Nursing Process Practice Questions Quizlet

Nursing Process Practice Questions Quizlet Related

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The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error? NursingStoreRN

  • A. Assessment
  • B. Diagnosis
  • C. Implementation
  • D. Evaluation
Correct Answer: A

Rationale: The correct answer is A: Assessment. In this scenario, the nurse failed to complete a thorough assessment by not informing the nurse about the patient's condition. Assessment is the first step in the nursing process where data is collected and analyzed to identify the patient's problems. By not communicating the patient's symptoms to the nurse, the nurse missed crucial information that could have led to timely intervention.

Explanation of other choices:
B: Diagnosis - The nurse did not have the opportunity to make a diagnosis because the assessment phase was incomplete.
C: Implementation - The nurse did not reach the implementation phase yet as the assessment phase was not properly conducted.
D: Evaluation - The nurse cannot evaluate the effectiveness of interventions as the assessment and subsequent phases were not properly carried out.

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The nurse is caring for a client who is HIV positive. To prevent the spread of the HIV virus, what do the Centers for Disease Control and Prevention recommend?

  • A. Universal blood and body fluid precautions
  • B. Body systems isolation
  • C. Laminar flow room during active infection
  • D. Needle and syringe precautions
Correct Answer: A

Rationale: The correct answer is A: Universal blood and body fluid precautions. This is recommended by the CDC to prevent the spread of HIV because the virus can be present in blood and certain body fluids. Universal precautions involve treating all blood and body fluids as potentially infectious.

Incorrect choices:
B: Body systems isolation - This is not specific to preventing the spread of HIV and is not recommended by the CDC.
C: Laminar flow room during active infection - This is not a standard recommendation for preventing the spread of HIV.
D: Needle and syringe precautions - While important in preventing needlestick injuries, it is not the primary method recommended by the CDC for preventing the spread of HIV.

The nurse is teaching a client who suspects that she has a lump in her breast. The nurse instructs the client that a diagnosis of breast cancer is confirmed by:

  • A. Breast self-examination
  • B. Mammography
  • C. Fine needle aspiration
  • D. Chest x-ray
Correct Answer: C

Rationale: The correct answer is C: Fine needle aspiration. This procedure involves inserting a thin needle into the lump to extract cells for examination. It provides a definitive diagnosis of breast cancer by analyzing the cells for cancerous features. Breast self-examination (A) is a screening tool but cannot confirm a diagnosis. Mammography (B) is used for screening and detecting abnormalities but also requires further testing for diagnosis. Chest x-ray (D) is not used to diagnose breast cancer.

Which of the following medications should then nurse explain may cause headache as a side effect?

  • A. Furosemide (Lasix)
  • B. Clonidine (Catapres)
  • C. Atenolol ((Tenormin)
  • D. Adalat (Procardia)
Correct Answer: B

Rationale: The correct answer is B: Clonidine (Catapres). Clonidine is known to cause headache as a side effect due to its mechanism of action affecting blood pressure regulation in the brain. Furosemide (A) is a diuretic that typically causes electrolyte imbalances, not headaches. Atenolol (C) is a beta-blocker used for hypertension, which can cause fatigue but not typically headaches. Adalat (D) is a calcium channel blocker that usually causes peripheral edema, not headaches.

Which of the ff. does the nurse understand are the reasons a patient with pulmonary edema is given morphine sulphate? i.To reduce anxiety iv.To increase BP ii.To relieve chest pain v.To reduce preload and afterload iii.To strengthen heart contractions

  • A. 2 and 4
  • B. 3 and 5
  • C. 1 and 5
  • D. 2 and 3
Correct Answer: C

Rationale: The correct answer is C because morphine sulfate is given to a patient with pulmonary edema to reduce anxiety (i) and to reduce preload and afterload (v). Morphine sulfate does not increase blood pressure (ii), relieve chest pain (iii), or strengthen heart contractions (iv) in the context of pulmonary edema. Choice A is incorrect because it includes increasing BP, which is not a reason for giving morphine sulfate in this case. Choice B is incorrect because it includes strengthening heart contractions, which is not a reason for administering morphine sulfate. Choice D is incorrect because it includes relieving chest pain, which is not a primary purpose of giving morphine sulfate to a patient with pulmonary edema.

Maintaining the infusion rate of hyperalimentation solutions is a nursing responsibility. What side effects would you anticipate from too rapid infusion rate?

  • A. Cellular dehydration and potassium
  • B. Hypoglycemia and hypovolemia
  • C. Potassium excess and CHF
  • D. Circulatory overload and hypoglycemia SITUATION: In the recall of the fluids and electrolytes, the nurse should be able to understand the calculations and other conditions related to loss or retention.
Correct Answer: D

Rationale: Rationale:
1. Rapid infusion of hyperalimentation solutions can lead to circulatory overload due to increased fluid volume in the circulatory system.
2. Circulatory overload can result in symptoms such as hypertension, tachycardia, and edema.
3. Hypoglycemia can occur as a result of excess insulin release due to the sudden increase in glucose from the hyperalimentation solution.

Summary:
A. Cellular dehydration and potassium: Incorrect. Rapid infusion would lead to fluid overload, not dehydration.
B. Hypoglycemia and hypovolemia: Incorrect. Hypovolemia is unlikely with rapid infusion, and hypoglycemia is a possible side effect.
C. Potassium excess and CHF: Incorrect. Rapid infusion may cause circulatory overload, not CHF, and potassium excess is not a common side effect.
D. Circulatory overload and hypoglycemia: Correct. These are the most likely side effects of rapid

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