Nursing Process Quizlet Questions

Correct Answer: B

Rationale: The correct answer is B: soften the fecal mass and lubricate the walls of the rectum and colon. First, the oil retention enema helps soften the fecal mass, making it easier to pass. Second, the oil lubricates the walls of the rectum and colon, reducing friction and making the passage of stool smoother. This helps prepare the fecal impaction for removal during the subsequent cleansing enema. Choices A, C, and D are incorrect because they do not directly address the primary goal of softening the fecal mass and lubricating the walls of the intestines to facilitate the removal of the impaction.

Correct Answer: D

Rationale: The correct answer is D: Active listening. Active listening involves fully concentrating, understanding, responding, and remembering what is being said. In end-of-life care, it is crucial to provide emotional support and create a safe space for clients and their families to express their thoughts and feelings. Active listening helps the nurse to establish trust, show empathy, and validate the emotions of the clients and their families. Reflection (A), Clarification (B), and Interpretation (C) may be beneficial in certain situations, but in end-of-life care, active listening plays a pivotal role in fostering meaningful and supportive communication.

Correct Answer: A

Rationale: The correct answer is A: Bleeding precautions. With low platelets (50,000/ul), the client is at risk for bleeding. Platelets help with blood clotting, so precautions to prevent bleeding are essential. This includes avoiding activities that can cause injury, using a soft toothbrush, and reporting any signs of bleeding. Summary: B: Isolation to prevent infection - This is not related to the client's lab values. C: Seizure precautions - Not relevant to the client's lab values. D: Control of pain with analgesics - Pain management is not the priority given the client's lab values indicating a risk of bleeding.

Correct Answer: C

Rationale: The correct answer is C because it clearly states a measurable outcome by specifying that the client will be able to list five symptoms of infection. This outcome is specific, measurable, achievable, relevant, and time-bound (SMART). Choice A lacks specificity and measurability. Choice B is vague and does not provide a quantifiable measure of success. Choice D does not specify who will be observing the symptoms or how they will be documented. Overall, choice C stands out as the most appropriate outcome as it is clear, achievable, and directly related to assessing the client's understanding of infection symptoms.

Correct Answer: D

Rationale: The correct answer is D because asking the patient about their usual sleep patterns and onset of difficulty resting is crucial to understand the situation fully. This helps to identify any potential underlying issues contributing to the sleep disturbance. Choice A is incorrect as it dismisses the patient's concerns. Choice B is not as effective as directly addressing the patient's sleep issues. Choice C delays the assessment, potentially missing important information. By choosing answer D, the nurse can gather valuable information to address the patient's sleep problem effectively.