Nursing Process Test Questions

Nursing Process Test Questions Related

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The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the nurse using?

  • A. Gordon’s Functional Health Patterns
  • B. Activity-exercise pattern assessment
  • C. General to specific assessment
  • D. Problem-oriented assessment
Correct Answer: C

Rationale: The correct answer is C: General to specific assessment. This type of assessment approach involves starting with a broad overview of the patient's condition and then narrowing down to specific details. In this scenario, the nurse begins by examining the surgical dressing, which is a specific aspect of the patient's condition, after which they can proceed to gather more detailed information about the drainage, wound healing, and any associated symptoms. This approach allows the nurse to systematically assess the patient's postoperative status and identify any potential issues.

A: Gordon’s Functional Health Patterns is a comprehensive framework for organizing patient data, but it does not specifically address the sequence of assessment in this scenario.
B: Activity-exercise pattern assessment focuses on the patient's activity level and exercise habits, which is not the primary concern in this situation.
D: Problem-oriented assessment involves identifying and addressing specific health problems, but it does not capture the systematic progression from general to specific assessment as seen in this scenario.

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Mr. Umali, 52-year-old male is being evaluated for acute ulcerative colitis. im preparing Mr. Umali for a barium enema, the nurse can expect that he will be:

  • A. contraindicated with cathartics
  • B. given an oil retention enema the morning of the study
  • C. instructed to swallow six radiopaque tablets the evening before the study
  • D. positioned in ahigh fowler’s position immediately following the procedure
Correct Answer: A

Rationale: The correct answer is A because cathartics can exacerbate ulcerative colitis symptoms by increasing bowel motility and causing further inflammation. Giving an oil retention enema (choice B) is not necessary for a barium enema. Ingesting radiopaque tablets (choice C) is not typically part of the preparation for a barium enema. Positioning the patient in a high Fowler's position (choice D) is not a specific requirement following the procedure. Overall, avoiding cathartics is crucial in patients with acute ulcerative colitis to prevent worsening of symptoms during the barium enema.

Which of the ff. would the nurse explain to a patient is the main purpose of a hearing aid?

  • A. Amplify background noise
  • B. Amplify musical sounds
  • C. Occlude the ear
  • D. Improve ability to hear
Correct Answer: D

Rationale: The correct answer is D: Improve ability to hear. A hearing aid is designed to improve a person's ability to hear by amplifying sound. This helps individuals with hearing loss to better understand speech and sounds in their environment.

A: Amplifying background noise is not the main purpose of a hearing aid. It may actually hinder the user's ability to focus on important sounds.
B: Amplifying musical sounds is not the primary function of a hearing aid. The main focus is on improving speech understanding.
C: Occluding the ear is not the purpose of a hearing aid. It is meant to enhance hearing, not block sound.

A client is diagnosed with rheumatoid arthritis, an autoimmune disorder. When teaching the client and family about autoimmune disorders, the nurse should provide which information?

  • A. Clients with autoimmune disorders may have false-negative but not false-positive serologic tests
  • B. Advanced medical interventions can cure most autoimmune disorders
  • C. Autoimmune disorders include connective tissue (collagen) disorders
  • D. Autoimmune disorders are distinctive, adding differential diagnosis
Correct Answer: C

Rationale: Correct Answer: C - Autoimmune disorders include connective tissue (collagen) disorders.

Rationale: Autoimmune disorders involve the immune system mistakenly attacking healthy cells and tissues in the body, which can lead to various conditions, including connective tissue disorders like rheumatoid arthritis. Providing this information to the client and family is crucial for understanding the nature of autoimmune disorders and the potential impact on the body.

Summary of other choices:
A: False-negative or false-positive serologic tests can occur in autoimmune disorders, so this statement is not specific enough to be the most appropriate information to provide.
B: Advanced medical interventions can manage symptoms but not cure autoimmune disorders, making this statement inaccurate and misleading.
D: Autoimmune disorders can present with a wide range of symptoms and can be challenging to diagnose, but this statement does not address the specific link between autoimmune disorders and connective tissue disorders.

Which iron-rich foods should the nurse encourage an anemic client requiring iron therapy to eat?

  • A. Shrimp and tomatoes
  • B. Cheese and bananas
  • C. Lobster and squash
  • D. Lamb and peaches
Correct Answer: D

Rationale: The correct answer is D (Lamb and peaches) because lamb is a good source of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant-based foods. Peaches are high in vitamin C, which enhances iron absorption. Shrimp and tomatoes (A) have some iron but are not as rich in iron as lamb. Cheese and bananas (B) are not significant sources of iron. Lobster and squash (C) also do not provide as much iron as lamb. Overall, the combination of heme iron from lamb and vitamin C from peaches makes them the most suitable choices for an anemic client requiring iron therapy.

After receiving a dose of penicillin, a client develops dyspnea and hypotension. The nurse suspects the client is experiencing anaphylactic shock. What should the nurse do first?

  • A. Page an anesthesiologist immediately and prepare to intubate the client
  • B. Administer epinephrine, as prescribed, and prepare to intubate the client if necessary
  • C. Administer the antidote for penicillin, as prescribed, and continue to monitor the client’s vital signs
  • D. Insert an indwelling urinary catheter and begin to infuse IV fluids as ordered
Correct Answer: B

Rationale: The correct answer is B. Administering epinephrine is the first-line treatment for anaphylactic shock to reverse hypotension and bronchoconstriction. Intubation may be necessary if airway compromise occurs despite epinephrine. Paging an anesthesiologist (A) is not the priority. Administering penicillin antidote (C) is not indicated in anaphylaxis. Inserting a urinary catheter and infusing IV fluids (D) may be necessary later but not the priority in managing anaphylactic shock.

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