Fundamentals Nursing Process Questions

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The nurse is reviewing a patient’s plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?

  • A. Etiology
  • B. Nursing diagnosis
  • C. Collaborative problem
  • D. Defining characteristic
Correct Answer: C

Rationale: The correct answer is C: Collaborative problem. In the given diagnostic statement, "Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate," the nurse needs to revise the mention of collaborative problem. The collaborative problem is a health issue that requires the expertise of multiple healthcare providers, whereas the statement provided focuses on a nursing diagnosis related to physical mobility impairment. The etiology (cause), nursing diagnosis, and defining characteristic are all relevant to the nursing diagnostic statement and do not need revision. The collaborative problem aspect is not appropriate in this context as it does not fit the criteria for a collaborative problem.

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A patient is being given Digoxin to treat heart failure. Which of the ff. is a usual adult daily dosage of digoxin (Lanoxin)?

  • A. 0.005 mg
  • B. 0.025 mg
  • C. 0.25 mg
  • D. 2.5 mg
Correct Answer: C

Rationale: Rationale:
C: 0.25 mg is the correct daily dosage of Digoxin for adults with heart failure. This dosage is within the usual range of 0.125-0.25 mg. It helps improve heart function and manage heart failure symptoms.
A: 0.005 mg is too low and ineffective.
B: 0.025 mg is also too low for therapeutic effect.
D: 2.5 mg is too high and may lead to toxicity in most adult patients.

A client is brought to the emergency department in an unconscious condition. The client’s wife hands over the previous medical files and points out that the client had suddenly fallen unconscious after trying to get out of bed. Which of the following is a primary source of information?

  • A. Client’s wife
  • B. Medical documents
  • C. Test results
  • D. Assessment data
Correct Answer: A

Rationale: The correct answer is A: Client’s wife. She is the primary source of information as she witnessed the event firsthand and provided relevant details. In this scenario, the wife's account of the event is crucial in understanding the sequence of events leading to the client's unconscious condition. Medical documents (B), test results (C), and assessment data (D) are all secondary sources of information that may provide additional data but do not have the same level of immediacy or firsthand knowledge as the client's wife. In an emergency situation, information from a reliable eyewitness is often the most valuable initial source for healthcare providers to make critical decisions.

Wilma is using a portable suction unit at home, What is the amount of suction required by James using this unit?

  • A. 2-5 mmHg
  • B. 10-15 mmHg
  • C. 5-10 mmHg
  • D. 20-25 mmHg
Correct Answer: B

Rationale: The correct answer is B (10-15 mmHg) because this range is considered safe and effective for suctioning in most cases. Lower suction pressures (such as 2-5 mmHg) may not effectively clear secretions, while higher pressures (20-25 mmHg) can cause tissue damage. Choice C (5-10 mmHg) falls within the safe range but may not provide enough suction for effective clearance. Therefore, the optimal suction pressure for James using the portable suction unit at home is 10-15 mmHg.

What is the primary purpose of the outcome identification and planning step of the nursing process?

  • A. To collect and analyze data to establish a database
  • B. To interpret and analyze data so as to identify health problems
  • C. To write appropriate client-centered nursing diagnoses
  • D. To design a plan of care for and with the client
Correct Answer: D

Rationale: The primary purpose of the outcome identification and planning step of the nursing process (step 3) is to design a plan of care for and with the client. This involves setting specific, measurable, achievable, relevant, and time-bound (SMART) goals to address the client's health problems. By involving the client in the planning process, it promotes client autonomy and ensures that the plan is tailored to their individual needs and preferences. Options A and B focus on data collection and analysis, which are steps 1 and 2 of the nursing process. Option C refers to nursing diagnosis, which is part of step 2 (diagnosis). Therefore, option D is the correct answer as it pertains to the specific purpose of the outcome identification and planning step.

A patient is admitted with symptoms of a recent weight gain, 3+ pitting edema of his feet, distended neck veins, and crackles in his lungs. Which of the following nursing diagnoses is most appropriate for this patient’s plan of care?

  • A. Deficient fluid volume
  • B. Imbalanced nutrition more than body requirements
  • C. Excess fluid volume
  • D. Noncompliance
Correct Answer: C

Rationale: The correct answer is C: Excess fluid volume. This patient is presenting with signs and symptoms of fluid overload, such as weight gain, pitting edema, distended neck veins, and crackles in the lungs. These indicate an excess of fluid in the body. Nursing care for this patient should focus on managing fluid balance.

A: Deficient fluid volume is incorrect because the patient is showing signs of fluid overload, not deficit.

B: Imbalanced nutrition more than body requirements is incorrect as the symptoms described are related to fluid volume, not nutrition intake.

D: Noncompliance is irrelevant to the patient's current symptoms and does not address the underlying issue of fluid overload.

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