Nursing Process Test Bank

Correct Answer: D

Rationale: The correct answer is D because a multilumen pulmonary artery catheter can provide detailed information about preload, afterload, and cardiac output. Preload refers to the volume of blood in the ventricles at the end of diastole, afterload is the resistance the heart has to overcome to eject blood, and cardiac output is the amount of blood pumped by the heart per minute. This catheter allows for direct measurement of these parameters by monitoring pressures in the pulmonary artery. Choices A, B, and C are incorrect individually as they do not encompass the full range of information that can be obtained with a multilumen pulmonary artery catheter.

Correct Answer: C

Rationale: The correct answer is C: high protein, low residue. For patients with ulcerative colitis, a high protein diet helps in tissue healing and repair. Low residue foods are recommended to reduce bowel irritation. Choice A is incorrect because low protein can impair healing. Choice B is unsuitable as high fiber may worsen symptoms. Choice D is not ideal as high carbohydrate can be difficult to digest for colitis patients.

Correct Answer: B

Rationale: The correct answer is B because after developing a plan of care, the nurse must communicate it to all healthcare professionals involved in the patient's care to ensure everyone is aware of the plan and can collaborate effectively. This promotes continuity of care and prevents errors. Choice A is incorrect because the plan of care should not be placed in the chart to avoid tampering; it should be easily accessible for updates. Choice C is incorrect as filing in the administration office is unnecessary for routine care. Choice D is incorrect as sending the plan to quality assurance is not the immediate next step after developing the plan.

Correct Answer: B

Rationale: The correct answer is B: Monitor for fatigue, muscle weakness, restlessness, and flushed skin. The patient is at risk for dehydration due to the combination of high temperature, age, and thiazide diuretic use. Thiazide diuretics can lead to electrolyte imbalances, including hypokalemia, which can cause symptoms such as muscle weakness and fatigue. Monitoring for signs of dehydration and electrolyte imbalances is crucial in this scenario to prevent complications. A: Making sure he drinks 8 glasses of water a day is not the priority as he is already at risk for dehydration and electrolyte imbalances. C: Hyperchloremia is not a common concern in this scenario based on the given lab values. D: Neurologic changes may occur in severe cases of electrolyte imbalances but monitoring for physical symptoms such as fatigue and muscle weakness is more relevant at this stage.

Correct Answer: C

Rationale: The correct answer is C: Ineffective cerebral tissue perfusion. In the late stage of AIDS, the client is at risk for neurological complications, including AIDS-related dementia due to decreased blood flow to the brain. This nursing diagnosis takes the highest priority as it directly addresses the client's impaired brain perfusion, which can lead to serious cognitive and functional deficits. Prioritizing this diagnosis ensures timely interventions to optimize cerebral blood flow and prevent further deterioration. Summary: A: Self-care deficient: Bathing/hygiene - important but not the highest priority compared to addressing neurological complications. B: Dysfunctional grieving - while emotional support is essential, it is not the priority when dealing with a life-threatening physiological issue. D: Risk for injury - while important, it is secondary to addressing the underlying cause of the dementia in this scenario.