client has been diagnosed with Osteomyelitis. The nurse expects to assess which of the following?

  • A. pale, cool, tender skin at site
  • B. decreased white blood cell count
  • C. positive wound cultures
  • D. decreased erythrocyte sedimentation rate
Correct Answer: C

Rationale: The correct answer is C: positive wound cultures. Osteomyelitis is an infection of the bone that is typically diagnosed through wound cultures. This assessment helps to identify the causative organism and guide appropriate treatment. Choices A and D are not typical findings in osteomyelitis. Choice A describes symptoms of poor circulation which are not specific to osteomyelitis. Choice B, decreased white blood cell count, is typically not seen in the presence of an infection like osteomyelitis.

When can a donor and recipient of blood be considered compatible?

  • A. If there is no change in the blood color when both samples are mixed in the laboratory
  • B. If there are blood clots when both samples are mixed in the laboratory
  • C. If there is no clumping or hemolysis when both samples are mixed in the laboratory
  • D. If a blood drop does not sink when dropped in water after both samples are mixed in the laboratory
Correct Answer: C

Rationale: The correct answer is C because compatibility between blood donor and recipient is determined by the absence of clumping or hemolysis when both samples are mixed. Clumping indicates an incompatible blood type reaction, leading to potential harm. Blood clots (option B) are not indicative of compatibility but rather a sign of coagulation issues. Blood color change (option A) and blood drop sinking in water (option D) are not reliable indicators of blood compatibility. In summary, option C is correct as it directly assesses for the absence of a harmful reaction, while the other choices do not accurately determine blood compatibility.

When assessing the external ear, the nurse palpates a small protrusion of the helix called a Darwin tubercle. The nurse would document this finding as which of the following?

  • A. A normal finding
  • B. An abnormal finding
  • C. A normal finding only in the older adult
  • D. An abnormal finding only in the older adult
Correct Answer: A

Rationale: The correct answer is A: A normal finding. The Darwin tubercle is a small, painless, bony nodule at the helix of the ear and is considered a normal anatomical variation. It is present in a significant portion of the population, regardless of age. It does not indicate any pathology or abnormality. Choices B, C, and D are incorrect because the presence of a Darwin tubercle is not indicative of any abnormality, and it is not limited to older adults.

Which of the ff instructions should be given to the clients family if a client with impaired swallowing has to take solid medication?

  • A. Mix the medication with food
  • B. Use the liquid form of the medication
  • C. Check with the physician or pharmacist before crushing or breaking tablets, or opening capsules
  • D. Perform ROM exercises after the medication is administered
Correct Answer: C

Rationale: The correct answer is C because crushing or breaking tablets can alter the medication's effectiveness or cause harm. Step 1: Consult a physician or pharmacist ensures safety and effectiveness. Step 2: This step helps in determining if the medication can be safely altered for easier swallowing. Step 3: Using liquid form (B) may not always be an option. Mixing with food (A) can affect absorption. ROM exercises (D) are unrelated to medication administration.

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