Nursing Process Final Exam Questions

Correct Answer: B

Rationale: The correct answer is B because before discontinuing a patient's plan of care related to physical mobility, the nurse needs to evaluate whether the patient goals and outcomes have been met. This step ensures that the patient has achieved the desired level of physical mobility improvement and is ready to safely continue their care at home. A: Determining whether the patient has transportation to get home is important but not directly related to the patient's physical mobility goals and outcomes. C: Establishing a follow-up appointment is important but does not directly address the evaluation of the patient's physical mobility improvement. D: Ensuring that the patient's prescriptions are filled is crucial for medication management but does not specifically evaluate the patient's physical mobility progress.

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: A

Rationale: The correct answer is A because pursed lip breathing helps to slow down and control the exhalation process, allowing the individual to exhale a smaller volume of air with more force. This helps to prevent air trapping in the lungs, improve oxygen exchange, and reduce shortness of breath. B: Incorrect - Pursed lip breathing does not increase expiration but rather controls it. C: Incorrect - While pursed lip breathing can promote deep breathing and better oxygen exchange, its primary purpose is to regulate exhalation volume. D: Incorrect - Pursed lip breathing does not specifically target the upper thorax but rather facilitates a more efficient breathing pattern by reducing air trapping in the lungs.

Correct Answer: A

Rationale: The correct answer is A: Measure the client�s oral temperature. This is the best follow-up because it directly assesses the client's body temperature, providing objective data to confirm the presence of fever. It is essential to gather accurate information to guide appropriate interventions. Asking a colleague for assistance (B) may not address the immediate need for temperature assessment. Giving the client a clean gown and warm blankets (C) may provide comfort but does not address the need for temperature measurement. Obtaining an order for blood cultures (D) is not the initial priority when the client is showing signs of fever; temperature measurement is the first step in assessing the client's condition.

Correct Answer: B

Rationale: The correct answer is B: Apply insect repellent to clothing and exposed skin. This advice helps prevent insect bites, reducing the risk of recurrence. Insect repellent creates a barrier against insects, hence minimizing the chances of getting bitten. Other choices are incorrect as they do not directly address the prevention of insect bites. Choice A is vague and does not provide a specific preventive measure. Choice C is incorrect as thick woollen clothing may not necessarily prevent insect bites. Choice D, sunscreen lotion, protects against UV rays, not insect bites.