Nursing Process Questions

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: C

Rationale: The nurse interprets this as respiratory alkalosis because the patient is likely experiencing hyperventilation, leading to a decrease in CO2 levels and respiratory alkalosis. This is indicated by an increase in pH and a decrease in PaCO2 on arterial blood gas analysis. Metabolic acidosis (choice B) is characterized by low pH and low bicarbonate levels, not seen in this scenario. Respiratory acidosis (choice A) is characterized by high PaCO2 levels and low pH, which is not the case here. Metabolic alkalosis (choice D) is characterized by high pH and high bicarbonate levels, which is not consistent with the patient's presentation.

Correct Answer: C

Rationale: The correct answer is C because the food pyramid suggests daily food choices based on the different food groups. It provides a visual guide on the proportions of each food group to consume for a balanced diet. It does not specify the exact number of servings (A), calculate calories (B), or divide food into four basic groups (D). The food pyramid is a tool to help individuals make healthier food choices by emphasizing variety and moderation.

Correct Answer: C

Rationale: Objective data are measurable and observable facts obtained through physical examination or diagnostic tests. In this case, "Respirations 16" is a quantifiable and observable measurement, making it objective data. It is not influenced by personal interpretation or feelings. The other choices, such as "States 'doesn't feel good'", "Reports a headache", and "Nauseated" are subjective data because they are based on the patient's feelings or experiences, which can vary depending on individual perception and interpretation, making them less reliable for making clinical decisions. By focusing on objective data like "Respirations 16", the nurse can provide a more accurate assessment of the patient's condition.

Correct Answer: C

Rationale: The correct answer is C because respirations of 16 are measurable and quantifiable, making them objective data. Subjective data, like choices A, B, and D, are based on the patient's feelings or experiences and cannot be measured or observed directly. Choice A is subjective as it relies on the patient's self-report. Choice B is subjective as it describes a symptom reported by the patient. Choice D is subjective as it reflects the patient's feeling of nausea. Objective data is essential for making accurate clinical assessments and decisions.