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 as it directly addresses the underlying physiological issue of impaired gas exchange due to alveolar-capillary membrane changes. The infiltrates indicate infection and inflammation in the lower lobes, leading to difficulty in oxygen and carbon dioxide exchange. This diagnosis aligns with the patient's medical condition and helps guide nursing interventions focused on improving oxygenation. Choice A is incorrect because ineffective breathing pattern is a broad diagnosis that does not specifically address the gas exchange issue seen in pneumonia. Choice B is incorrect as the risk for infection is already present with the diagnosis of pneumonia and does not directly address the patient's current respiratory status. Choice C is incorrect as dehydration is not the primary concern in a patient with pneumonia and lower lobe infiltrates.

Correct Answer: A

Rationale: The correct answer is A because a nursing diagnosis typically consists of two parts: the problem (Risk for Aspiration) and the related factor (reduced level of consciousness). This format helps clearly identify the client's health issue and its cause. Choice B is incorrect as it refers to a nursing diagnosis focusing on the client's response. Choice C is incorrect as it describes an outcome, not a diagnosis. Choice D is incorrect as a nursing diagnosis should be based on evidence, not made without support. Therefore, the correct choice is A due to the structure and clarity it provides in identifying the client's risk.

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 as it directly addresses the underlying physiological issue of impaired gas exchange due to alveolar-capillary membrane changes. The infiltrates indicate infection and inflammation in the lower lobes, leading to difficulty in oxygen and carbon dioxide exchange. This diagnosis aligns with the patient's medical condition and helps guide nursing interventions focused on improving oxygenation. Choice A is incorrect because ineffective breathing pattern is a broad diagnosis that does not specifically address the gas exchange issue seen in pneumonia. Choice B is incorrect as the risk for infection is already present with the diagnosis of pneumonia and does not directly address the patient's current respiratory status. Choice C is incorrect as dehydration is not the primary concern in a patient with pneumonia and lower lobe infiltrates.

Correct Answer: A

Rationale: The correct answer is A: Administer the acetaminophen. The rationale is as follows: 1. The patient has a standing order for acetaminjson for headache relief. 2. The nurse has assessed that the patient needs headache relief and has not had the medication in the past 4 hours. 3. Administering the acetaminophen aligns with the prescribed treatment plan and the patient's needs. Summary: - Option B is incorrect because obtaining a verbal order is not necessary when there is a standing order. - Option C is incorrect as nursing assistive personnel should not administer medications without direct supervision. - Option D is incorrect as pain assessment should precede medication administration to ensure appropriateness.

Correct Answer: D

Rationale: The correct answer is D - Shallow breathing and increasing lethargy. This could indicate a potential complication such as respiratory distress or postoperative infection. Shallow breathing may suggest respiratory compromise, while increasing lethargy could be a sign of systemic infection or inadequate oxygenation. A: Abdominal pain is common postoperatively and can be managed with pain medication. B: Serous drainage from the incision is normal and expected in the early postoperative period. C: Hypoactive bowel sounds are common after abdominal surgery due to anesthesia and manipulation of the bowel; it typically resolves as the patient recovers. In summary, the other options are common postoperative findings, while shallow breathing and increasing lethargy are concerning signs that require immediate attention.