Nursing Process Practice Questions

Correct Answer: B

Rationale: The correct answer is B because the problem-oriented approach involves focusing on the patient's presenting situation to identify the main issues and prioritize data collection. This step helps the nurse understand the immediate concerns and sets the direction for further assessment and interventions. Choice A is incorrect because completing questions in chronological order may not address the most urgent issues. Choice C is incorrect as accurate interpretations come after collecting relevant data. Choice D is incorrect as conducting an observational overview is part of the assessment process but not the first step in the problem-oriented approach.

Correct Answer: D

Rationale: The correct answer is D: �Your heart is not an efficient pump.� This response is the best choice as it accurately describes heart failure, which is a condition where the heart is unable to pump blood effectively. This leads to symptoms such as fatigue, shortness of breath, and fluid retention. Explanation: 1. Choice A is incorrect because heart failure does not mean the heart stops; it means the heart is not functioning properly. 2. Choice B is incorrect because heart failure does not necessarily mean there is dead muscle tissue in the heart. 3. Choice C is incorrect because heart failure is not about pumping too much blood; it is about the heart's inability to pump blood efficiently, leading to circulation problems and other symptoms.

Correct Answer: C

Rationale: The correct answer is C: 1� to 1.5�. When irrigating a colostomy, the client should insert the lubricated catheter about 1� to 1.5� into the stoma. This depth allows for effective irrigation of the colon without causing discomfort or damage. Inserting the catheter too shallow (choice A) may not reach the colon, while inserting it too deep (choices B and D) can cause injury or perforation. Therefore, the optimal depth of 1� to 1.5� ensures proper irrigation while minimizing risks of complications.

Correct Answer: B

Rationale: The correct answer is B: Focus on the patient's presenting situation. This is the first step in the problem-oriented approach as it helps the nurse understand the immediate issues and prioritize data collection. By focusing on the presenting situation, the nurse can gather relevant information efficiently. A: Completing questions in chronological order may not address the current problem effectively. C: Making accurate interpretations of the data comes after data collection, not as the first step. D: Conducting an observational overview is important but typically follows focusing on the presenting situation to guide what observations are necessary.

Correct Answer: B

Rationale: The correct answer is B because focusing on the patient's presenting situation is the first step in the problem-oriented approach. This allows the nurse to gather relevant data related to the current health issue, which is crucial for identifying the problem and formulating a care plan. Option A is incorrect as chronological order may not prioritize the most critical data. Option C is incorrect as interpretations come after data collection. Option D is incorrect as observation typically follows data collection and analysis. Focusing on the patient's presenting situation ensures efficient and effective data collection for problem-solving.