Nursing Process Exam Questions

Nursing Process Exam Questions Related

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Which of the following method if used by Wilma will best assure that the tracheostomy ties are not too tightly placed?

  • A. Wilma places 2 fingers between the tie and neck
  • B. The tracheotomy can be pulled slightly away from the neck
  • C. James’ neck veins are not engorged
  • D. Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process
Correct Answer: A

Rationale: The correct answer is A: Wilma places 2 fingers between the tie and neck. This method ensures that the tracheostomy ties are not too tightly placed by providing a standardized and easily replicable measurement. Placing 2 fingers ensures there is adequate space for proper airflow and movement without causing pressure or constriction. This method is a widely accepted practice in healthcare settings to prevent complications such as skin breakdown or restricted blood flow.

Incorrect choices:
B: The tracheotomy can be pulled slightly away from the neck - This does not provide a standardized measurement and may not accurately assess the tightness of the ties.
C: James’ neck veins are not engorged - Monitoring neck veins does not directly correlate with the tightness of tracheostomy ties.
D: Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process - This method may not accurately reflect the appropriate tightness of the ties around the neck.

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While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?

  • A. Consider cultural differences during this assessment.
  • B. Ask the patient to make eye contact to determine her affect.
  • C. Continue with the interview and document that the patient is depressed.
  • D. Notify the health care provider to recommend a psychological evaluation.
Correct Answer: A

Rationale: The correct answer is A: Consider cultural differences during this assessment. In many Asian cultures, avoiding direct eye contact is a sign of respect and humility, especially when speaking to authority figures. By being aware of this cultural norm, the nurse can avoid misinterpreting the patient's behavior as a sign of depression or dishonesty. Asking the patient to make eye contact (choice B) may make the patient uncomfortable and disrupt the therapeutic relationship. Continuing with the interview and documenting depression (choice C) without considering cultural differences can lead to inaccurate assessment and inappropriate interventions. Notifying the health care provider for a psychological evaluation (choice D) is premature and unnecessary without first understanding the cultural context of the patient's behavior.

The nurse is providing dietary instructions to a client with hypoglycemia. To control hypoglycemic episodes, the nurse should recommend:

  • A. increasing saturated fat intake and fasting in the afternoon.
  • B. increasing intake of vitamins B and D and taking iron supplements.
  • C. eating a candy bar if light-headedness occurs.
  • D. consuming a low-carbohydrate, high-protein diet and avoiding fasting.
Correct Answer: D

Rationale: The correct answer is D because a low-carbohydrate, high-protein diet helps stabilize blood sugar levels and prevents hypoglycemic episodes. Carbohydrates cause rapid spikes and drops in blood sugar, while protein helps maintain stable levels. Avoiding fasting also helps regulate blood sugar. Choice A is incorrect as increasing saturated fat and fasting can worsen hypoglycemia. Choice B is incorrect as vitamins and iron do not directly address hypoglycemia. Choice C is incorrect as relying on sugary foods like candy bars can lead to further blood sugar imbalances.

What orders would likely be included fro a client diagnosed with multiple myeloma?

  • A. Bed rest
  • B. Fluid restriction
  • C. Corticosteroid therapy
  • D. Calcium replacement therapy
Correct Answer: C

Rationale: The correct answer is C, Corticosteroid therapy. In multiple myeloma, corticosteroids are commonly used to help reduce inflammation, suppress the immune system, and slow the growth of cancer cells. This treatment can help manage symptoms and improve quality of life for the client.

A: Bed rest is not typically prescribed for multiple myeloma unless there are specific complications requiring immobilization.
B: Fluid restriction is not a common treatment for multiple myeloma unless there is a specific need to manage fluid balance.
D: Calcium replacement therapy may be necessary in some cases of multiple myeloma due to bone involvement, but it is not a primary treatment option compared to corticosteroid therapy in managing the disease.

Which of the ff. would the nurse explain to the patient is indicated by a Snellen chart finding 20/80?

  • A. The eye can see at 80 feet what the normal eye can see at 20 feet.
  • B. The eye can see at 20 feet what the normal eye can see at 80 feet.
  • C. The eye can see four times what the normal eye can see.
  • D. The eye sees normally.
Correct Answer: B

Rationale: The correct answer is B because a Snellen chart reading of 20/80 means the patient can see at 20 feet what a normal eye can see at 80 feet. This indicates that the patient's vision is below average. Choice A is incorrect because it reverses the numerator and denominator. Choice C is incorrect because it does not accurately represent the Snellen chart findings. Choice D is incorrect because 20/80 is not considered normal vision.

What is the role of a nurse during scratch test to detect allergies?

  • A. Applying the liquid test antigen
  • B. Determining the type of allergy
  • C. Measuring the length and width of the
  • D. Documenting the findings raised wheal
Correct Answer: A

Rationale: The correct answer is A: Applying the liquid test antigen. During a scratch test to detect allergies, the nurse's role is to apply the liquid test antigen onto the skin to observe the body's reaction. This antigen contains potential allergens that may trigger a response in allergic individuals. By applying this antigen, the nurse can assess if the patient develops a raised wheal or redness at the site, indicating an allergic reaction. This step is crucial in identifying specific allergens causing the patient's symptoms. Choices B, C, and D are incorrect as determining the type of allergy, measuring the length and width of the reaction, and documenting the findings are all important steps but do not directly relate to the initial action of applying the test antigen during a scratch test.