Fundamentals Nursing Process Questions

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen therapy. This is the priority intervention because a high temperature and diaphoresis indicate potential respiratory distress. Oxygen therapy can help improve oxygenation and support respiratory function. Providing frequent linen changes (B) is important for hygiene but not the priority. Fluid intake (C) is essential but not as urgent as addressing respiratory distress. Maintaining complete bed rest (D) may be necessary but addressing oxygenation takes precedence in this case.

Correct Answer: A

Rationale: The correct answer is A: To detect rejection. After heart transplantation, heart biopsy is performed to monitor for rejection, a common complication. Tissue samples are examined for signs of rejection, such as inflammation. This is crucial for timely intervention to prevent rejection-related complications. Other choices are incorrect: B: Heart functionality is typically assessed through imaging tests like echocardiograms, not biopsy. C: Heart rate monitoring can be done through non-invasive methods like electrocardiograms, not biopsy. D: Checking for heart tumors is not a primary purpose of heart biopsy post-transplantation.

Correct Answer: B

Rationale: The correct answer is B: Related to impaired balance. The rationale for this is that a cerebellar brain tumor can affect the client's coordination and balance due to its location in the brain responsible for fine motor movements. Impaired balance increases the risk for falls and injuries. Visual field deficits (choice A) may contribute to the risk of injury but not as directly as impaired balance. Difficulty swallowing (choice C) and psychomotor seizures (choice D) are not directly related to the client's risk for injury due to a cerebellar brain tumor.

Correct Answer: C

Rationale: The correct answer is C: Collaborative problem. In the given diagnostic statement, "Impaired physical mobility related to tibial fracture as evidenced by patient�s inability to ambulate," the nurse needs to revise the mention of collaborative problem. The collaborative problem is a health issue that requires the expertise of multiple healthcare providers, whereas the statement provided focuses on a nursing diagnosis related to physical mobility impairment. The etiology (cause), nursing diagnosis, and defining characteristic are all relevant to the nursing diagnostic statement and do not need revision. The collaborative problem aspect is not appropriate in this context as it does not fit the criteria for a collaborative problem.

Correct Answer: B

Rationale: The correct answer is B. The nurse should explain that zidovudine (AZT) works by blocking reverse transcriptase, the enzyme necessary for HIV replication. This is the key mechanism of action for AZT in managing HIV. Choice A is incorrect because it provides a partial truth - it does slow the disease process but does not provide the mechanism of action. Choice C is incorrect as it provides incorrect information that there are no medications to stop or cure HIV, which is not true. Choice D is incorrect as it provides misleading information about the drug becoming immune to HIV, which is not the primary concern in this context.