Fundamentals Nursing Process Questions

Correct Answer: A

Rationale: The correct answer is A: Client�s wife. She is the primary source of information as she witnessed the event firsthand and provided relevant details. In this scenario, the wife's account of the event is crucial in understanding the sequence of events leading to the client's unconscious condition. Medical documents (B), test results (C), and assessment data (D) are all secondary sources of information that may provide additional data but do not have the same level of immediacy or firsthand knowledge as the client's wife. In an emergency situation, information from a reliable eyewitness is often the most valuable initial source for healthcare providers to make critical decisions.

Correct Answer: A

Rationale: The correct answer is A: Neutrophil. Neutrophils are the most numerous type of WBC, typically comprising 50-70% of total WBC count. They are key players in the body's immune response, phagocytizing pathogens. Basophils, eosinophils, and lymphocytes are less numerous than neutrophils. Basophils are involved in allergic reactions, eosinophils combat parasitic infections, and lymphocytes play a critical role in adaptive immunity. However, in terms of sheer numbers, neutrophils outnumber the other types of WBC.

Correct Answer: D

Rationale: The correct answer is D: Evaluation. In the nursing process, evaluation involves determining if the patient's condition has improved and if the expected outcomes have been met. The nurse assesses the patient's progress, compares it to the expected outcomes set during planning, and determines the effectiveness of the interventions implemented. This step ensures that the care provided is meeting the patient's needs and helps in making any necessary adjustments to the care plan. Incorrect choices: A: Assessment - This step involves gathering information about the patient's condition and needs at the beginning of the nursing process. B: Planning - Involves setting goals and developing a plan of care based on the assessment data. C: Implementation - Involves carrying out the interventions outlined in the care plan to meet the patient's goals.

Correct Answer: C

Rationale: The correct answer is C. The nurse can infer that the patient is apprehensive about discharge based on the subjective data of the patient expressing fear of going home and being alone. This indicates the patient may not feel ready to leave the hospital setting. Choice A is incorrect because the patient's fear of going home suggests they may not be comfortable performing dressing changes alone. Choice B is incorrect because there is no information provided to support that the patient can begin retaking all previous medications. Choice D is incorrect as there is no indication that the fear of going home is related to the success of the surgery.

Correct Answer: C

Rationale: The correct answer is C: Wear gloves for blood/body fluid contact. This is the most appropriate action for infection control when caring for a patient with AIDS because HIV is primarily transmitted through blood and certain body fluids. Wearing gloves when coming into contact with blood or body fluids reduces the risk of transmission. Explanation for why other choices are incorrect: A: Wearing gloves at all times may not be necessary and can lead to unnecessary waste of resources. B: Wearing gown and mask at all times is excessive and not indicated unless there is a risk of exposure to blood or body fluids. D: Wearing a mask during patient contact times is not necessary unless there is a risk of exposure to respiratory secretions.