Fundamentals of Nursing Nursing Process Questions

Correct Answer: C

Rationale: The correct answer is C: To rule out cholinergic crisis Neostigmine. Edrophonium HCL is a short-acting cholinesterase inhibitor used to differentiate between myasthenic crisis and cholinergic crisis, as both conditions present similarly with muscle weakness. Administering edrophonium HCL will help determine if the patient's worsening weakness is due to excessive cholinergic stimulation from neostigmine (cholinergic crisis) or inadequate acetylcholine at the neuromuscular junction (myasthenic crisis). This step is crucial for proper management, as treating cholinergic crisis with more cholinesterase inhibitors like neostigmine can worsen symptoms. Incorrect choices: A: For its synergistic effect - Edrophonium HCL does not have a synergistic effect with neostigmine. B: Because of the client's resistance to - Resistance to neostigmine is not a reason to administer edrophonium H

Correct Answer: D

Rationale: The correct answer is D, suggesting the use of glasses or contact lenses. This is because as older clients experience lens changes associated with aging, they may develop presbyopia or other vision issues that can be corrected with corrective lenses. Glasses or contact lenses can help improve their vision and quality of life. A, offering teaching aids with large-sized letters, may be helpful for clients with visual impairments but may not directly address the specific lens changes associated with aging. B, suggesting reduced visual activity, is not beneficial as it may further limit the client's engagement in daily activities and social interactions. C, suggesting the use of eye drops for comfort, may provide temporary relief for dry eyes but does not address the underlying lens changes affecting vision.

Correct Answer: B

Rationale: The correct answer is B: Drinking cranberry juice. Cranberry juice is known to help reduce urinary odor due to its acidic nature which can help eliminate bacteria that cause odor. It also helps to maintain urinary tract health. The other choices are incorrect because: A: Eating spicy foods can actually increase body odor and may not have any impact on urinary odor. C: Foods like eggs, asparagus, or cheese may contribute to strong body odor but do not specifically address urinary odor. D: Drinking tea, coffee, and colas can potentially worsen urinary odor due to their caffeine content and impact on urinary tract health.

Correct Answer: C

Rationale: The correct answer is C: Diagnostic reasoning. The nurse is utilizing assessment data to analyze and interpret the information to develop a nursing diagnosis. This involves critical thinking skills to make conclusions and create a plan of care. A: Assigning clinical cues - This choice is incorrect as it refers to identifying objective and subjective data during assessment, not the process of analyzing and synthesizing data to form a diagnosis. B: Defining characteristics - This choice is incorrect as it typically refers to the specific manifestations or symptoms associated with a particular nursing diagnosis, not the process of diagnosing itself. D: Diagnostic labeling - This choice is incorrect as it refers to the final step in the nursing diagnosis process where the nurse assigns a label to the identified problem, not the overall process of diagnostic reasoning.

Correct Answer: C

Rationale: Correct Answer: C Rationale: 1. Potassium is typically administered on a secondary line to prevent rapid infusion and potential adverse effects. 2. The primary line carries the D5 � NS solution without potassium, while the secondary line delivers the potassium. 3. Reporting that "potassium is on the secondary line" accurately describes the setup for this IV infusion. Summary: A: Incorrect - Incorrectly states that the potassium bag is piggybacked into the dextrose. B: Incorrect - Closing the clamp below the D5 � NS bag is unnecessary and does not address the potassium infusion. D: Incorrect - Fails to address the specific issue of the potassium infusion being on a secondary line.