Fundamentals of Nursing Nursing Process Questions

Correct Answer: B

Rationale: Step 1: Crowded living conditions do not directly increase the risk of lung cancer. Step 2: Passive smoke (choice A) and air pollution (choice C) contain carcinogens linked to lung cancer. Step 3: Diet low in fruits and vegetables (choice D) may lead to poor immune function, potentially impacting cancer risk. Step 4: In summary, crowded living conditions do not contribute to lung cancer risk compared to the other choices.

Correct Answer: C

Rationale: The correct answer is C: Diagnostic reasoning. The nurse is utilizing assessment data to analyze and interpret the information to develop a nursing diagnosis. This involves critical thinking skills to make conclusions and create a plan of care. A: Assigning clinical cues - This choice is incorrect as it refers to identifying objective and subjective data during assessment, not the process of analyzing and synthesizing data to form a diagnosis. B: Defining characteristics - This choice is incorrect as it typically refers to the specific manifestations or symptoms associated with a particular nursing diagnosis, not the process of diagnosing itself. D: Diagnostic labeling - This choice is incorrect as it refers to the final step in the nursing diagnosis process where the nurse assigns a label to the identified problem, not the overall process of diagnostic reasoning.

Correct Answer: D

Rationale: The correct answer is D: Leucovorin. Leucovorin is given during methotrexate therapy to protect normal cells by acting as a rescue agent that helps to reduce the toxic effects of methotrexate. It works by enhancing the efficacy of methotrexate in cancer cells while reducing its toxicity in normal cells. Probenecid (A) is not used to protect normal cells during methotrexate therapy. Cytarabine (B) and Thioguanine (C) are other chemotherapeutic agents and are not typically given to protect normal cells during methotrexate therapy.

Correct Answer: E

Rationale: The correct answer is missing from the choices provided. However, for a client with an immune system disorder, essential nursing actions include: E: Educate the client on the importance of maintaining a healthy lifestyle, avoiding exposure to infections, and adhering to prescribed medications. This is crucial for managing the immune system disorder effectively. Incorrect choices: A: Following agency guidelines is important but doesn't specifically address the client's immune system disorder. B: Reviewing drug references may be necessary but is not a priority in managing the immune system disorder. C: Advising the client on modifying the home environment is not directly related to managing the immune system disorder. D: Monitoring the client for depression is important but not specific to addressing the immune system disorder.

Correct Answer: A

Rationale: Correct Answer: A: Cover wound with moist sterile dressing Rationale: 1. Covering the wound with a moist sterile dressing helps maintain a clean and moist environment, promoting wound healing. 2. Moist dressing prevents the wound from drying out and minimizes the risk of infection. 3. The moist environment supports healing by promoting cell growth and preventing tissue damage. 4. It protects the exposed bowel from further injury and contamination. Summary: B: Finding out how this happened is important but not an immediate priority for patient care. C: Placing sterile dry gauze can lead to the wound drying out and hinder healing. D: Pouring sterile water into the wound is not recommended as it can introduce contaminants and is not considered standard care for this situation.