Nursing Process Practice Questions

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

Correct Answer: D

Rationale: Rationale: - Choice D is correct as it offers the patient autonomy and promotes self-care, which is important for maintaining independence and dignity. - By giving the patient a choice between brushing their own teeth or having assistance, it empowers them to make decisions. - Choices A, B, and C are not as appropriate because they do not address the patient's autonomy and may come across as directive or intrusive, which can further exacerbate the altered thought process.

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: C

Rationale: Rationale: Choice C is correct because antibodies are indeed produced by B-cells as part of the adaptive immune response. B-cells differentiate into plasma cells that produce antibodies to target specific antigens. This process is essential for generating immunity against pathogens. Incorrect Choices: A: Antibody-mediated defense occurs through the B-cell system, not the T-cell system. T-cells are involved in cell-mediated immunity. B: Cellular immunity is mediated by T-cells, not antibodies produced by B-cells. T-cells directly attack infected cells. D: Lymphocytes can increase during an allergic response, but this does not specifically relate to immunity through antibody production by B-cells.

Correct Answer: D

Rationale: The correct answer is D: Pallor, tachycardia, and a sore tongue. Pernicious anemia is caused by a deficiency in vitamin B12, leading to symptoms such as pallor (due to decreased red blood cells), tachycardia (as the heart works harder to compensate for decreased oxygen-carrying capacity of the blood), and a sore tongue (due to inflammation of the tongue). Choice A is incorrect because bradycardia would not be expected in pernicious anemia, and reduced pulse is not a typical finding. Choice B is incorrect because weight gain is not a common symptom of pernicious anemia. Choice C is incorrect because angina and double vision are not typical findings of pernicious anemia, and anorexia is more likely due to other causes.