Nursing Process Practice Questions Quizlet

Correct Answer: C

Rationale: The correct answer is C: administer oxygen via face mask. Given Aling Nena's sudden chest heaviness post-surgery, oxygen administration is the priority to ensure adequate oxygenation. This can help rule out potential respiratory issues or hypoxemia, which are common post-operatively. Providing oxygen promptly can prevent further complications such as respiratory distress or cardiac compromise. Documenting the pain characteristics (choice A) can be done after ensuring immediate physiological needs are met. Offering analgesics (choice B) without confirming the underlying cause can mask symptoms and delay appropriate interventions. Informing the physician (choice D) is important but not as urgent as addressing potential respiratory compromise.

Correct Answer: D

Rationale: The correct answer is D because it involves collaboration with the client to validate the identified health problem. By asking the client directly if they agree that fatigue is a problem for them, it promotes client-centered care and empowers the client in their own care. Choice A is incorrect as it assumes the nurse's assessment is enough to confirm fatigue. Choice B is incorrect as it focuses on the nurse's analysis rather than the client's experience. Choice C is incorrect because it is a closed-ended question that may not encourage open communication or validation from the client.

Correct Answer: D

Rationale: The correct answer is D: To establish a database to identify problems and strengths. This initial assessment is crucial for gathering comprehensive information about the client's health status, including past medical history, current health problems, and potential risk factors. By establishing a database, the nurse can identify both existing health issues that need to be addressed and strengths that can be built upon for effective care planning. This assessment serves as the foundation for developing an individualized care plan and monitoring the client's progress throughout their hospital stay. Explanation of other options: A: To gather data about a specific and current health problem - While this may be part of the assessment process, the main purpose is broader in scope to establish a comprehensive database. B: To identify life-threatening problems that require immediate attention - While identifying urgent issues is important, the initial assessment is not solely focused on life-threatening problems. C: To compare and contrast current health status to baseline data - While comparing to baseline data is important for tracking changes, the primary purpose

Correct Answer: A

Rationale: The correct answer is A: Universal blood and body fluid precautions. This is recommended by the CDC to prevent the spread of HIV because the virus can be present in blood and certain body fluids. Universal precautions involve treating all blood and body fluids as potentially infectious. Incorrect choices: B: Body systems isolation - This is not specific to preventing the spread of HIV and is not recommended by the CDC. C: Laminar flow room during active infection - This is not a standard recommendation for preventing the spread of HIV. D: Needle and syringe precautions - While important in preventing needlestick injuries, it is not the primary method recommended by the CDC for preventing the spread of HIV.

Correct Answer: C

Rationale: Step 1: Most clients are not hospitalized long after a mastectomy - Correct. This is because mastectomy is often performed as an outpatient procedure, and clients are discharged home shortly after surgery. Step 2: The adverse effects of mastectomy are not immediate - Incorrect. Adverse effects may occur post-surgery, but early discharge is not solely due to immediate adverse effects. Step 3: The wound of the surgery is not highly contagious - Incorrect. Mastectomy wounds are not contagious, and isolation precautions are not necessary. Step 4: Suicidal tendencies in women undergoing mastectomy are not high - Incorrect. While emotional support is crucial, early discharge is not primarily due to suicidal tendencies. Summary: Choice C is correct because mastectomy clients are typically not hospitalized long, making early discharge instructions and home care arrangements necessary. Choices A, B, and D are incorrect as they do not directly relate to the primary reason for early discharge and home care planning.