Nursing Process Exam Questions

Correct Answer: D

Rationale: The correct answer is D because a respiratory rate of 8 breaths/min indicates respiratory depression, a serious adverse effect of morphine. Morphine is a central nervous system depressant that can suppress the respiratory drive, leading to hypoventilation and potentially respiratory failure. This is a life-threatening complication that requires immediate intervention. A: Voiding of 350mL of concentrated urine is not typically associated with morphine use. B: An irregular heart rate of 82 beats/min is within a normal range and not a common adverse effect of morphine. C: Pupils constricted and equal is a common side effect of morphine due to its action on the central nervous system, not necessarily indicating an adverse effect.

Correct Answer: A

Rationale: The correct answer is A: Facial tenderness. Sinus infections commonly present with facial tenderness due to the inflammation and pressure within the sinuses. This symptom is often accompanied by pain or pressure around the eyes, cheeks, and forehead. Photophobia (B) is more commonly associated with conditions like migraines or meningitis. Chest pain (C) is not a typical symptom of a sinus infection. Ear drainage (D) is more indicative of an ear infection rather than a sinus infection.

Correct Answer: A

Rationale: Rationale: 1. A: Blood pressure apparatus is essential to monitor for any signs of bleeding or clot formation after carotid angioplasty. 2. B: IV infusion stand is important but not the priority for immediate postoperative monitoring. 3. C: Call bell is important for the client to call for assistance but not the priority for immediate postoperative care. 4. D: Endotracheal intubation is not necessary after a carotid angioplasty and is not a priority item for bedside care. Summary: Monitoring blood pressure is crucial for detecting complications post carotid angioplasty. IV stand, call bell, and endotracheal intubation are important but not the priority in this scenario.

Correct Answer: C

Rationale: The correct answer is C: Myotic. Myotic eyedrops constrict the pupil, allowing aqueous humor to flow around the lens. Myotic agents, such as pilocarpine, work by stimulating the sphincter muscle of the iris. Osmotic eyedrops (A) reduce intraocular pressure, mydriatic eyedrops (B) dilate the pupil, and cycloplegic eyedrops (D) paralyze the ciliary muscle to prevent accommodation.

Correct Answer: B

Rationale: The correct answer is B, Altered level of consciousness, because it is a critical assessment in determining Mr. Reyes's neurological status and overall well-being. Assessing for altered level of consciousness helps identify potential neurological issues, such as brain injury or stroke, which require immediate intervention. A: Decreased carotid pulses - This is related to cardiovascular assessment, not specific to Mr. Reyes's neurological status. C: Bleeding from oral cavity - While important to assess for, it is not directly related to Mr. Reyes's neurological status. D: Absence of deep tendon-reflexes - This is a specific neurological assessment, but altered level of consciousness takes priority in this scenario.