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: C

Rationale: The correct answer is C: The patient is apprehensive about discharge. The rationale is that the patient's fear of going home and being alone indicates anxiety about leaving the hospital setting. This subjective data suggests that the patient may not feel ready for discharge despite stable vital signs and nearly healed incision. Choices A and B are incorrect because they assume the patient's readiness for self-care without considering emotional factors. Choice D is incorrect as there is no evidence provided that the surgery was unsuccessful.

Correct Answer: B

Rationale: The correct answer is B (10-15 mmHg) because this range is considered safe and effective for suctioning in most cases. Lower suction pressures (such as 2-5 mmHg) may not effectively clear secretions, while higher pressures (20-25 mmHg) can cause tissue damage. Choice C (5-10 mmHg) falls within the safe range but may not provide enough suction for effective clearance. Therefore, the optimal suction pressure for James using the portable suction unit at home is 10-15 mmHg.

Correct Answer: A

Rationale: The correct answer is A: Client�s wife. She is the primary source of information as she witnessed the event firsthand and provided relevant details. In this scenario, the wife's account of the event is crucial in understanding the sequence of events leading to the client's unconscious condition. Medical documents (B), test results (C), and assessment data (D) are all secondary sources of information that may provide additional data but do not have the same level of immediacy or firsthand knowledge as the client's wife. In an emergency situation, information from a reliable eyewitness is often the most valuable initial source for healthcare providers to make critical decisions.

Correct Answer: C

Rationale: Step-by-step rationale: 1. Anemia is a condition where there is a decrease in the concentration of red blood cells. 2. Red blood cells carry oxygen to the body's tissues, so a decrease in their concentration leads to reduced oxygen delivery. 3. This decrease in red blood cell concentration can be measured through a decrease in hematocrit levels. 4. Choices A and B are incorrect because anemia involves a decrease, not an increase, in red blood cells and hemoglobin. 5. Choice D is incorrect as it mentions "decreased blood count cells," which is not a specific term related to anemia. Summary: The correct answer is C because anemia is characterized by a decrease in the concentration of red blood cells, leading to reduced oxygen delivery, while the other choices are incorrect due to inaccuracies in describing anemia.