Nursing Process Test Questions

Nursing Process Test Questions Related

Review Nursing Process Test Questions related questions and content

Which intervention is appropriate for the nurse caring for a client in severe pain receiving a continuous I.V. infusion of morphine?

  • A. Assisting with a naloxone challenge test before therapy begins
  • B. Discontinuing the drug immediately if signs of dependence appear
  • C. Changing the administration route to P.O. if the client can tolerate fluids
  • D. Obtaining baseline vital signs before administering the first dose
Correct Answer: D

Rationale: The correct answer is D: Obtaining baseline vital signs before administering the first dose. This intervention is crucial to establish the client's baseline condition before starting morphine therapy. Baseline vital signs provide a comparison for monitoring the client's response to the medication and detecting any adverse effects. This step ensures the nurse can identify and address any potential complications promptly.

Other choices are incorrect:
A: Assisting with a naloxone challenge test before therapy begins - Naloxone challenge test is used to diagnose opioid dependence, not appropriate for monitoring pain management.
B: Discontinuing the drug immediately if signs of dependence appear - Abrupt discontinuation can lead to withdrawal symptoms and should be managed gradually.
C: Changing the administration route to P.O. if the client can tolerate fluids - Changing the route of administration should be based on clinical indications, not solely on the client's ability to tolerate fluids.

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A client who is scheduled for a parathyroidectomy is worried about having to wear a scarf around his neck after surgery. What nursing diagnosis should the nurse document in the care plan?

  • A. Risk for impaired physical mobility due to surgery
  • B. Ineffective denial related to poor coping mechanisms
  • C. Disturbed body image related to the incision scar
  • D. Risk of injury related to surgical outcomes
Correct Answer: C

Rationale: The correct answer is C, Disturbed body image related to the incision scar. This is the most appropriate nursing diagnosis as the client's concern about wearing a scarf around his neck post-surgery indicates a potential disturbance in body image. This diagnosis addresses the client's emotional response to physical changes, which is common in surgical patients.

Choice A is incorrect because impaired physical mobility is not directly related to the client's worry about wearing a scarf. Choice B is incorrect as ineffective denial does not directly address the client's specific concern about body image. Choice D is also incorrect as the risk of injury is not the primary issue in this scenario; it is more about the client's perception of their appearance post-surgery.

In summary, the client's worry about wearing a scarf post-surgery indicates a disturbance in body image, making choice C the most appropriate nursing diagnosis.

After receiving a dose of penicillin, a client develops dyspnea and hypotension. The nurse suspects the client is experiencing anaphylactic shock. What should the nurse do first?

  • A. Page an anesthesiologist immediately and prepare to intubate the client
  • B. Administer epinephrine, as prescribed, and prepare to intubate the client if necessary
  • C. Administer the antidote for penicillin, as prescribed, and continue to monitor the client’s vital signs
  • D. Insert an indwelling urinary catheter and begin to infuse IV fluids as ordered
Correct Answer: B

Rationale: The correct answer is B. Administering epinephrine is the first-line treatment for anaphylactic shock to reverse hypotension and bronchoconstriction. Intubation may be necessary if airway compromise occurs despite epinephrine. Paging an anesthesiologist (A) is not the priority. Administering penicillin antidote (C) is not indicated in anaphylaxis. Inserting a urinary catheter and infusing IV fluids (D) may be necessary later but not the priority in managing anaphylactic shock.

When performing a neurological examination on Mr. RR, which of the following would not be considered an important or useful part of the examination?

  • A. Eye movements
  • B. Reflexes
  • C. Nuchal rigidity
  • D. Pupil size NEUROLOGIC MEDICATIONS
Correct Answer: D

Rationale: The correct answer is D because pupil size is not typically a part of a routine neurological examination. A: Eye movements are assessed to evaluate cranial nerve functions. B: Reflexes help determine the integrity of the spinal cord and peripheral nervous system. C: Nuchal rigidity is important to assess for signs of meningitis or other neurological conditions. In contrast, pupil size is more relevant in ophthalmological examinations or when assessing response to specific medications affecting the pupil size.

What is the nurse’s firstaction?

  • A. Follow the clinical protocol for a stroke.
  • B. Review the most recent lab results for the patient’s potassium level. Assess the patient for other symptoms or problems, and then notify the health care
  • C. provider. Administer an antihypertensive medication from the stock supply, and then notify the
  • D. health care provider.
Correct Answer: B

Rationale: The correct answer is B. First, reviewing lab results for potassium level is important in assessing potential electrolyte imbalances that may contribute to the patient's symptoms. This allows for a comprehensive understanding of the patient's condition. Assessing the patient for other symptoms or problems is crucial to gather additional information. Finally, notifying the healthcare provider ensures timely communication and collaboration for appropriate care. Choice A is incorrect as following a clinical protocol for a stroke is premature without a comprehensive assessment. Choice C is incorrect as administering medication without a thorough assessment and provider notification can be dangerous. Choice D is incorrect as notifying the healthcare provider should precede administering any medication.

A client with vaginal cancer asks the nurse, “What is the usual treatment for this type of cancer?” Which treatment should the nurse name?

  • A. Surgery
  • B. Radiation
  • C. Chemotherapy
  • D. Immunotherapy
Correct Answer: A

Rationale: The correct answer is A: Surgery. Surgery is the primary treatment for vaginal cancer, especially for early-stage cases. It involves removing the cancerous tissue from the vagina. Radiation (B) and chemotherapy (C) may also be used in addition to surgery in some cases, but they are not the primary treatment. Immunotherapy (D) is not a standard treatment for vaginal cancer. It is important to prioritize surgery as it directly targets and removes the cancerous cells from the affected area, increasing the chances of successful treatment and recovery.

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