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: B

Rationale: The correct answer is B (10-15 mmHg) because this range is considered safe and effective for suctioning in most cases. Lower suction pressures (such as 2-5 mmHg) may not effectively clear secretions, while higher pressures (20-25 mmHg) can cause tissue damage. Choice C (5-10 mmHg) falls within the safe range but may not provide enough suction for effective clearance. Therefore, the optimal suction pressure for James using the portable suction unit at home is 10-15 mmHg.

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: C

Rationale: The correct answer is C: Cold sensitivity. Severe anemia leads to decreased oxygen delivery to tissues, causing symptoms like pallor, fatigue, and dyspnea on exertion due to the body compensating for low oxygen levels. Cold sensitivity is not a common symptom associated with anemia. The other choices are directly related to severe anemia due to the lack of oxygen delivery to tissues.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen therapy. This is the priority intervention because a high temperature and diaphoresis indicate potential respiratory distress. Oxygen therapy can help improve oxygenation and support respiratory function. Providing frequent linen changes (B) is important for hygiene but not the priority. Fluid intake (C) is essential but not as urgent as addressing respiratory distress. Maintaining complete bed rest (D) may be necessary but addressing oxygenation takes precedence in this case.