Nursing Process Final Exam Questions

Correct Answer: C

Rationale: The correct answer is C: Health promotion. In this scenario, the nurse identified the patient's desire to enhance urinary elimination abilities through self-catheterization, indicating a readiness for positive change. Health promotion diagnoses focus on improving well-being and enhancing quality of life. This diagnosis supports the patient's proactive approach to managing their condition. Incorrect choices: A: Risk - This diagnosis would be used if the patient was at risk for complications related to urinary elimination, not actively seeking to improve it. B: Problem focused - This type of diagnosis would be used if the patient was experiencing issues with urinary elimination that needed to be addressed. D: Collaborative problem - This diagnosis would involve identifying a problem that requires collaboration between healthcare professionals to resolve, which is not the case in this scenario.

Correct Answer: C

Rationale: The correct answer is C: Close the roller clamp on the new tubing after priming it. This step ensures that the tubing is primed with the solution and ready for use while preventing air from entering the central line. Option A is incorrect because using the present solution may introduce contamination. Option B is incorrect as connecting tubing before running fluid can introduce air into the line. Option D is incorrect as positioning the client on the right side does not prevent air embolism during tubing change.

Correct Answer: B

Rationale: The correct answer is B because a fixed nodular mass with dimpling of the overlying skin is a classic sign of breast cancer. This finding is concerning as it indicates an abnormal growth that has invaded surrounding tissues. Dimpling occurs due to fibrotic changes pulling on the skin. Choices A, C, and D are incorrect. A slight asymmetry of the breasts is common and not necessarily indicative of cancer. Bloody discharge from the nipple can be a sign of other conditions like intraductal papilloma. Multiple firm, round, freely movable masses that change with the menstrual cycle are likely benign fibrocystic changes.

Correct Answer: B

Rationale: The correct answer is B: 7 to 14 days. Marrow suppression from floxuridine typically occurs 1-2 weeks after administration due to its effects on rapidly dividing cells in the bone marrow. This is known as the nadir period. Choices A, C, and D are incorrect because 24 hours is too soon for noticeable effects, 2 to 4 days is too short for the nadir period, and 21 to 28 days is too long for the onset of marrow suppression. The correct choice aligns with the expected timeframe for floxuridine's impact on bone marrow function.

Correct Answer: C

Rationale: The correct answer is C: Health promotion. The nurse wrote a diagnosis related to enhancing the patient's urinary elimination abilities through self-catheterization, which focuses on promoting the patient's health and well-being. The Readiness for enhanced urinary elimination diagnosis indicates the patient's motivation and readiness to improve their urinary elimination abilities, aligning with the concept of health promotion. This type of diagnosis acknowledges the patient's potential for growth and improvement in their health status. Incorrect choices: A: Risk - This choice would be more appropriate if the diagnosis focused on potential complications or adverse events related to the patient's urinary elimination abilities. B: Problem focused - This choice would be suitable if the diagnosis identified an existing issue or problem with the patient's urinary elimination abilities that needed to be addressed. D: Collaborative problem - This choice would be relevant if the diagnosis required collaboration between healthcare providers to manage the patient's urinary elimination abilities effectively.