Nursing Process Test Questions

Correct Answer: A

Rationale: The correct answer is A: RBC fragments. In idiopathic autoimmune hemolytic anemia, the immune system attacks and destroys red blood cells, leading to hemolysis. The presence of RBC fragments in the blood smear confirms this diagnosis as it indicates mechanical damage to RBCs. Explanation: 1. RBC fragments (schistocytes) are a hallmark of hemolysis, seen in conditions like autoimmune hemolytic anemia. 2. Microcytic, hypochromic RBCs (Choice B) are typically seen in iron deficiency anemia, not autoimmune hemolytic anemia. 3. Macrocytic, normochromic RBCs (Choice C) are characteristic of megaloblastic anemias like vitamin B12 deficiency, not autoimmune hemolytic anemia. 4. Hemoglobin molecules (Choice D) are not directly indicative of autoimmune hemolytic anemia; the presence of free hemoglobin in the blood would suggest intrav

Correct Answer: D

Rationale: The correct answer is D: Draw up clear insulin first when mixing two types of insulin in one syringe. This is important because mixing insulin requires drawing up the clear (short-acting) insulin first to prevent contamination. This ensures accurate dosing and prevents clouding of the insulin. Drawing up cloudy insulin first can lead to inaccurate dosing and potential mixing errors. Administering insulin after the first meal (choice A) is not the focus of this question. Administering insulin at a 45-degree angle into the deltoid muscle (choice B) is not recommended for insulin injections. Vigorously shaking the vial of insulin before withdrawal (choice C) can cause bubbles and affect the accuracy of the dose.

Correct Answer: A

Rationale: The correct answer is A because subjective data refers to information reported by the client, such as their symptoms or feelings. In this case, the client experiencing nausea and loss of appetite due to chemotherapy is subjective as it is based on the client's personal experience and perception. Choice B is incorrect because the client becoming teary is an observable behavior, making it an objective data point. Choice C is incorrect as the amount of effluent from the ileostomy is a measurable and quantifiable data, making it objective. Choice D is also incorrect as the patient's unwillingness to manipulate or empty his ostomy bag is an observable behavior, not based on the client's report.

Correct Answer: B

Rationale: The correct answer is B: Fluorouracil (5-fluorouracil, 5-FU). Fluorouracil is a commonly used chemotherapy drug for treating advanced liver cancer. It works by inhibiting the growth of cancer cells. This drug is specifically effective in targeting rapidly dividing cells, which is a characteristic of cancer cells. Fluorouracil is often used in combination with other chemotherapy drugs to improve treatment outcomes. Summary of other choices: A: Fluoxymesterone (Halotestin) - This is an androgen hormone used to treat certain types of breast cancer, not liver cancer. C: Tamoxifen (Nolvadex) - This is a hormonal therapy drug used in breast cancer, not liver cancer. D: Megestrol (Megace) - This is a hormonal therapy drug used for certain types of cancers, but not typically for liver cancer.

Correct Answer: C

Rationale: The correct answer is C: Turn frequently every 2 hours. This is because changing positions regularly helps to relieve pressure on specific areas, reducing the risk of developing decubitus ulcers. Turning every 2 hours helps to maintain blood flow and prevent tissue damage. A: Massaging reddened areas with lotion or oils can actually cause further damage by increasing friction and pressure on the skin. B: While using a special water mattress can help distribute pressure more evenly, it is not as effective as regular turning to prevent decubitus ulcers. D: Keeping the skin clean and dry is important for overall skin health but alone is not sufficient to prevent decubitus ulcers. Regular repositioning is crucial in reducing pressure and avoiding tissue breakdown.