Fundamentals Nursing Process Questions

Fundamentals Nursing Process Questions Related

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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. The nurse needs to revise the collaborative problem part of the diagnostic statement because impaired physical mobility related to tibial fracture is a nursing diagnosis, not a collaborative problem. A collaborative problem involves potential complications that require both nursing and medical interventions. In this case, impaired physical mobility is a nursing diagnosis that requires nursing interventions to address the patient's inability to ambulate. Choices A, B, and D are incorrect because they are all relevant components of a nursing diagnostic statement: A - Etiology identifies the cause of the nursing diagnosis, B - Nursing diagnosis states the health problem, and D - Defining characteristic provides evidence supporting the nursing diagnosis.

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Which of the following nursing actions is appropriate when a patient returns to his or her room after a bronchoscopy?

  • A. Order a meal because the patient has been nil per os (NPO) for 8 hours.
  • B. Encourage fluids to flush dye from the patient’s system.
  • C. Monitor the patient for return to consciousness.
  • D. Check for a gag reflex before allowing the patient to drink.
Correct Answer: D

Rationale: The correct answer is D - Check for a gag reflex before allowing the patient to drink. This is important after a bronchoscopy to prevent aspiration. Step 1: Assessing gag reflex ensures the patient can protect their airway. Step 2: Aspiration risk is high post-bronchoscopy due to sedation and possible throat numbness. Step 3: Allowing fluids without confirming gag reflex can lead to aspiration pneumonia. Other choices are incorrect. A: Ordering a meal immediately is inappropriate after NPO period. B: Encouraging fluids without assessing gag reflex may lead to aspiration. C: Monitoring consciousness is important but not directly related to post-bronchoscopy care.

A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data?

  • A. The patient can now perform the dressing changes without help.
  • B. The patient can begin retaking all of the previous medications.
  • C. The patient is apprehensive about discharge.
  • D. The patient’s surgery was not successful.
Correct Answer: C

Rationale: The correct answer is C because the patient expressing fear of going home and being alone indicates apprehension about discharge. This is supported by stable vital signs and nearly healed incision, suggesting physical recovery. Choice A is incorrect as fear of being alone does not necessarily mean the patient can perform dressing changes independently. Choice B is incorrect as resuming medications is not related to the patient's fear of being alone. Choice D is incorrect as there is no evidence to suggest the surgery was unsuccessful based on the information provided.

Which of the following is the most numerous type of white blood cell (WBC)?

  • A. Neutrophil
  • B. Basophil
  • C. Eosinophil
  • D. Lymphocyte
Correct Answer: A

Rationale: The correct answer is A: Neutrophil. Neutrophils are the most numerous type of WBC, typically comprising 50-70% of total WBC count. They are key players in the body's immune response, phagocytizing pathogens. Basophils, eosinophils, and lymphocytes are less numerous than neutrophils. Basophils are involved in allergic reactions, eosinophils combat parasitic infections, and lymphocytes play a critical role in adaptive immunity. However, in terms of sheer numbers, neutrophils outnumber the other types of WBC.

What is the focus of a diagnostic statement for a collaborative problem?

  • A. The client problem
  • B. The potential complication
  • C. The nursing diagnosis
  • D. The medical diagnosis
Correct Answer: B

Rationale: The correct answer is B: The potential complication. In a collaborative problem, the focus of a diagnostic statement should be on identifying potential complications that may arise due to the client's health issue. This is important for developing effective interventions to prevent or manage these complications. Choice A focuses on the client's problem itself, not on potential complications. Choice C is related to nursing diagnosis, not collaborative problems. Choice D refers to medical diagnosis, which is different from collaborative problems involving nursing and other healthcare disciplines. Therefore, B is the correct focus for a diagnostic statement in a collaborative problem scenario.

A client seeks care for hopeless that has lasted for 1 month. To elicit the most appropriate information about this problem, the nurse should ask which question.

  • A. “Do you smoke cigarettes, cigars or pipe?”
  • B. “Do you eat a lot of red meat?”
  • C. “Have you strained your voice recently?”
  • D. “Do you eat spicy foods?”
Correct Answer: C

Rationale: The correct answer is C because asking if the client has strained their voice recently is the most relevant question to assess the issue of hopelessness. Voice strain can be a symptom of underlying emotional distress or mental health concerns, which could be contributing to the client's feelings of hopelessness. Choices A, B, and D are unrelated to the client's presenting issue and would not provide valuable information in addressing the problem at hand.

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