Nursing Process Exam Questions

Nursing Process Exam Questions Related

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The nurse is reviewing a patient’s database for significant changes and discovers that the patient has not voided in over 8 hours. The patient’s kidney function lab results are abnormal, and the patient’s oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review?

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

Rationale: The correct answer is A: Diagnosis. After reviewing the patient's database and identifying concerning signs such as not voiding for over 8 hours, abnormal kidney function, and decreased oral intake, the nurse must move to the diagnosis step. In this step, the nurse will analyze the data collected to identify the patient's actual and potential health problems. This will help the nurse formulate appropriate nursing diagnoses and develop a plan of care to address the identified issues.

Choice B (Planning) comes after the diagnosis step, where specific goals and interventions are established; Choice C (Implementation) follows planning and involves executing the planned interventions; Choice D (Evaluation) is the final step where the nurse assesses the effectiveness of the interventions. In this scenario, the nurse must first determine the patient's health problems before proceeding to planning, implementing, and evaluating care.

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Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5g/dl and has vertigo when getting out of bed. The nurse suspects abnormal orthostatic changes. The vital sign values that would most support the nurse’s analysis are:

  • A. Rise in blood pressure and heart rate
  • B. Rise in blood pressure and drop in heart rate
  • C. Drop in blood pressure and rise in heart rate
  • D. none of the above
Correct Answer: C

Rationale: The correct answer is C: Drop in blood pressure and rise in heart rate. After a splenectomy, the client is at risk for orthostatic hypotension due to decreased blood volume. A drop in blood pressure and a compensatory rise in heart rate are common orthostatic changes. This occurs because the body tries to maintain perfusion to vital organs. A rise in blood pressure and heart rate (Choice A) would not align with orthostatic changes. A rise in blood pressure and drop in heart rate (Choice B) is contradictory to the body's compensatory response to maintain perfusion. Therefore, the most supportive vital sign values for abnormal orthostatic changes in this client would be a drop in blood pressure and a rise in heart rate.

The nurse is assigned to a client with acquired immunodeficiency syndrome (AIDS). When handling the client’s blood and body fluids, the nurse uses standard precautions, which include:

  • A. Wearing gloves to empty a bedpan
  • B. Wearing gown, gloves, and protective eyewear when obtaining a urine specimen via catheterization
  • C. Disposing of needles uncapped
  • D. Wearing gloves when applying eyedrops
Correct Answer: A

Rationale: The correct answer is A. Standard precautions include wearing gloves when there is a potential for contact with blood or body fluids. Emptying a bedpan involves contact with bodily fluids, thus gloves are necessary to prevent exposure to pathogens.

Choice B is incorrect because wearing a gown and protective eyewear is not necessary for obtaining a urine specimen via catheterization unless there is a risk of splashing or spraying of fluids.

Choice C is incorrect as needles should always be disposed of in a proper sharps container with the cap secured to prevent accidental needlestick injuries.

Choice D is incorrect because applying eyedrops does not involve contact with blood or body fluids, so wearing gloves is not necessary according to standard precautions.

When administering oxygen to a client, under which of the ff situations should the nurse discontinue the administration and notify the physician?

  • A. When the client’s color does not improve
  • B. When the client level of consciousness decreases
  • C. When the client is in a state of respiratory arrest
  • D. When the client cannot effectively use the diaphragm
Correct Answer: C

Rationale: The correct answer is C. When the client is in a state of respiratory arrest, immediate medical intervention is required. Discontinuing oxygen administration and notifying the physician is crucial to address the life-threatening situation. A: Improving color is a positive sign. B: Decreased consciousness may indicate a need for further assessment but does not require immediate discontinuation of oxygen. D: Inability to use the diaphragm may require intervention but does not indicate an immediate threat as respiratory arrest does.

Which of the following is not a criterion for a valid informed consent that a nurse should identify?

  • A. freely given
  • B. with coercion
  • C. has an explanation of procedures
  • D. describes the alternatives
Correct Answer: B

Rationale: The correct answer is B: with coercion. Informed consent must be freely given without any form of coercion to ensure the individual's autonomy and decision-making capacity. Coercion can lead to involuntary consent, undermining the principle of respect for autonomy. Choices A, C, and D are all criteria for valid informed consent. Choice A ensures the individual is voluntarily agreeing without any external pressure. Choice C ensures the individual understands the procedures involved, promoting transparency. Choice D ensures the individual is aware of alternative options, allowing for an informed decision-making process.

The nurse is caring for a patient who requires a complex dressing change. While in the patient’s room, the nurse decides to change the dressing. Which action will the nurse take just before changing the dressing?

  • A. Gathers and organizes needed supplies
  • B. Decides on goals and outcomes for the patient
  • C. Assesses the patient’s readiness for the procedure
  • D. Calls for assistance from another nursing staff member
Correct Answer: A

Rationale: The correct answer is A because gathering and organizing needed supplies is a crucial step before performing a complex dressing change. By ensuring all necessary supplies are readily available, the nurse can streamline the process, minimize interruptions, and promote efficiency. This step also helps maintain aseptic technique and prevent the spread of infection. Deciding on goals and outcomes (B) is important but typically done as part of the care planning process, not immediately before a dressing change. Assessing the patient's readiness (C) is also important but can be done concurrently with gathering supplies. Calling for assistance (D) may be necessary in some situations, but it is not the immediate step required just before changing the dressing.

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