Nursing Process Questions and Answers PDF

Correct Answer: A

Rationale: The correct answer is A because auscultation of the lungs involves direct observation and measurement, making it objective data. This data is based on what the nurse hears through the stethoscope, which can be verified and measured. Choices B, C, and D involve subjective experiences or interpretations that cannot be directly observed or measured. Complaint of nausea, sensation of burning, and belief in demons are all based on the client's feelings, perceptions, or beliefs, which are subjective and can vary from person to person. Objective data is factual, measurable, and observable, making choice A the correct answer in this scenario.

Correct Answer: A

Rationale: The correct answer is A because auscultation of the lungs involves direct observation and measurement, making it objective data. This data is based on what the nurse hears through the stethoscope, which can be verified and measured. Choices B, C, and D involve subjective experiences or interpretations that cannot be directly observed or measured. Complaint of nausea, sensation of burning, and belief in demons are all based on the client's feelings, perceptions, or beliefs, which are subjective and can vary from person to person. Objective data is factual, measurable, and observable, making choice A the correct answer in this scenario.

Correct Answer: B

Rationale: The correct answer is B: Renal failure. Acute respiratory distress syndrome (ARDS) can lead to hypoxemia and respiratory acidosis, causing decreased perfusion to the kidneys and potentially leading to renal failure. Monitoring for signs of renal failure, such as decreased urine output and elevated creatinine levels, is crucial in managing clients with ARDS. Incorrect choices: A: Chest wall bulging is not a common complication of ARDS. It may be seen in conditions like tension pneumothorax. C: Difficulty swallowing is not a typical complication of ARDS. It may be seen in neurological conditions or esophageal disorders. D: Orthopnea is not a direct complication of ARDS. It is more commonly associated with heart failure or pulmonary edema.

Correct Answer: C

Rationale: Rationale: Step 1: Coughing is the primary way TB bacteria are spread. Step 2: By coughing into a handkerchief or tissue, the TB bacteria are contained. Step 3: Washing the handkerchief in hot water or discarding it prevents the bacteria from spreading. Step 4: This method reduces the risk of infecting family members. Summary of Incorrect Choices: A: Wearing gloves does not prevent airborne transmission of TB. B: Keeping windows closed can increase the concentration of bacteria in the air. D: Boiling water is not necessary to prevent TB transmission.

Correct Answer: A

Rationale: The correct answer is A. The most appropriate outcome for the nurse to include in the plan of care is for the patient to have one soft, formed bowel movement by the end of the shift. This outcome directly addresses the nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. By aiming for a soft, formed bowel movement, the nurse is working towards alleviating the constipation issue caused by the pain medications. This outcome is specific, measurable, achievable, relevant, and time-bound (SMART), making it an appropriate goal for the patient's care plan. Choice B is incorrect because walking unassisted to the bathroom does not directly address the constipation issue. Choice C is incorrect as offering laxatives or stool softeners is a nursing intervention and not an outcome. Choice D is incorrect as withholding pain medications may not be in the best interest of the patient's overall care and does not directly target the constipation issue.