Nursing Process Test Questions

Correct Answer: B

Rationale: The correct answer is B: To prevent cerebrospinal fluid (CSF) leakage. Rationale: During a spinal block, the anesthesiologist injects anesthesia into the subarachnoid space, which contains CSF. Proper positioning ensures that the anesthesia stays in place and prevents leakage of CSF, which could lead to complications such as post-dural puncture headache. Incorrect choices: A: To prevent confusion - Irrelevant to the procedure. C: To prevent seizures leakage - Seizures are not a concern with spinal blocks. D: To prevent cardiac arrhythmias - Cardiac arrhythmias are not directly related to spinal blocks.

Correct Answer: B

Rationale: The correct answer is B: Offering emotional support. In the preoperative phase, a nurse's role includes comforting and reassuring the patient to reduce anxiety and promote emotional well-being. This is crucial for the patient's overall experience and can positively impact their recovery. Obtaining preoperative orders (A) is typically the responsibility of the physician. Explaining the surgical procedure (C) is usually done by the surgeon. Providing informed consent (D) involves ensuring the patient understands the risks and benefits of the procedure, which is typically the responsibility of the healthcare provider performing the procedure.

Correct Answer: C

Rationale: The correct answer is C: Increased risk of respiratory complications. Clients with myasthenia gravis, Guillain-Barre Syndrome, or amyotrophic lateral sclerosis all experience muscle weakness, including respiratory muscles, leading to a higher risk of respiratory complications such as difficulty breathing or respiratory failure. This is due to the involvement of the neuromuscular system in these conditions. Choices A, B, and D are incorrect because they do not directly correlate with the respiratory complications commonly seen in these specific neuromuscular disorders.

Correct Answer: C

Rationale: The correct answer is C: Turn frequently every 2 hours. This is because changing positions regularly helps to relieve pressure on specific areas, reducing the risk of developing decubitus ulcers. Turning every 2 hours helps to maintain blood flow and prevent tissue damage. A: Massaging reddened areas with lotion or oils can actually cause further damage by increasing friction and pressure on the skin. B: While using a special water mattress can help distribute pressure more evenly, it is not as effective as regular turning to prevent decubitus ulcers. D: Keeping the skin clean and dry is important for overall skin health but alone is not sufficient to prevent decubitus ulcers. Regular repositioning is crucial in reducing pressure and avoiding tissue breakdown.

Correct Answer: D

Rationale: The correct answer is D: Whole grains and meats. Zinc is mainly found in animal-based foods like meats and seafood. Meats, particularly red meats, are rich sources of zinc. Whole grains like wheat, rice, and oats also contain zinc. Legumes (Choice C) are sources of other minerals but not high in zinc. Fruits and vegetables (Choices A and B) are not significant sources of zinc. The correct answer provides the best options for the cancer patient to obtain an adequate amount of zinc for recovery.