Fundamentals of Nursing Nursing Process Questions

Fundamentals of Nursing Nursing Process Questions Related

Review Fundamentals of Nursing Nursing Process Questions related questions and content

The nurse is caring for a client with type I diabetes mellitus who exhibits confusion, light-headedness, and aberrant behavior. The client is still conscious. The nurse should first administer:

  • A. I.M. or subcutaneous glucagon.
  • B. I.V. bolus of dextrose 50%.
  • C. 15 to 20 g of a fast-acting carbohydrate such as orange juice.
  • D. 10 U of fast-acting insulin.
Correct Answer: C

Rationale: The correct answer is C: 15 to 20 g of a fast-acting carbohydrate such as orange juice. In this scenario, the client is experiencing hypoglycemia, which can lead to confusion and abnormal behavior. Administering fast-acting carbohydrates like orange juice will help quickly raise the blood sugar levels. This is the first-line treatment for conscious patients with hypoglycemia.

Choice A (I.M. or subcutaneous glucagon) is used for unconscious patients or when oral intake is not possible. Choice B (I.V. bolus of dextrose 50%) is too aggressive for a conscious patient and may lead to complications. Choice D (10 U of fast-acting insulin) would further lower the blood sugar levels and worsen the situation.

Administering fast-acting carbohydrates is the safest and most effective approach for conscious patients with hypoglycemia to quickly raise their blood sugar levels and resolve their symptoms.

You may also like to solve these questions

What is the nurse’s primary legal responsibility when implementing nursing interventions?

  • A. Ensure client safety
  • B. Follow physician orders precisely
  • C. Document care comprehensively
  • D. Provide client-centered education
Correct Answer: A

Rationale: The correct answer is A: Ensure client safety. This is the nurse's primary legal responsibility as it aligns with the ethical principle of beneficence, prioritizing the well-being and safety of the client. Ensuring client safety is essential to prevent harm and promote positive health outcomes. Following physician orders precisely (B) is important but not the primary legal responsibility of the nurse. Documenting care comprehensively (C) is crucial for accountability and continuity of care but is not the primary legal responsibility. Providing client-centered education (D) is essential for empowering clients but is not the primary legal responsibility in terms of legal accountability and duty of care.

A nurse completes a thorough database and carries out nursing interventions based on priority diagnoses. Which action will the nurse take next?

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

Rationale: The correct answer is D: Evaluation. After implementing nursing interventions based on priority diagnoses, the nurse must evaluate the effectiveness of these interventions to determine if the desired outcomes have been achieved. Evaluation is crucial to assess the progress, make necessary modifications, and ensure the effectiveness of the care provided. Assessment (A) is already completed before interventions are carried out. Planning (B) involves developing a care plan based on assessment findings. Implementation (C) is the actual carrying out of the interventions. Therefore, the next step after implementing nursing interventions is to evaluate their effectiveness.

The nurse is caring for a client with bronchogenic carcinoma. Which nursing diagnosis takes highest priority?

  • A. Disturbed body image related to changes in body functions
  • B. Ineffective airway clearance related to obstruction by a tumor or secretions
  • C. Anxiety related to actual threat to health status and changes in family dynamics
  • D. Imbalanced nutrition: Less than body requirements related to anorexia and vomiting secondary to chemotherapy
Correct Answer: B

Rationale: The correct answer is B: Ineffective airway clearance related to obstruction by a tumor or secretions. This takes highest priority as compromised airway can lead to respiratory distress and potential respiratory failure. Maintaining clear airways is essential for oxygenation and ventilation. Choices A, C, and D are important but do not pose immediate life-threatening risks compared to compromised airway. Disturbed body image, anxiety, and imbalanced nutrition can be addressed once the airway clearance is stabilized.

A nurse is preparing an IM injection of prednisolone acetate, 30 mg. It is supplied as 50 mg/mL. How many mL should the nurse prepare?

  • A. 0.5 mL
  • B. 0.7 mL
  • C. 0.6 mL
  • D. 0.8 mL
Correct Answer: B

Rationale: To calculate the mL needed for the injection, divide the prescribed dose by the concentration of the medication. In this case, 30 mg ÷ 50 mg/mL = 0.6 mL. However, since the nurse should round up to ensure the full dose is administered, the correct answer is 0.7 mL. Choice A is incorrect as it is rounded down. Choice C is incorrect as it is the exact division without rounding up. Choice D is incorrect as it is rounded up too much.

Which of the following responses indicates sympathetic nervous system function?

  • A. Tachycardia, dilated pupils
  • B. Hypoglycaemia, headache
  • C. Increased peristalsis, abdominal cramping
  • D. Pupil constriction, bronchoconstriction
Correct Answer: A

Rationale: The correct answer is A because tachycardia (increased heart rate) and dilated pupils are classic responses of the sympathetic nervous system activation. Sympathetic nervous system is responsible for the fight or flight response, leading to increased heart rate and dilated pupils to prepare the body for quick action.

Choice B is incorrect because hypoglycemia and headache are not specific to sympathetic nervous system function. Choice C is incorrect because increased peristalsis and abdominal cramping are more indicative of parasympathetic nervous system activity. Choice D is incorrect because pupil constriction and bronchoconstriction are actions of the parasympathetic nervous system, responsible for rest and digest functions.

Copyright © 2025 Nokea. All rights reserved.