Nursing Process Final Exam Questions

Correct Answer: B

Rationale: The correct answer is B: Use a soft toothbrush and electric razor. Patients with bone marrow depression are at increased risk of bleeding due to low platelet count. Using a soft toothbrush and electric razor helps prevent injury to the gums and skin, reducing the risk of bleeding. Choices A, C, and D are incorrect because: A: Sleeping with the head of the bed slightly elevated is not directly related to preventing bleeding in bone marrow depression. C: Drinking citrus juices may irritate the stomach lining and are not specifically indicated for preventing bleeding. D: Increasing activity level and frequent ambulation may increase the risk of injury and bleeding in a patient with bone marrow depression.

Correct Answer: C

Rationale: The hallmark of nephritic syndrome is edema due to proteinuria leading to hypoalbuminemia. Protein loss in urine causes decreased colloid osmotic pressure, leading to fluid leaking into tissues, causing edema. Osmotic diuresis (A) is unrelated to nephritic syndrome. Hypolipidemia (B) and hyperproteinemia (D) are not characteristic of nephritic syndrome.

Correct Answer: B

Rationale: The correct answer is B: Drowsiness. Muscle relaxants can cause drowsiness as a common side effect due to their sedative properties. This can impair alertness and coordination, so it's crucial for the patient to be aware of this potential effect. Choice A, hypoglycemia, is not typically associated with muscle relaxants. Choice C, hypotension, is more commonly linked to medications like antihypertensives. Choice D, dyspnea, which is difficulty breathing, is not a common side effect of muscle relaxants. Therefore, the nurse should primarily focus on educating the patient about the potential side effect of drowsiness.

Correct Answer: C

Rationale: The nurse would identify platelets at 115,000/ul as an abnormal finding because it is below the normal range of 150,000-450,000/ul. Low platelet count can lead to increased bleeding risk. RBC count and hematocrit levels are within normal ranges, making them normal findings. Option D is incorrect as platelets are abnormal.

Correct Answer: A

Rationale: The correct answer is A because pursed lip breathing helps to slow down and control the exhalation process, allowing the individual to exhale a smaller volume of air with more force. This helps to prevent air trapping in the lungs, improve oxygen exchange, and reduce shortness of breath. B: Incorrect - Pursed lip breathing does not increase expiration but rather controls it. C: Incorrect - While pursed lip breathing can promote deep breathing and better oxygen exchange, its primary purpose is to regulate exhalation volume. D: Incorrect - Pursed lip breathing does not specifically target the upper thorax but rather facilitates a more efficient breathing pattern by reducing air trapping in the lungs.