Nursing Process Final Exam Questions

Correct Answer: C

Rationale: Correct Answer: C - Encourage fluid intake of 3000ml/day Rationale: Encouraging fluid intake of 3000ml/day helps to flush out bacteria from the urinary tract, reducing the risk of infection spread. Adequate hydration also prevents further stone formation. Incorrect Choices: A: Administering IV fluids and blood transfusions may not directly address the urinary tract infection. B: Administering narcotic analgesics may mask symptoms but not treat the root cause of the infection. D: Suggesting herbs or spices does not address the need for adequate fluid intake to manage the urinary tract infection.

Correct Answer: D

Rationale: The correct answer is D because a normal corneal light reflex involves light being reflected at the same spot in both eyes. This indicates that both eyes are aligned properly and focusing light in the same direction. Choice A is incorrect because it refers to accommodation, not the corneal light reflex. Choice B is incorrect as convergence is related to eye movement, not the corneal light reflex. Choice C is incorrect as pupil constriction in response to light is known as the pupillary light reflex, not the corneal light reflex.

Correct Answer: C

Rationale: The correct answer is C: "You may feel a burning sensation when the dye is injected." This is important to include in preprocedure teaching for carotid angiography because it prepares the patient for a common sensation they may experience during the procedure. Providing this information helps manage expectations and reduce anxiety. Choice A is incorrect because carotid angiography is typically done with the patient awake. Choice B is incorrect as carotid angiography usually takes around 30-60 minutes. Choice D is incorrect because there can be complications associated with carotid angiography, such as allergic reactions or damage to blood vessels.

Correct Answer: D

Rationale: Step 1: In HHNS, there is severe hyperglycemia leading to osmotic diuresis. Step 2: Osmotic diuresis causes loss of potassium in urine, leading to hypokalemia. Step 3: Hypokalemia is a common electrolyte imbalance in HHNS due to excessive urinary loss of potassium. Step 4: Therefore, the nurse should anticipate a below-normal serum potassium level in a client with HHNS. Summary: A: Elevated serum acetone level is seen in diabetic ketoacidosis, not HHNS. B: Serum alkalosis is not typically associated with HHNS. C: Serum ketone bodies are elevated in diabetic ketoacidosis, not HHNS.

Correct Answer: C

Rationale: The correct answer is C: severe, unrelieved pain. Compartment syndrome is characterized by increased pressure within a muscle compartment leading to decreased blood flow and tissue damage. Severe, unrelieved pain is a hallmark sign as the pressure builds up. Weak movement of the patient's toes (choice A) could indicate nerve damage but is not specific to compartment syndrome. Decreased pedal pulses (choice B) could suggest vascular compromise but are not specific to compartment syndrome. Presence of foot pallor (choice D) could indicate poor circulation but is not a definitive sign of compartment syndrome.