Nursing Process Practice Questions

Correct Answer: A

Rationale: The correct answer is A: Detects the presence of malignant cells. Biopsy involves taking a sample of tissue to examine under a microscope for the presence of abnormal or cancerous cells. This procedure is crucial for diagnosing cancer accurately. Choice B (Measures hemoglobin content) is incorrect because hemoglobin content is typically measured through blood tests, not biopsies. Choice C (Measures the RBC size) is incorrect as RBC size is usually assessed through a complete blood count (CBC) test, not a biopsy. Choice D (Detects arterial occlusion) is incorrect because arterial occlusion is typically diagnosed through imaging studies like Doppler ultrasound or angiography, not through a biopsy procedure.

Correct Answer: C

Rationale: The correct answer is C: Implementation. In this step of the nursing process, the nurse is carrying out the care plan based on the identified nursing diagnoses. The nurse is actively providing care and interventions to meet the patient's needs. Assessment (A) is the initial step where data is collected and analyzed. Planning (B) is where goals and interventions are determined based on assessment findings. Evaluation (D) is the final step where the nurse assesses the effectiveness of the care provided. In this scenario, the nurse has already completed the care plan and is now executing the plan by implementing the interventions, making choice C the correct answer.

Correct Answer: C

Rationale: The correct answer is C: 1� to 1.5�. When irrigating a colostomy, the client should insert the lubricated catheter about 1� to 1.5� into the stoma. This depth allows for effective irrigation of the colon without causing discomfort or damage. Inserting the catheter too shallow (choice A) may not reach the colon, while inserting it too deep (choices B and D) can cause injury or perforation. Therefore, the optimal depth of 1� to 1.5� ensures proper irrigation while minimizing risks of complications.

Correct Answer: A

Rationale: The correct answer is A: A clot can enter the circulation. When a clotted cannula is aggressively flushed, the force can dislodge the clot, allowing it to enter the circulation and potentially leading to serious complications such as embolism. Incorrect choices: B: An air embolism can enter the circulation - In the context of a clotted cannula, air embolism is less likely compared to a clot entering the circulation. C: A painful arterial spasm can occur - Arterial spasm is a potential complication but not directly related to flushing a clotted cannula. D: Fluid extravasation into surrounding tissue can occur - Flushing a clotted cannula may not specifically lead to fluid extravasation, as it is more related to needle dislodgement or improper placement.

Correct Answer: B

Rationale: Step-by-step rationale: 1. Metabolic acidosis is characterized by low pH and low plasma bicarbonate. 2. In this condition, there is an excess of acids or a loss of bicarbonate. 3. The kidneys are unable to adequately excrete acids or retain bicarbonate. 4. This leads to a decrease in bicarbonate levels and a decrease in pH. 5. Respiratory acidosis (A) is characterized by low pH and high CO2 levels. 6. Respiratory alkalosis (C) is characterized by high pH and low CO2 levels. 7. Metabolic alkalosis (D) is characterized by high pH and high bicarbonate levels. Summary: - Choice A is incorrect as it describes a condition with high CO2 levels. - Choice C is incorrect as it describes a condition with high pH. - Choice D is incorrect as it describes a condition with high bicarbonate levels. - Choice B is correct as it accurately describes the characteristics of a condition with low pH