Nursing Process 1 Test Questions

Correct Answer: D

Rationale: The correct answer is D: To determine clients response to therapy. Evaluating BUN, creatinine, and serum electrolyte levels in a client being treated for acute pyelonephritis helps the nurse assess the effectiveness of the therapy. Changes in these levels indicate how well the kidneys are functioning and how the client is responding to treatment. Monitoring these parameters allows for adjustments in therapy if needed. Incorrect choices: A: To determine the severity of the disorder - While these tests can provide information about the severity of kidney dysfunction, the primary focus is on monitoring the response to therapy. B: To identify signs of fluid retention - While BUN and creatinine levels can indirectly indicate fluid status, the main purpose of evaluating these tests is to assess therapy response. C: To determine the location of discomfort - These tests do not provide information about the location of discomfort but rather focus on kidney function and response to treatment.

Correct Answer: A

Rationale: The correct answer is A: Daily intake and output. Monitoring fluid balance involves tracking the amount of fluids taken in and expelled from the body. Intake includes oral, IV, and tube feedings, while output includes urine, vomitus, diarrhea, and any other fluid losses. Daily intake and output provide a comprehensive view of a patient's fluid status, helping identify trends and potential issues. Vital signs (B) provide general information but not specific to fluid balance. Daily weight (C) can fluctuate due to various factors, not just fluid status. Skin turgor (D) is a late sign of dehydration and not as reliable as intake and output monitoring.

Correct Answer: A

Rationale: The correct answer is A: Vision changes. This is crucial to report immediately because tamoxifen can cause serious eye problems such as retinopathy. Vision changes could indicate a potentially serious adverse reaction that requires prompt medical attention to prevent permanent damage. Headache, hearing loss, and anorexia are not typically associated with tamoxifen use and are less urgent in nature. Reporting vision changes promptly can help prevent irreversible harm and ensure timely intervention.

Correct Answer: C

Rationale: The most pertinent nursing diagnosis for this patient is acute pain (Choice C). This is because the patient's right femur fracture would likely cause significant pain and discomfort, which is a priority to address for optimal recovery and comfort. Managing pain effectively is crucial in promoting healing and preventing complications. Posttrauma syndrome (Choice A) is not as immediate a concern in this scenario. While constipation (Choice B) and anxiety (Choice D) are important considerations, addressing acute pain takes precedence in the initial plan of care to ensure the patient's comfort and well-being.

Correct Answer: A

Rationale: The correct answer is A because green leafy vegetables and soybeans are high in Vitamin K, which counteracts the anticoagulant effect of warfarin. Warfarin works by inhibiting Vitamin K-dependent clotting factors in the liver. By consuming Vitamin K-rich foods, the medication's effectiveness is reduced, leading to an increased risk of blood clot formation. Choices B, C, and D are incorrect because they do not address the specific interaction between Vitamin K and warfarin in affecting coagulation. Choice B suggests the opposite effect of what actually occurs. Choices C and D are irrelevant to the pharmacological mechanism of warfarin.