Nursing Process Exam Questions

Correct Answer: D

Rationale: The correct answer is D because a class V finding on a Pap test indicates severe dysplasia or carcinoma in situ, which requires further evaluation through a biopsy to confirm the presence of abnormal cells. This finding is not normal and necessitates immediate action for diagnosis and potential treatment. Choices A, B, and C are incorrect because they do not address the urgency and seriousness of a class V finding, which mandates prompt follow-up to rule out or confirm the presence of precancerous or cancerous cells.

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 because the client remains radioactive for a period of time after the implant removal, typically around 10 days. During this time, the nurse should take precautions to limit exposure to radiation. Choice A is incorrect because bodily fluids are not highly radioactive, and proper disposal procedures should be followed. Choice C is incorrect as soiled linens should be handled appropriately to prevent contamination. Choice D is incorrect as bed rest may not be necessary, and mobility should be encouraged within safety guidelines.

Correct Answer: A

Rationale: The correct answer is A: Applying the liquid test antigen. During a scratch test to detect allergies, the nurse's role is to apply the liquid test antigen onto the skin to observe the body's reaction. This antigen contains potential allergens that may trigger a response in allergic individuals. By applying this antigen, the nurse can assess if the patient develops a raised wheal or redness at the site, indicating an allergic reaction. This step is crucial in identifying specific allergens causing the patient's symptoms. Choices B, C, and D are incorrect as determining the type of allergy, measuring the length and width of the reaction, and documenting the findings are all important steps but do not directly relate to the initial action of applying the test antigen during a scratch test.

Correct Answer: A

Rationale: The correct answer is A: Consider cultural differences during this assessment. In many Asian cultures, avoiding direct eye contact is a sign of respect, humility, or shyness, rather than an indication of depression or dishonesty. By understanding and respecting cultural norms, the nurse can build rapport and trust with the patient. This approach promotes effective communication and a positive patient-provider relationship. Option B is incorrect because forcing the patient to make eye contact may make her uncomfortable and hinder the therapeutic relationship. Option C is incorrect because assuming the patient is depressed based on cultural differences is inappropriate and may lead to misdiagnosis. Option D is incorrect because jumping to recommendations for a psychological evaluation without considering cultural differences first can be stigmatizing and unnecessary.