Nursing Process Test Bank

Correct Answer: D

Rationale: The correct answer is D because a regular diet with extra fruits and green vegetables can provide essential nutrients for overall health, potassium-sparing diuretics can help manage potassium levels in the body, and discontinuing oral magnesium salts can prevent further complications in the patient. Option A focuses on promoting a healthy diet, B addresses specific medication for potassium management, and C avoids potential interactions with magnesium salts. Therefore, all of the measures (A, B, and C) are necessary for comprehensive management of the patient's condition.

Correct Answer: D

Rationale: The correct answer is D, the elderly patient receiving a diuretic for fluid overload. This patient would benefit most from a capped IV catheter used intermittently because diuretics can lead to fluctuations in fluid balance that require careful monitoring and adjustment of IV fluids. By using the catheter intermittently, healthcare providers can better control the amount of fluid administered to prevent electrolyte imbalances. Option A is incorrect because a patient with pneumonia requiring fluids and antibiotics would likely benefit from a continuous IV to maintain stable levels of medications and hydration. Option B is incorrect as a patient with major blood loss would require continuous IV fluids to restore blood volume. Option C is incorrect as a dehydrated young child would also benefit from continuous IV fluids to rehydrate effectively.

Correct Answer: B

Rationale: The correct answer is B: The waiting area with the television turned off. This setting provides a quiet environment, minimizing distractions for the patient with a hearing deficit. It allows the nurse to communicate effectively by speaking clearly and facing the patient directly. Option A is incorrect because a closed door may not be enough to reduce background noise. Option C is incorrect as pain medication may affect the patient's ability to concentrate. Option D is incorrect because the occupational therapist working on leg exercises may create additional noise and distractions.

Correct Answer: C

Rationale: The correct answer is C: ABG. Monitoring ABG in Guillain-Barre Syndrome patients is crucial as they are at risk for respiratory complications like respiratory failure due to muscle weakness. ABG provides information on oxygenation, ventilation, and acid-base balance. Regular monitoring helps detect early signs of respiratory distress and guide appropriate interventions. A: BUN and creatinine are important for assessing renal function, but they do not directly relate to acute complications in Guillain-Barre Syndrome. B: Hgb and Hct are markers for anemia, which is not a common acute complication in Guillain-Barre Syndrome. D: Serum potassium levels are important, but ABG monitoring takes precedence in patients with Guillain-Barre Syndrome due to the risk of respiratory issues.

Correct Answer: B

Rationale: The correct answer is B: 45-year old woman who has never been pregnant. The risk of ovarian cancer increases with age and nulliparity (never having been pregnant) is a significant risk factor. The older a woman gets without having been pregnant, the higher her risk of developing ovarian cancer. The other choices do not have as high of a risk factor for ovarian cancer. Choice A, a 30-year old woman taking contraceptives, actually reduces the risk of ovarian cancer. Choice C, a 40-year old woman with three children, and choice D, a 36-year old woman who had her first child at age 22, both have lower risk factors compared to choice B.