Nursing Process Exam Questions

Correct Answer: B

Rationale: The correct answer is B: Halos around lights. Digoxin toxicity can cause visual disturbances like seeing halos around lights, which is a common symptom. This is due to its effect on the eyes. Poor appetite (choice A) is a common side effect but not specific to toxicity. Constipation (choice C) is not a typical sign of digoxin toxicity. Tachycardia (choice D) is more commonly associated with digoxin toxicity, but visual disturbances like halos around lights are more specific and should be explained to the patient.

Correct Answer: A

Rationale: The correct answer is A: Maintenance of a clear airway. In cases of coma or unconsciousness, ensuring a clear airway is crucial to prevent respiratory complications and maintain oxygenation. This involves positioning the patient correctly, suctioning if necessary, and monitoring breathing. Choice B, good nursing care, is too broad and does not address the immediate priority of airway management. Choice C, retention of a catheter, is irrelevant to managing a coma or unconsciousness. Therefore, the correct therapeutic measure in this scenario is to focus on maintaining a clear airway to support respiratory function.

Correct Answer: A

Rationale: The correct answer is A: Risk for impaired skin integrity. This is the highest priority as patients with spinal cord injuries are at high risk for pressure ulcers due to immobility. Preventing skin breakdown is crucial to avoid complications. Choices B, C, and D are not as urgent. Choice B may be a concern but preventing skin breakdown takes precedence. Choices C and D are important but not life-threatening like potential skin issues in this patient population.

Correct Answer: A

Rationale: Rationale: 1. A: Blood pressure apparatus is essential to monitor for any signs of bleeding or clot formation after carotid angioplasty. 2. B: IV infusion stand is important but not the priority for immediate postoperative monitoring. 3. C: Call bell is important for the client to call for assistance but not the priority for immediate postoperative care. 4. D: Endotracheal intubation is not necessary after a carotid angioplasty and is not a priority item for bedside care. Summary: Monitoring blood pressure is crucial for detecting complications post carotid angioplasty. IV stand, call bell, and endotracheal intubation are important but not the priority in this scenario.

Correct Answer: C

Rationale: The correct answer is C. When the client is in a state of respiratory arrest, immediate medical intervention is required. Discontinuing oxygen administration and notifying the physician is crucial to address the life-threatening situation. A: Improving color is a positive sign. B: Decreased consciousness may indicate a need for further assessment but does not require immediate discontinuation of oxygen. D: Inability to use the diaphragm may require intervention but does not indicate an immediate threat as respiratory arrest does.