Nursing Process Exam Questions

Nursing Process Exam Questions Related

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The nurse in the postoperative unit prepares to receive a client after a balloon angioplasty of the carotid artery. Which of the ff items of priority should the nurse keep at the bedside for such client?

  • A. Blood pressure apparatus
  • B. IV infusion stand
  • C. Call bell
  • D. Endotracheal intubation
Correct Answer: A

Rationale: Rationale:
1. A: Blood pressure apparatus is essential to monitor for any signs of bleeding or clot formation after carotid angioplasty.
2. B: IV infusion stand is important but not the priority for immediate postoperative monitoring.
3. C: Call bell is important for the client to call for assistance but not the priority for immediate postoperative care.
4. D: Endotracheal intubation is not necessary after a carotid angioplasty and is not a priority item for bedside care.

Summary: Monitoring blood pressure is crucial for detecting complications post carotid angioplasty. IV stand, call bell, and endotracheal intubation are important but not the priority in this scenario.

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What orders would likely be included fro a client diagnosed with multiple myeloma?

  • A. Bed rest
  • B. Fluid restriction
  • C. Corticosteroid therapy
  • D. Calcium replacement therapy
Correct Answer: C

Rationale: The correct answer is C, Corticosteroid therapy. In multiple myeloma, corticosteroids are commonly used to help reduce inflammation, suppress the immune system, and slow the growth of cancer cells. This treatment can help manage symptoms and improve quality of life for the client.

A: Bed rest is not typically prescribed for multiple myeloma unless there are specific complications requiring immobilization.
B: Fluid restriction is not a common treatment for multiple myeloma unless there is a specific need to manage fluid balance.
D: Calcium replacement therapy may be necessary in some cases of multiple myeloma due to bone involvement, but it is not a primary treatment option compared to corticosteroid therapy in managing the disease.

The normal range of hemoglobin in the blood of an adult:

  • A. 7-11 mg
  • B. 14-20 mg
  • C. 12-18 mg
  • D. 20-26 mg
Correct Answer: C

Rationale: The normal range of hemoglobin in adult blood is typically between 12-18 g/dL. This range is the most common and widely accepted range based on clinical guidelines and research studies. Hemoglobin levels outside this range may indicate anemia or other health conditions. Choice A (7-11 mg) is too low for normal hemoglobin levels in adults and indicates severe anemia. Choice B (14-20 mg) is slightly higher and could be normal for some individuals, but generally, 12-18 g/dL is the standard range. Choice D (20-26 mg) is too high and may indicate dehydration or other medical conditions.

As the nurse talks to the daughter of Mr. Dela Isla, which of the following statement of the daughter will require the nurse to give further teaching?

  • A. I know the hallucinations are parts of the disease
  • B. I told her she is wrong and I explained to her what is right
  • C. I help her do some tasks he cannot do for himself
  • D. Ill turn off the TV when we go to another room
Correct Answer: B

Rationale: The correct answer is B because it indicates a confrontational and possibly disrespectful attitude towards the nurse. This can hinder effective communication and collaboration. A: Shows understanding of hallucinations. C: Demonstrates assistance to the father. D: Reflects consideration for the father's needs. B is incorrect as it does not promote positive interaction.

Following a unilateral adrenalectomy, the nurse would assess for hyperkalemia shown by which of the following?

  • A. Muscle weakness
  • B. Diaphoresis
  • C. Tremors
  • D. Constipation
Correct Answer: A

Rationale: The correct answer is A: Muscle weakness. After unilateral adrenalectomy, there is a risk of hyperkalemia due to decreased aldosterone production. Aldosterone helps regulate potassium levels in the body. Muscle weakness is a common symptom of hyperkalemia as high potassium levels can affect muscle function. Diaphoresis, tremors, and constipation are not typically associated with hyperkalemia. Diaphoresis is excessive sweating, tremors are involuntary muscle movements, and constipation is difficulty passing stool. These symptoms are not directly related to potassium imbalance.

The nurse has taught a patient with thrombocytopenia how to prevent bleeding. Which of the ff. is the best evidence that the teaching has been effective?

  • A. The patient states that he will be careful to avoid injury.
  • B. The patient can list signs and symptoms of bleeding.
  • C. The patient uses an electric razor instead of his safety razor.
  • D. The patient states when he should call the doctor.
Correct Answer: C

Rationale: The correct answer is C because using an electric razor instead of a safety razor demonstrates understanding of the risk of injury associated with thrombocytopenia. This action shows practical application of the teaching to prevent bleeding. Choice A only indicates awareness but not necessarily action. Choice B shows knowledge but not necessarily application. Choice D is related to general healthcare knowledge but not directly linked to bleeding prevention in thrombocytopenia.