Nursing Process Test Questions

Correct Answer: C

Rationale: The correct answer is C: Weighing the client before and after the procedure. This is crucial as it helps monitor fluid removal during dialysis, ensuring the process is effective and safe. Weighing helps determine if the correct amount of fluid has been removed. A: Keeping dialysis supplies in a clean area is important for infection control but not a direct responsibility during the procedure. B: Inspecting the catheter insertion site for signs of infection is essential for monitoring the site's health but not a direct responsibility during dialysis. D: Washing hands before and after handling the catheter is a general infection control measure but not specific to the dialysis procedure itself.

Correct Answer: C

Rationale: The correct answer is C: General to specific assessment. In this scenario, the nurse is starting the assessment by examining a specific aspect (surgical dressing with drainage) and will likely proceed to gather more detailed information based on the initial findings. This approach involves moving from a broad overview to specific details, which is essential in assessing postoperative patients for complications. A: Gordon�s Functional Health Patterns is a comprehensive assessment framework that covers various aspects of an individual's health, not specifically focusing on the progression from general to specific assessments in this situation. B: Activity-exercise pattern assessment focuses on the patient's activity levels and exercise routines, which is not the primary focus of the scenario described. D: Problem-oriented assessment is a method that involves identifying and addressing specific health issues or concerns, which is not the primary aim of the assessment approach used by the nurse in this scenario.

Correct Answer: A

Rationale: The correct answer is A because subjective data refers to information reported by the client, such as their symptoms or feelings. In this case, the client experiencing nausea and loss of appetite due to chemotherapy is subjective as it is based on the client's personal experience and perception. Choice B is incorrect because the client becoming teary is an observable behavior, making it an objective data point. Choice C is incorrect as the amount of effluent from the ileostomy is a measurable and quantifiable data, making it objective. Choice D is also incorrect as the patient's unwillingness to manipulate or empty his ostomy bag is an observable behavior, not based on the client's report.

Correct Answer: D

Rationale: The correct answer is D: Strengthens heart contraction. Digoxin is an inotropic agent that works by increasing the force of the heart's contractions. This leads to improved cardiac output and helps manage conditions like heart failure. Choices A, B, and C are incorrect because digoxin does not decrease heart rate, increase conduction time, or increase heart rate. It specifically targets the strength of the heart's contractions, making option D the most appropriate choice. This action of digoxin is crucial in improving the efficiency of the heart's pumping function.

Correct Answer: C

Rationale: The correct answer is C: Muscle weakness. Metolazone is a diuretic that can lead to low potassium levels, causing muscle weakness. Instructing the patient to report muscle weakness is crucial to prevent any potential serious complications. Numb hands, gastrointestinal distress, and nightmares are not commonly associated with metolazone and do not pose as immediate risks as muscle weakness does. It is essential to prioritize the most critical side effect to ensure the patient's safety and well-being.