Nursing Process Test Questions

Nursing Process Test Questions Related

Review Nursing Process Test Questions related questions and content

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. In this scenario, the nurse is starting the assessment by examining a specific aspect (surgical dressing with drainage) and will likely proceed to gather more detailed information based on the initial findings. This approach involves moving from a broad overview to specific details, which is essential in assessing postoperative patients for complications.

A: Gordon’s Functional Health Patterns is a comprehensive assessment framework that covers various aspects of an individual's health, not specifically focusing on the progression from general to specific assessments in this situation.

B: Activity-exercise pattern assessment focuses on the patient's activity levels and exercise routines, which is not the primary focus of the scenario described.

D: Problem-oriented assessment is a method that involves identifying and addressing specific health issues or concerns, which is not the primary aim of the assessment approach used by the nurse in this scenario.

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What is the nurse’s firstaction?

  • A. Follow the clinical protocol for a stroke.
  • B. Review the most recent lab results for the patient’s potassium level. Assess the patient for other symptoms or problems, and then notify the health care
  • C. provider. Administer an antihypertensive medication from the stock supply, and then notify the
  • D. health care provider.
Correct Answer: B

Rationale: The correct answer is B. First, reviewing lab results for potassium level is important in assessing potential electrolyte imbalances that may contribute to the patient's symptoms. This allows for a comprehensive understanding of the patient's condition. Assessing the patient for other symptoms or problems is crucial to gather additional information. Finally, notifying the healthcare provider ensures timely communication and collaboration for appropriate care. Choice A is incorrect as following a clinical protocol for a stroke is premature without a comprehensive assessment. Choice C is incorrect as administering medication without a thorough assessment and provider notification can be dangerous. Choice D is incorrect as notifying the healthcare provider should precede administering any medication.

Patients with lymphoma are at risk for infection. Which of the ff. activities increases this risk?

  • A. Going to church
  • B. Cleaning the house
  • C. Taking a walk outside
  • D. Watching television
Correct Answer: C

Rationale: The correct answer is C: Taking a walk outside. Patients with lymphoma have weakened immune systems, making them more susceptible to infections. Walking outside exposes them to various environmental pathogens, increasing the risk of infection. Going to church (A) and cleaning the house (B) can be done in controlled environments, while watching television (D) does not involve exposure to external pathogens like going for a walk outside does. Therefore, taking a walk outside poses the highest risk for infection among the given activities.

The most likely cause of her chief complaint this morning is

  • A. A decrease in postoperative stress causing poiyuria
  • B. The onset of diabetes mellitus, an unusual complication
  • C. An expected result of the removal of the pituitary gland
  • D. A frequent complication of the hypophysectomy
Correct Answer: D

Rationale: The correct answer is D because polyuria is a common complication of hypophysectomy, the surgical removal of the pituitary gland. The pituitary gland plays a crucial role in regulating water balance in the body, and its removal can lead to excessive urine production. Choices A, B, and C are incorrect because a decrease in stress does not typically cause polyuria, diabetes mellitus is not an immediate complication of surgery, and polyuria is not an expected result of pituitary gland removal.

Which of the following positions would be most appropriate for a patient with right-sided paralysis following a stroke?

  • A. On the side with support to the back, with pillows to keep the body in alignment, hips slightly flexed, and hands tightly holding a rolled washcloth.
  • B. On the side with support to the back, pillows to keep the body in alignment, hips slightly flexed, and a washcloth placed so that fingers are slightly curled.
  • C. On the back with two large pillows under the head, pillow under" the knees, and a footboard.
  • D. On the back with no pillows used, with trochanter rolls and a footboard.
Correct Answer: B

Rationale: The correct answer is B. Placing the patient on the side with support to the back, pillows for body alignment, and a washcloth to slightly curl the fingers helps prevent contractures, aids in maintaining proper alignment, and provides support for the affected side. This position also promotes optimal blood flow and prevents pressure sores.

Choice A is incorrect because tightly holding a rolled washcloth can restrict blood flow and cause discomfort. Choice C is incorrect as lying on the back with pillows under the head and knees does not address the specific needs of right-sided paralysis. Choice D is incorrect as trochanter rolls may not provide adequate support for the paralyzed side, and no pillows can lead to pressure sores and discomfort.

A patient is admitted with a 2-month history of fatigue, SOB, pallor, and dizziness. The patient is diagnosed with idiopathic autoimmune haemolytic anemia. On reviewing the laboratory results, the nurse notes which of the following that confirms this diagnosis?

  • A. RBC fragments
  • B. Microcytic, hypochromic RBCs
  • C. Macrocytic, normochromic RBCs
  • D. Hemoglobin molecules
Correct Answer: A

Rationale: The correct answer is A: RBC fragments. In idiopathic autoimmune hemolytic anemia, the immune system attacks and destroys red blood cells, leading to hemolysis. The presence of RBC fragments in the blood smear confirms this diagnosis as it indicates mechanical damage to RBCs.

Explanation:
1. RBC fragments (schistocytes) are a hallmark of hemolysis, seen in conditions like autoimmune hemolytic anemia.
2. Microcytic, hypochromic RBCs (Choice B) are typically seen in iron deficiency anemia, not autoimmune hemolytic anemia.
3. Macrocytic, normochromic RBCs (Choice C) are characteristic of megaloblastic anemias like vitamin B12 deficiency, not autoimmune hemolytic anemia.
4. Hemoglobin molecules (Choice D) are not directly indicative of autoimmune hemolytic anemia; the presence of free hemoglobin in the blood would suggest intrav

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