Nursing Process Questions

Nursing Process Questions Related

Review Nursing Process Questions related questions and content

The nurse is working in a support group for client with acquired immunodeficiency syndrome (AIDS). Which point is most important for the nurse to stress?

  • A. Avoiding the use of recreational drugs and alcohol
  • B. Refraining from telling anyone about the diagnosis
  • C. Following safer-sex practices
  • D. Telling potential sex partners about the diagnosis, as required by the law
Correct Answer: C

Rationale: Rationale: Choice C is the correct answer because following safer-sex practices is crucial in preventing the spread of HIV/AIDS. By emphasizing this point, the nurse can educate clients on reducing the risk of transmission. Safer-sex practices include using condoms and practicing monogamy.

Choice A is incorrect because avoiding recreational drugs and alcohol, while important for overall health, is not directly related to preventing the spread of HIV/AIDS.

Choice B is incorrect as it is essential for individuals to inform their sexual partners about their HIV status to prevent transmission and ensure informed consent.

Choice D is incorrect because while it may be required by law in some places, it is not the most crucial point for preventing the spread of HIV/AIDS within a support group setting.

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Which patient should be monitored most closely for dehydration?

  • A. The 50-year-old with an ileostomy
  • B. The 72-year-old with diabetes mellitus
  • C. The 19-year-old with chronic asthma
  • D. The 28-year-old with a broken femur
Correct Answer: A

Rationale: The correct answer is A, the 50-year-old with an ileostomy, should be monitored most closely for dehydration. Patients with an ileostomy have a higher risk of dehydration due to increased fluid loss through the stoma. Monitoring their fluid intake, output, electrolyte levels, and signs of dehydration is crucial to prevent complications. The other choices are less likely to experience severe dehydration compared to the patient with an ileostomy. The 72-year-old with diabetes mellitus may be at risk for dehydration, but it is not as high a risk as the patient with an ileostomy. The 19-year-old with chronic asthma and the 28-year-old with a broken femur are not as directly related to dehydration compared to the patient with an ileostomy.

A patient’s serum sodium is within normal range. The nurse estimates that serum osmolality should be:

  • A. Less than 136mOsm/kg
  • B. Greater than 408mOsm/kg
  • C. 280 to 295mOsm/kg
  • D. 350 to 544mOsm/kg
Correct Answer: C

Rationale: The correct answer is C (280 to 295mOsm/kg) because serum osmolality is primarily determined by sodium, glucose, and blood urea nitrogen levels. Normal serum sodium range is 135-145 mEq/L, which corresponds to an osmolality range of 280-295 mOsm/kg. Choices A and B are incorrect as they do not align with normal serum sodium levels. Choice D is incorrect as it includes an excessively wide range that is not consistent with normal osmolality values.

Which nursing actions will the nurse perform in the evaluation phase of the nursing process? (Select all that apply.)

  • A. Set priorities for patient care.
  • B. Determine whether outcomes or standards are met.
  • C. Ambulate patient 25 feet in the hallway.
  • D. Document results of goal achievement.
Correct Answer: A

Rationale: In the evaluation phase of the nursing process, the nurse sets priorities for patient care to determine the effectiveness of nursing interventions. This involves comparing achieved outcomes with established goals. Choices B and D are related to evaluation as they involve determining whether outcomes or standards are met and documenting results of goal achievement, respectively. However, choice C, ambulating the patient, is an intervention that would typically occur in the implementation phase, not the evaluation phase. Therefore, the correct answer is A because setting priorities for patient care is a key component of the evaluation phase.

The nurse is gathering data on a patient. Which data will the nurse report as objective data?

  • A. States “doesn’t feel good”
  • B. Reports a headache
  • C. Respirations 16
  • D. Nauseated
Correct Answer: C

Rationale: The correct answer is C because respirations of 16 is an observable and measurable data point that can be quantified. Objective data are factual, measurable, and based on observable phenomena. In contrast, choices A, B, and D are subjective data as they rely on the patient's feelings or experiences, which are not directly measurable or observable by the nurse. Reporting a headache or feeling nauseated are subjective symptoms that are based on the patient's perception and cannot be verified without further assessment. Therefore, only choice C provides objective data that can be accurately reported by the nurse.

The nurse is gathering data on a patient. Which data will the nurse report as objective data?

  • A. States “doesn’t feel good”
  • B. Reports a headache
  • C. Respirations 16
  • D. Nauseated
Correct Answer: C

Rationale: Objective data are measurable and observable, such as vital signs. Respirations of 16 are a specific numerical measurement that can be quantified. This makes choice C the correct answer as it is factual and quantifiable. Choices A, B, and D are subjective data, as they rely on the patient's feelings or experiences, which are open to interpretation and not measurable. Therefore, the nurse should report choice C as objective data as it provides concrete information for assessment and decision-making.

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