Nursing Process Quizlet Questions

Nursing Process Quizlet Questions Related

Review Nursing Process Quizlet Questions related questions and content

While the patient’s lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take?

  • A. Tell the patient to just focus on the leg and cast right now.
  • B. Document the sleep patterns and information in the patient’s chart.
  • C. Explain that a more thorough assessment will be needed next shift.
  • D. Ask the patient about usual sleep patterns and the onset of having difficulty resting.
Correct Answer: D

Rationale: The correct answer is D. Asking the patient about usual sleep patterns and the onset of having difficulty resting is the best action for the nurse to take. This allows the nurse to gather more information and assess if there is a possible correlation between the leg cast and the restless sleep. It is important to consider all aspects of the patient's condition and not dismiss any symptoms.

Choice A is incorrect because telling the patient to just focus on the leg and cast disregards the patient's concerns about restless sleep.

Choice B is incorrect as simply documenting the information without further assessment does not address the patient's issue.

Choice C is incorrect as postponing a thorough assessment to the next shift may delay necessary intervention for the patient's sleep problem.

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The nurse is preparing to administer a unit of blood to a client’s who’s anemic. After its removal from the refrigerator, the blood should be administered within:

  • A. 1 hour
  • B. 4 hours
  • C. 2 hours
  • D. 6 hours
Correct Answer: C

Rationale: The correct answer is C: 2 hours. Blood should be administered within 30 minutes to 4 hours after removal from the refrigerator to prevent bacterial growth and maintain its efficacy. Option C falls within this timeframe, ensuring safety and effectiveness. Option A (1 hour) is too short, while option B (4 hours) and option D (6 hours) exceed the recommended timeframe, increasing the risk of bacterial contamination and compromising the quality of the blood product.

The nurse performs an intervention for a collaborative problem. Which type of intervention did the nurse perform?

  • A. Dependent NursingStoreRN
  • B. Independent
  • C. Interdependent
  • D. Physician-initiated
Correct Answer: C

Rationale: The correct answer is C: Interdependent. In this scenario, the nurse performed an intervention for a collaborative problem, which involves working together with other healthcare professionals to address the issue. Interdependent interventions require collaboration and communication among healthcare team members to achieve the best outcomes for the patient.

Choice A (Dependent Nursing) refers to interventions that require an order from a healthcare provider.
Choice B (Independent) involves nursing actions that the nurse can initiate without the need for a healthcare provider's order.
Choice D (Physician-initiated) specifically denotes interventions initiated by a physician without direct involvement from the nurse.

In this case, the nurse's intervention for a collaborative problem aligns with the definition of interdependent intervention, making it the correct choice.

A 34 year old male client is diagnosed with encephalitis. Medication has been started for him and he is receiving nursing care. Which of the ff nursing interventions are the most critical for such a client? Choose all that apply

  • A. Measuring fluid intake and output
  • B. Evaluating the clients ventilation capacity and lung sound frequently
  • C. Observing closely for signs of respiratory distress
  • D. Administering an indwelling urethral catheter
Correct Answer: C

Rationale: The correct answer is C - Observing closely for signs of respiratory distress. In encephalitis, there is a risk of respiratory compromise due to brain inflammation affecting the respiratory center. Monitoring for signs of respiratory distress is critical to intervene promptly if breathing becomes compromised.

A - Measuring fluid intake and output is important but not as critical as monitoring respiratory distress in encephalitis.
B - Evaluating ventilation capacity and lung sounds is important, but close observation for respiratory distress takes precedence for immediate intervention.
D - Administering an indwelling urethral catheter is not directly related to the client's immediate critical needs in encephalitis.

Approximately how much fluid is lost in acute weight loss of .5kg?

  • A. 50 ml
  • B. 750 ml
  • C. 500 ml
  • D. 75 ml
Correct Answer: C

Rationale: The correct answer is C: 500 ml. When someone loses 0.5 kg of weight, it is estimated that about 500 ml of fluid has been lost, as 1 kg of body weight is roughly equivalent to 1 liter of fluid. This fluid loss is due to water loss through sweating, breathing, and urine. Choice A (50 ml) is too small of an amount for a significant weight loss. Choice B (750 ml) is too high and would correspond to a larger weight loss. Choice D (75 ml) is also too small to account for a 0.5 kg weight loss.

Place the following four nursing actions for the new laryngectomee in correct order of priority? i.Assist with ambulation ii.Set up a visit from a well-adjusted laryngectomee iii.Maintain a patent airway iv.Control postoperative pain

  • A. 1, 2, 3, 4
  • B. 3, 4, 1, 2
  • C. 2, 3, 4, 1
  • D. 4, 1, 2, 3
Correct Answer: C

Rationale: The correct order of priority for nursing actions for a new laryngectomee is: ii.Set up a visit from a well-adjusted laryngectomee, iii.Maintain a patent airway, iv.Control postoperative pain, i.Assist with ambulation. Setting up a visit from a well-adjusted laryngectomee comes first to provide emotional support and guidance. Maintaining a patent airway is crucial for breathing. Controlling postoperative pain is important for comfort. Assisting with ambulation is necessary but can be done after ensuring the other priorities are addressed. Other choices are incorrect because they do not prioritize emotional support, airway maintenance, and pain control before assisting with ambulation.

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