Nursing Process Questions

Correct Answer: D

Rationale: The correct answer is D: Sigmoidoscopy. Sigmoidoscopy is a direct visualization procedure that allows for examination of the lower part of the colon and rectum, where colorectal cancer commonly occurs. This procedure can help identify any abnormal growths or polyps that may indicate cancer. Stool hematest (A) detects blood in stool but does not confirm colorectal cancer. Abdominal CT (B) provides imaging of the abdomen but may not definitively diagnose colorectal cancer. CEA scan (C) measures a tumor marker associated with colorectal cancer but is not a definitive diagnostic test. Thus, sigmoidoscopy is the most appropriate diagnostic study for confirming colorectal cancer.

Correct Answer: D

Rationale: The correct answer is D: Impaired gas exchange related to alveolar-capillary membrane changes. This nursing diagnosis is appropriate for a patient with pneumonia and lower lobe infiltrates because pneumonia causes inflammation and fluid accumulation in the alveoli, impairing gas exchange. The nurse chose this diagnosis based on the patient's chest x-ray results indicating lower lobe infiltrates, which directly affect gas exchange. Choice A is incorrect because "ineffective breathing pattern" does not specifically address the underlying physiological issue of impaired gas exchange. Choice B is incorrect as it focuses on infection risk from the chest x-ray procedure, not the patient's medical condition. Choice C is incorrect as dehydration is not directly related to pneumonia and infiltrates.

Correct Answer: A

Rationale: Correct Answer: A: Respiratory acidosis Rationale: 1. Respiratory acidosis is caused by inadequate ventilation leading to increased PCO? and decreased pH. 2. Low pH indicates acidosis, and high PCO? indicates respiratory component. 3. Metabolic acidosis (B) results from non-respiratory causes. 4. Respiratory alkalosis (C) is characterized by high pH and low PCO?. 5. Metabolic alkalosis (D) is caused by non-respiratory factors with high pH.

Correct Answer: C

Rationale: The correct answer is C (280 to 295mOsm/kg) because serum osmolality is primarily determined by sodium, glucose, and blood urea nitrogen levels. Normal serum sodium range is 135-145 mEq/L, which corresponds to an osmolality range of 280-295 mOsm/kg. Choices A and B are incorrect as they do not align with normal serum sodium levels. Choice D is incorrect as it includes an excessively wide range that is not consistent with normal osmolality values.

Correct Answer: A

Rationale: The correct size of suction catheter for James would be Fr. 5. The selection of suction catheter size is based on the patient's height and weight, as well as the secretions to be cleared. A Fr. 5 catheter is appropriate for an average adult like James, as it balances between being too small or too large. Fr. 12 and Fr. 18 are too large for his size and could cause trauma, while Fr. 10 is slightly larger than needed, increasing the risk of mucosal damage. Therefore, Fr. 5 is the most suitable choice for James.