Fundamentals of Nursing Nursing Process Questions

Correct Answer: C

Rationale: Step 1: The optimal suctioning pressure for adults is usually between 80-120 mmHg. Step 2: Choice C falls within this recommended range (95-110 mmHg). Step 3: Higher pressures (like in choices B and D) can cause tissue damage. Step 4: Lower pressures (like in choice A) may not effectively remove secretions. Summary: Choice C (95-110 mmHg) is correct as it falls within the safe and effective suctioning pressure range for adults, while the other choices are either too high or too low, risking harm or inefficiency.

Correct Answer: C

Rationale: The correct answer is C: 5% dextrose in 0.9% NaCl. This solution is hypertonic because it has a higher osmolarity compared to the other choices. The presence of dextrose and NaCl in this solution increases its solute concentration, causing water to move out of the cells by osmosis. Normal saline (A) and 0.45% NaCl (B) are isotonic solutions, meaning they have the same osmolarity as body fluids. 0.225% NaCl (D) is a hypotonic solution with lower osmolarity than body fluids.

Correct Answer: A

Rationale: The presence of redness, swelling, and induration at the wound site are indicative of infection. Redness and swelling suggest inflammation, while induration indicates tissue hardening and can be a sign of infection spreading. Infection can delay healing and lead to complications if not treated promptly. Evisceration refers to wound opening with protrusion of internal organs, not indicated by the symptoms. Dehiscence is the partial or complete separation of wound layers, not represented by the symptoms. Hemorrhage involves excessive bleeding, which is not described in the scenario. Therefore, choice A is correct as it aligns with the signs observed and is the most appropriate response for the situation.

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: A

Rationale: The correct answer is A: Hypertension. In hypovolemia, the body compensates by increasing heart rate (B: Tachycardia) to maintain perfusion, decreasing urine output (C: Oliguria) to conserve fluid, and increasing respiratory rate (D: Tachypnea) to improve oxygenation. Hypertension is not a typical compensatory response to hypovolemia; instead, blood pressure tends to decrease due to reduced circulating volume. Therefore, hypertension is the symptom that would not be expected in a patient with hypovolemic shock.