Nursing Process Final Exam Questions

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: D

Rationale: The correct answer is D, the Western blot test with ELISA. First, ELISA is used as a screening test for HIV antibodies. If positive, a confirmatory test like Western blot is needed to detect specific antibodies. Western blot is highly specific and confirms the presence of HIV antibodies. E-rosette immunofluorescence is not typically used for HIV diagnosis. Quantification of T-lymphocytes is used to monitor disease progression in HIV but does not confirm HIV infection. ELISA alone is not confirmatory; it needs to be followed by a more specific test like Western blot.

Correct Answer:

Rationale: Correct Answer: B: Ask about the chief concerns or problems. Rationale: 1. Asking about chief concerns helps to focus the interview on the patient's needs. 2. It demonstrates active listening and empathy. 3. Allows the nurse to prioritize issues and provide appropriate care. 4. Introductions are already done, and ending the interview abruptly or mentioning medication timing is not patient-centered.

Correct Answer: B

Rationale: The correct answer is B: The need to feel good about oneself. This is the priority because the resident's refusal to eat is tied to her desire to maintain her personal appearance and feel good about herself. By addressing this need first, the resident may become more willing to eat. The other choices are incorrect because while nutrition (A) is important, addressing the resident's self-esteem and well-being should come first. The need to live in a safe environment (C) is also important but not the priority in this specific scenario. The need for love from others (D) is significant but not directly related to the resident's refusal to eat based on her personal grooming preferences.

Correct Answer: A

Rationale: The correct answer is A: Etiology. Etiology in a nursing diagnosis refers to the cause or contributing factors of the identified problem. In this case, the large scar over the left side of the face is the reason for the disturbed self-esteem. It is the underlying factor that is leading to the self-esteem issue. The problem itself is the disturbed self-esteem, the defining characteristics are the signs and symptoms that support the diagnosis, and client need is the desired outcome or goal for the client. In summary, the presence of the large scar is the cause or etiology of the disturbed self-esteem, making it the correct choice.