Fundamentals of Nursing Nursing Process Questions

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Rodolfo, an 85 year old, is admitted for comtinuous cramping pain as the result of intermittent claudication. When conducting an initial physical assessment, the nurse is unable to palpate the pedal pulses. Which of the following actions should the nurse take first?

  • A. notify the physician and anticipate emergency surgery
  • B. assess the apical and radial pulses for any irregularity and notify the physician
  • C. elevate the foot of the bed and apply warm compress
  • D. obtain a Doppler and recheck the pedal pulses
Correct Answer: D

Rationale: The correct action for the nurse to take first is to obtain a Doppler and recheck the pedal pulses. This is the correct choice because it allows the nurse to further assess the circulation in the lower extremities. By using a Doppler, the nurse can accurately detect the presence or absence of pedal pulses, which is crucial in evaluating the severity of the patient's condition. This step provides objective data that can guide the next course of action.

Choice A is incorrect because emergency surgery should not be anticipated without further assessment. Choice B is incorrect as assessing apical and radial pulses is not relevant in this situation. Choice C is incorrect as elevating the foot of the bed and applying warm compress may not address the underlying circulation issue.

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A male client recently underwent a surgical procedure for a malignant tumor. As a result of the surgery, his urine is diverted to a stomal pouch. What should the nurse suggest so that he remains odor free.

  • A. Eating spicy foods
  • B. Drinking cranberry juice
  • C. Eating eggs, asparagus, or cheese
  • D. Drinking tea, coffee and colas
Correct Answer: B

Rationale: The correct answer is B: Drinking cranberry juice. Cranberry juice is known to help reduce urinary odor due to its acidic nature which can help eliminate bacteria that cause odor. It also helps to maintain urinary tract health. The other choices are incorrect because:
A: Eating spicy foods can actually increase body odor and may not have any impact on urinary odor.
C: Foods like eggs, asparagus, or cheese may contribute to strong body odor but do not specifically address urinary odor.
D: Drinking tea, coffee, and colas can potentially worsen urinary odor due to their caffeine content and impact on urinary tract health.

Emil, just had a thyroidectomy this morning. Upon awakening, he complains of circumoral tingling, has a positive Chvostek’s sign and positive Trousseau’s sign. Nurse Ofel assesses this to be an indication of:

  • A. Overstimulation of the parathyroid hormone
  • B. Insufficient iodine intake
  • C. inadvertent removal of the parathyroid
  • D. Overuse of radioactive iodine gland
Correct Answer: A

Rationale: Rationale: The correct answer is A, overstimulation of the parathyroid hormone. After a thyroidectomy, there is a risk of unintentional damage to the parathyroid glands, leading to hypoparathyroidism. Circumoral tingling, positive Chvostek’s sign, and positive Trousseau’s sign are classic signs of hypocalcemia resulting from parathyroid insufficiency. Choices B, C, and D are incorrect because they do not explain the specific symptoms observed in Emil, which are indicative of low calcium levels due to parathyroid dysfunction.

Which of the ff information should the nurse provide to clients who are prescribed rifampin?

  • A. Take medication with meals
  • B. Inform that contact lenses, if worn, may
  • C. Avoid wearing glasses become colored
  • D. Avoid tuna, aged cheese, and red wine
Correct Answer: B

Rationale: The correct answer is B because rifampin can cause discoloration of bodily fluids, including tears. If clients wear contact lenses, they need to be informed that the lenses may become colored due to this medication. This is important for the client's awareness and to prevent any potential harm to their eyes.

A: Taking medication with meals is not necessary for rifampin administration.
C: Avoiding wearing glasses is not relevant to rifampin treatment.
D: Avoiding tuna, aged cheese, and red wine is not specifically related to rifampin use.

Which method of data collection will the nurse use to establish a patient’s database?

  • A. Reviewing the current literature to determine evidence-based nursing actions
  • B. Checking orders for diagnostic and laboratory tests
  • C. Performing a physical examination
  • D. Ordering medications
Correct Answer: C

Rationale: The correct answer is C: Performing a physical examination. This method allows the nurse to directly gather patient data through observation, palpation, percussion, and auscultation. It helps in assessing the patient's overall health status, identifying any abnormalities, and establishing a baseline for further care. Reviewing literature (A) helps in evidence-based practice but does not directly collect patient data. Checking orders for tests (B) and ordering medications (D) involve actions based on data collected rather than collecting the data itself.

What are the essential nursing actions that should be taken for a client with immune system disorder? Choose all that apply

  • A. Follow agency guidelines to control
  • B. Review drug references
  • C. Advise the client on modifying the
  • D. Monitor client for depression home environment
Correct Answer: E

Rationale: The correct answer is missing from the choices provided. However, for a client with an immune system disorder, essential nursing actions include:
E: Educate the client on the importance of maintaining a healthy lifestyle, avoiding exposure to infections, and adhering to prescribed medications. This is crucial for managing the immune system disorder effectively.
Incorrect choices:
A: Following agency guidelines is important but doesn't specifically address the client's immune system disorder.
B: Reviewing drug references may be necessary but is not a priority in managing the immune system disorder.
C: Advising the client on modifying the home environment is not directly related to managing the immune system disorder.
D: Monitoring the client for depression is important but not specific to addressing the immune system disorder.

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