Nursing Process Exam Questions

Nursing Process Exam Questions Related

Review Nursing Process Exam Questions related questions and content

When the nurse inspects a postoperative incision site for infection, which one of the following types of assessments is being performed?

  • A. Complete
  • B. Focused
  • C. General
  • D. Time-lapse
Correct Answer: B

Rationale: The correct answer is B: Focused. When a nurse inspects a postoperative incision site for infection, they are conducting a focused assessment. This type of assessment is specific to a particular issue or body system, in this case, the incision site. By focusing solely on the incision site, the nurse can thoroughly evaluate for signs of infection, such as redness, swelling, warmth, or discharge.

A: Complete assessments involve a comprehensive evaluation of all body systems and are not necessary for this specific situation.
C: General assessments are broad and not targeted towards a specific issue like infection at an incision site.
D: Time-lapse assessments involve comparing current findings to previous assessments over a period of time, which is not relevant to immediately identifying signs of infection.

In summary, the correct answer is focused because it allows for a detailed evaluation of the incision site specifically for signs of infection, unlike the other options that are either too broad or not relevant to the situation.

You may also like to solve these questions

Which of the ff precautions must a nurse take while caring for clients with HIV/AIDS to reduce occupational risks?

  • A. Transport specimens of body fluid in leakproof containers
  • B. Seek prescription for a fusion inhibitor to reduce risk of infection
  • C. Avoid administering IV drugs
  • D. Avoid cleaning the clients room, esp cleaning urine, stool, or vomit
Correct Answer: A

Rationale: The correct answer is A. Transporting specimens of body fluid in leakproof containers reduces the risk of exposure to HIV/AIDS. This precaution ensures that any potentially infectious material is securely contained. Choice B is incorrect as fusion inhibitors are not prescribed for reducing occupational risks. Choice C is incorrect as it does not directly address reducing occupational risks related to HIV/AIDS. Choice D is incorrect as it is essential for a nurse to clean the client's room, but with proper precautions in place to prevent exposure to bodily fluids.

Which of the following is an adverse reaction to glipizide (Glucotrol)?

  • A. Headache
  • B. Hypotension
  • C. Constipation
  • D. Photosensitivity
Correct Answer: B

Rationale: The correct answer is B: Hypotension. Glipizide is a sulfonylurea medication used to treat diabetes by lowering blood sugar levels. Hypotension, or low blood pressure, can be an adverse reaction as glipizide may cause vasodilation leading to a drop in blood pressure. Headache (choice A), constipation (choice C), and photosensitivity (choice D) are not common adverse reactions associated with glipizide use. Headache may occur due to other factors, constipation is more commonly associated with opioids, and photosensitivity is typically seen with certain antibiotics or NSAIDs.

Which of the ff. nursing actions prepares a patient for a lumbar puncture?

  • A. Administering enemas until clear
  • B. Positioning the patient on his or her side
  • C. Removing all metal jewelry
  • D. Removing the patient’s dentures
Correct Answer: B

Rationale: The correct answer is B: Positioning the patient on his or her side. This is essential for a lumbar puncture as it helps to open up the spinal spaces, making it easier and safer for the procedure. Positioning the patient on their side also helps prevent complications such as nerve damage or spinal fluid leakage.

A: Administering enemas until clear is unnecessary and not directly related to preparing a patient for a lumbar puncture.
C: Removing all metal jewelry is important to prevent interference with imaging studies, but it is not directly related to preparing for a lumbar puncture.
D: Removing the patient’s dentures is not specifically required for a lumbar puncture procedure.

A client in the terminal stage of cancer is receiving continuous infusion of morphine (Duramorph) for pain management. Which assessment finding suggests that the client is experiencing an adverse effect of this drug?

  • A. Voiding of 350mL of concentrated urine in
  • B. Irregular heart rate of 82 beats/min
  • C. Pupils constricted and equal
  • D. Respiratory rate of 8breaths/min
Correct Answer: D

Rationale: The correct answer is D because a respiratory rate of 8 breaths/min indicates respiratory depression, a serious adverse effect of morphine. Morphine is a central nervous system depressant that can suppress the respiratory drive, leading to hypoventilation and potentially respiratory failure. This is a life-threatening complication that requires immediate intervention.

A: Voiding of 350mL of concentrated urine is not typically associated with morphine use.
B: An irregular heart rate of 82 beats/min is within a normal range and not a common adverse effect of morphine.
C: Pupils constricted and equal is a common side effect of morphine due to its action on the central nervous system, not necessarily indicating an adverse effect.

Ms. CC’s laboratory values indicate hemoconcentration secondary to fluid loss. Which of the following intravenous solutions would be most appropriate during initial fluid replacement therapy?

  • A. 10% dextrose and saline
  • B. 5% dextrose and water
  • C. 5% dextrose and water with 60 mEq
  • D. Distilled water KCl
Correct Answer: C

Rationale: The correct answer is C: 5% dextrose and water with 60 mEq. This solution is appropriate because it provides both fluid replacement (water) and electrolyte replacement (60 mEq). The dextrose helps prevent hypoglycemia. Choice A is incorrect as 10% dextrose and saline may worsen hemoconcentration. Choice B is not ideal as 5% dextrose and water lacks electrolytes needed for fluid balance. Choice D, distilled water with KCl, is dangerous as it lacks dextrose and may lead to electrolyte imbalances.

Copyright © 2025 Nokea. All rights reserved.