Nursing Process 1 Test Questions

Correct Answer: C

Rationale: The correct answer is C. Rolling Mr. Gabatan on his abdomen, placing a pad under his head, and covering him with any material available is the appropriate action. This position helps protect his airway and prevents potential complications from a possible spinal injury. It also allows for better assessment of his condition by healthcare professionals. Choice A is incorrect because leaving Mr. Gabatan on his back and instructing him to move can worsen any spinal injury he may have sustained. Choice B is incorrect because raising him to a sitting position can also exacerbate his condition. Choice D is incorrect because moving him without proper stabilization can lead to further injury.

Correct Answer: C

Rationale: The correct answer is C: Joint abnormalities. In rheumatoid arthritis, joint abnormalities such as swelling, warmth, and tenderness are the hallmark manifestations. Assessing joint abnormalities first is crucial as they are the primary clinical signs of the disease. Muscle weakness (A) is a common symptom but typically occurs later due to joint inflammation and disuse. Painful subcutaneous nodules (B) are present in some cases but are not as common or prominent as joint abnormalities. Gait disturbances (D) may occur as a result of joint damage, but they are secondary to the primary manifestation of joint abnormalities. By prioritizing the assessment of joint abnormalities, the nurse can promptly identify and address the most prevalent disease manifestations in rheumatoid arthritis.

Correct Answer: C

Rationale: The correct answer is C: Glucagon. In a hypoglycemic reaction, glucagon can be administered to raise blood sugar levels quickly. Glucagon works by stimulating the liver to release stored glucose into the bloodstream. This is crucial in emergencies when oral carbohydrates are not feasible. Epinephrine (A) is used for severe allergic reactions, not hypoglycemia. 50% dextrose (B) is an oral carbohydrate used for hypoglycemia but is not always practical. Hydrocortisone (D) is a corticosteroid used for inflammatory conditions, not for hypoglycemic emergencies.

Correct Answer: B

Rationale: The correct answer is B: Turn on the affected side. This position helps to promote the closure of the puncture site in the lung, reducing the risk of fluid leakage and pneumothorax. Placing the client flat in bed (A) may not allow gravity to assist in the closure of the puncture site. Turning on the unaffected side (C) may not effectively prevent fluid leakage from the puncture site. Bed rest (D) is a general instruction and does not specifically address the prevention of fluid leakage after thoracentesis.

Correct Answer: A

Rationale: The correct answer is A: Liver. Cancer cells commonly metastasize to the liver due to its rich blood supply, making it an ideal environment for tumor growth. Liver metastasis can occur from various primary cancer sites. The liver filters blood and is susceptible to receiving cancer cells circulating in the bloodstream. Metastasis to the colon (B) is less common as it is typically the primary site for colon cancer. Metastasis to the reproductive tract (C) can occur but is not as common as liver metastasis. White blood cells (D) are a part of the immune system and do not serve as a common site for cancer metastasis.