Fundamentals of Nursing Nursing Process Questions

Correct Answer: B

Rationale: The correct answer is B: Maintain strict aseptic technique. This is crucial during thoracentesis to prevent infection. Step 1: Before the procedure, sterile equipment and supplies must be used. Step 2: Proper hand hygiene is essential to reduce the risk of introducing pathogens. Step 3: During the procedure, maintaining a sterile field helps minimize the risk of contamination. Step 4: After the procedure, ensuring proper disposal of all used supplies prevents the spread of infection. Summary: A: Placing the patient in a quiet and cool room may be comforting but is not directly related to the safety of the procedure. C: Advising the patient to sit still is important for accurate needle insertion but does not address infection prevention. D: Applying pressure over the puncture site is important but does not prevent infection if aseptic technique is not maintained.

Correct Answer: A

Rationale: The correct answer is A: Peripheral neuropathy. Didanosine (ddl) can cause peripheral neuropathy as a side effect, which can exacerbate existing neuropathy. The client's history of peripheral neuropathy warrants caution with this drug to prevent further nerve damage. Incorrect choices: B: Hypertension - Didanosine is not contraindicated in hypertension. C: Diabetes mellitus - While monitoring blood sugar levels is important, didanosine does not directly affect diabetes. D: Asthma - Didanosine does not have a significant impact on asthma. In summary, the client's pre-existing peripheral neuropathy makes it important to exercise caution with didanosine to avoid worsening this condition.

Correct Answer: D

Rationale: The correct answer is D: All of the above. Involvement of the sacral plexus can affect bladder control, leading to bladder problems. It can also impact bowel function, requiring bowel management. Additionally, the sacral plexus plays a role in sexual function, so assessment should include sexual activity. Therefore, all options are relevant when assessing a disease process involving the sacral plexus. Other choices are incorrect as they do not cover the comprehensive assessment needed for this specific condition.

Correct Answer: B

Rationale: The correct answer is B: Ineffective airway clearance related to obstruction by a tumor or secretions. This takes highest priority as compromised airway can lead to respiratory distress and potential respiratory failure. Maintaining clear airways is essential for oxygenation and ventilation. Choices A, C, and D are important but do not pose immediate life-threatening risks compared to compromised airway. Disturbed body image, anxiety, and imbalanced nutrition can be addressed once the airway clearance is stabilized.

Correct Answer: C

Rationale: The correct answer is C: Tears and F: Breastmilk. HIV transmission has been established through breastmilk due to the presence of the virus in the milk. Tears can also transmit HIV if they contain blood from an HIV-positive individual. Saliva, sweat, and urine do not typically contain enough HIV to transmit the virus. Blood is a well-known mode of HIV transmission due to the high viral load present in blood. Therefore, choices A, B, D, and G are incorrect as they do not have sufficient levels of the virus to transmit HIV.