Nursing Process 1 Test Questions

Correct Answer: B

Rationale: The correct answer is B because it follows the SMART approach: Specific (monitor heart rhythm), Measurable (continuously this shift), Achievable (feed self at all mealtimes), Relevant (shortness of breath), and Time-bound (today). Choice A lacks specificity and measurability. Choice C focuses on the nurse's action, not patient outcomes. Choice D lacks specificity and measurability, focusing on the nurse's actions rather than patient outcomes.

Correct Answer: D

Rationale: The correct answer is D: leukocytosis. Carbamazepine can cause bone marrow suppression, leading to leukocytosis. Monitoring for elevated white blood cell count is essential to detect this potential complication early. A: Adult respiratory distress syndrome is not a common complication of carbamazepine. B: Elevated levels of phenytoin is not a direct complication of carbamazepine use. C: Diplopia is a common side effect of carbamazepine, not a potential complication like leukocytosis.

Correct Answer: A

Rationale: The correct answer is A: Liver. Cancer cells commonly metastasize to the liver due to its rich blood supply, making it an ideal environment for tumor growth. Liver metastasis can occur from various primary cancer sites. The liver filters blood and is susceptible to receiving cancer cells circulating in the bloodstream. Metastasis to the colon (B) is less common as it is typically the primary site for colon cancer. Metastasis to the reproductive tract (C) can occur but is not as common as liver metastasis. White blood cells (D) are a part of the immune system and do not serve as a common site for cancer metastasis.

Correct Answer: A

Rationale: The correct answer is A: 2 and 5. Diminished breath sounds indicate possible atelectasis or pneumonia post-operatively, making coughing and deep breathing (2) and ambulation (5) crucial to prevent complications. Decreasing fluid intake (iv) can lead to dehydration, worsening the situation. Administering antibiotics (i) without further assessment may not be necessary at this point. Acetaminophen (iii) can help with fever but does not address the underlying respiratory issue.

Correct Answer: B

Rationale: The correct answer is B. Monitoring for signs of restlessness, sweating, and excessive weight loss during thyroid replacement therapy is essential in managing hyperthyroidism. Restlessness can indicate increased metabolic rate, sweating can be due to excessive heat production, and weight loss can be a sign of overactive thyroid function. Providing extra blankets (Choice A) may worsen symptoms of heat intolerance. Balancing activity and rest (Choice C) is important, but not specific to hyperthyroidism. Encouraging activity to prevent constipation (Choice D) is not directly related to managing hyperthyroidism.