Nursing Process Test Questions

Correct Answer: D

Rationale: The correct answer is D, Leucovorin. Leucovorin is administered with methotrexate to protect normal cells from methotrexate toxicity by acting as a "rescue" agent. Methotrexate inhibits dihydrofolate reductase, leading to decreased levels of tetrahydrofolate needed for DNA synthesis. Leucovorin bypasses this step by directly providing the reduced form of folic acid, thus preventing toxicity in normal cells. Probenecid (choice A) is not used to protect normal cells during methotrexate therapy. Cytarabine (choice B) and Thioguanine (choice C) are not rescue agents for methotrexate toxicity.

Correct Answer: B

Rationale: The correct answer is B. Placing the patient on the side with support to the back, pillows for body alignment, and a washcloth to slightly curl the fingers helps prevent contractures, aids in maintaining proper alignment, and provides support for the affected side. This position also promotes optimal blood flow and prevents pressure sores. Choice A is incorrect because tightly holding a rolled washcloth can restrict blood flow and cause discomfort. Choice C is incorrect as lying on the back with pillows under the head and knees does not address the specific needs of right-sided paralysis. Choice D is incorrect as trochanter rolls may not provide adequate support for the paralyzed side, and no pillows can lead to pressure sores and discomfort.

Correct Answer: D

Rationale: The correct answer is D: The client is experiencing a mild overdosage. Tinnitus is a common symptom of aspirin toxicity. Aspirin overdose can lead to tinnitus due to its ototoxic effects. This occurrence indicates that the client may be taking too much aspirin, resulting in toxicity. The other choices (A, B, C) are incorrect because tinnitus is not a normal side effect of aspirin working correctly, upper GI bleed, or a metallic taste in the mouth.

Correct Answer: D

Rationale: The correct answer is D, Leucovorin. Leucovorin is administered with methotrexate to protect normal cells from methotrexate toxicity by acting as a "rescue" agent. Methotrexate inhibits dihydrofolate reductase, leading to decreased levels of tetrahydrofolate needed for DNA synthesis. Leucovorin bypasses this step by directly providing the reduced form of folic acid, thus preventing toxicity in normal cells. Probenecid (choice A) is not used to protect normal cells during methotrexate therapy. Cytarabine (choice B) and Thioguanine (choice C) are not rescue agents for methotrexate toxicity.

Correct Answer: C

Rationale: The correct answer is C: General to specific assessment. In this scenario, the nurse is starting with a broad assessment of the surgical dressing, which is a general observation, before moving on to more specific details. This approach allows the nurse to gather comprehensive information systematically. A: Gordon�s Functional Health Patterns involves assessing a patient's health across several categories, not specifically related to wound care. B: Activity-exercise pattern assessment focuses on the patient's physical activity and exercise routines, not the wound dressing. D: Problem-oriented assessment involves identifying and addressing specific health issues, rather than starting with a general observation like the appearance of a surgical dressing.