Nursing Process Exam Questions

Correct Answer: A

Rationale: The correct answer is A: immediately administer pain relief. After a lobectomy, the patient may experience significant pain due to the surgical incision and chest tube insertion. Providing prompt pain relief is crucial to ensure the patient's comfort and prevent complications such as shallow breathing or limited mobility. This action will also aid in the patient's early recovery and promote better outcomes. Choice B (keep patient in semi-fowler's position) is not the priority upon arrival from the Post Anesthesia Care Unit as pain management takes precedence. Choice C (turn client every hour) is important for preventing complications but is not the immediate action required upon arrival. Choice D (notify the family to report patient's condition) is important but not as urgent as providing pain relief to the patient.

Correct Answer: C

Rationale: The correct answer is C. When the client is in a state of respiratory arrest, immediate medical intervention is required. Discontinuing oxygen administration and notifying the physician is crucial to address the life-threatening situation. A: Improving color is a positive sign. B: Decreased consciousness may indicate a need for further assessment but does not require immediate discontinuation of oxygen. D: Inability to use the diaphragm may require intervention but does not indicate an immediate threat as respiratory arrest does.

Correct Answer: D

Rationale: The correct answer is D: Restricting fluids. In SIADH, there is an excess of antidiuretic hormone leading to water retention and dilutional hyponatremia. Restricting fluids helps to prevent further water retention and hyponatremia. Rapid IV fluid infusion (A) worsens the condition by further diluting sodium levels. Administering glucose-containing IV (B) is not directly related to treating SIADH. Encouraging increased oral intake (C) can exacerbate the condition by increasing fluid intake.

Correct Answer: C

Rationale: The correct answer is C because flushing the central venous catheter with a heparinized solution before blood withdrawal is essential to maintain catheter patency and prevent clot formation. This step ensures the catheter is clear of any blockages, allowing for accurate blood sampling. Choice A is incorrect because assembling supplies should come after preparing the catheter. Choice B is incorrect as discarding blood before flushing the catheter may lead to inaccurate test results. Choice D is incorrect as replacing the catheter cap without flushing may lead to clot formation and catheter malfunction.

Correct Answer: B

Rationale: The correct answer is B: Positioning the patient on his or her side. This is essential for a lumbar puncture as it helps to open up the spinal spaces, making it easier and safer for the procedure. Positioning the patient on their side also helps prevent complications such as nerve damage or spinal fluid leakage. A: Administering enemas until clear is unnecessary and not directly related to preparing a patient for a lumbar puncture. C: Removing all metal jewelry is important to prevent interference with imaging studies, but it is not directly related to preparing for a lumbar puncture. D: Removing the patient�s dentures is not specifically required for a lumbar puncture procedure.