Nursing Process Questions and Answers PDF

Correct Answer: D

Rationale: The correct answer is D: Right ventricular hypertrophy. Elevated pulmonary vascular pressures lead to increased resistance in the pulmonary circulation, causing the right ventricle to work harder to pump blood to the lungs. Over time, this can result in hypertrophy of the right ventricle as it adapts to the increased workload. Left atrial atrophy (A) and right atrial atrophy (C) are unlikely as the atria are not directly affected by elevated pulmonary pressures. Left ventricular hypertrophy (B) is not the correct choice as it typically occurs in response to systemic hypertension, not pulmonary hypertension.

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: 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, "Fluid volume deficit R/T uncontrolled vomiting." This option correctly identifies the cause of the fluid volume deficit as uncontrolled vomiting, which is a common reason for fluid loss. The nursing diagnosis should always reflect the underlying cause of the issue. A is incorrect as "furrow tongue" is not a recognized medical term related to fluid volume deficit. C is incorrect because dehydration is not typically related to subnormal body temperature unless it is severe. D is incorrect as incessant vomiting is more specific to the cause, but the term "dehydration" should be used instead of "fluid volume deficit" in this context. In summary, option B is the appropriate nursing diagnosis as it accurately links the fluid volume deficit to the cause of uncontrolled vomiting.

Correct Answer: A

Rationale: Step-by-step rationale for why choice A is correct: 1. Hypercalcemia can lead to dehydration due to increased urine output. 2. Encouraging 3 to 4 L of fluid daily helps prevent dehydration and promote renal excretion of excess calcium. 3. Adequate hydration reduces the risk of kidney stones and other complications associated with hypercalcemia. Summary of why other choices are incorrect: - Choice B (bed rest) does not directly address hypercalcemia complications. - Choice C (cough and deep breathe) is unrelated to managing hypercalcemia. - Choice D (apply heat to painful areas) does not address the underlying cause of hypercalcemia or its complications.