Nursing Process Test Questions

Correct Answer: A

Rationale: The correct answer is A: Preventing infection. With a low WBC count of 3,000/ul, the client is at high risk for infection due to compromised immune function. Priority is to prevent infection by implementing strict infection control measures, such as hand hygiene, sterile techniques, and isolation precautions. Alleviating pain (B) would be important but not the priority in this case. Controlling infection (C) is similar to preventing infection and would be a secondary intervention. Monitoring blood transfusion reactions (D) is not relevant to the client's current lab values.

Correct Answer: A

Rationale: The correct answer is A: Preventing infection. With a low WBC count of 3,000/ul, the client is at high risk for infection due to compromised immune function. Priority is to prevent infection by implementing strict infection control measures, such as hand hygiene, sterile techniques, and isolation precautions. Alleviating pain (B) would be important but not the priority in this case. Controlling infection (C) is similar to preventing infection and would be a secondary intervention. Monitoring blood transfusion reactions (D) is not relevant to the client's current lab values.

Correct Answer: B

Rationale: The correct answer is B. Administering epinephrine is the first-line treatment for anaphylactic shock to reverse hypotension and bronchoconstriction. Intubation may be necessary if airway compromise occurs despite epinephrine. Paging an anesthesiologist (A) is not the priority. Administering penicillin antidote (C) is not indicated in anaphylaxis. Inserting a urinary catheter and infusing IV fluids (D) may be necessary later but not the priority in managing anaphylactic shock.

Correct Answer: C

Rationale: The correct answer is C: Avoiding the use of carbonated beverages. Carbonated beverages often have high sodium content, which can contribute to increased sodium intake. By avoiding these beverages, the client can significantly reduce their sodium consumption. Explanation: 1. Carbonated beverages often contain added sodium for flavor enhancement. 2. By avoiding carbonated beverages, the client eliminates a significant source of hidden sodium in their diet. 3. This dietary practice directly targets reducing sodium intake without compromising other nutritional aspects of the diet. Summary of other choices: A: Increasing the use of dairy products - Dairy products do not necessarily impact sodium intake significantly. B: Using an artificial sweetener in coffee - Artificial sweeteners do not contribute to sodium intake. D: Using catsup for cooking and flavoring food - Catsup is high in sodium and would not help in reducing sodium intake.

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.