Nursing Process Questions and Answers PDF

Correct Answer: A

Rationale: The correct answer is A: 2 L/min. In emphysema, there is impaired gas exchange due to damaged lung tissue, resulting in decreased oxygen levels. Administering too high a flow rate can lead to oxygen toxicity. The standard oxygen therapy for emphysema is 1-2 L/min to maintain oxygen saturation without causing harm. Higher flow rates like 10 L/min (B) and 6 L/min (C) are excessive and can lead to oxygen toxicity. 95 L/min (D) is dangerously high and not suitable for oxygen therapy in emphysema. Therefore, A is the correct choice for safe and effective oxygen administration in emphysema.

Correct Answer: D

Rationale: Rationale: D is correct because cleanliness helps prevent infections. Washing hands and keeping breasts clean reduces the risk of mastitis and abscesses. A is incorrect because alternating breasts is a common practice in breastfeeding. B is incorrect as frequent nursing helps maintain milk supply and prevent engorgement, reducing the risk of mastitis. C is incorrect as breastfeeding itself is not a cause of mastitis or abscess; stopping abruptly can lead to further complications like engorgement.

Correct Answer: B

Rationale: The correct answer is B because encouraging the patient to do leg exercises within the limits of his traction promotes independence by maintaining muscle strength and mobility. This helps prevent muscle atrophy and promotes circulation. Choice A focuses on pain management but does not directly promote independence. Choice C provides assistance but does not actively involve the patient in self-care. Choice D is important for overall care but does not directly promote independence through active patient involvement.

Correct Answer: A

Rationale: The correct answer is A: Decreased gastrointestinal motility. This is the defining characteristic because it directly links the cause (pain medication administration) to the effect (constipation). The patient's lack of bowel movement, abdominal distention, and pain are all consequences of decreased gastrointestinal motility. Pain medication slows down the movement of the intestines, leading to constipation. Choices B, C, and D are incorrect because while they are related to the patient's condition, they are not the defining characteristic that connects the cause to the effect in this specific scenario.

Correct Answer: B

Rationale: The correct answer is B: Focused assessment. In this scenario, the client's abdominal pain is a known issue, so a focused assessment would be appropriate to gather specific information related to the current complaint. A focused assessment allows the nurse to concentrate on the particular problem at hand, which in this case is the abdominal pain. A: Initial assessment is not applicable as the client has been seen for this issue before. C: Emergency assessment is not necessary as the situation does not indicate an urgent or life-threatening condition. D: Time-lapsed assessment is not suitable because it involves assessing changes over time, which is not the primary concern in this scenario. In summary, a focused assessment is the most appropriate choice as it allows the nurse to address the client's specific complaint efficiently.