Nursing Process Practice Questions Quizlet

Correct Answer: B

Rationale: The correct answer is B: obtaining daily weights at the same time. This is crucial in monitoring fluid retention, a common issue in heart failure patients. Daily weights help detect early signs of fluid buildup. Option A is incorrect as physical activity is important for heart failure patients. Option C is incorrect as walking 2 miles daily may be too strenuous for some heart failure patients. Option D is incorrect as a high fiber diet is beneficial, but monitoring fluid retention is more critical in this case.

Correct Answer: D

Rationale: The correct answer is D: Turn off the antibiotic. This should be the nurse's first action because in an anaphylactic reaction, stopping the administration of the causative agent is crucial to prevent further harm. Continuing the antibiotic (Choice B) can worsen the reaction. Calling the doctor (Choice A) may cause a delay in the immediate intervention needed. Calling for help (Choice C) is important but turning off the antibiotic takes precedence to stop the allergen.

Correct Answer: D

Rationale: The correct answer is D: The patient is able to ambulate 25 feet without pain. This outcome indicates successful plan implementation for impaired mobility due to nerve compression. Ambulating without pain shows improved mobility and nerve compression relief. Choices A, B, and C do not directly address mobility improvement. Choice A focuses on pain level, which is important but not a direct measure of mobility. Choice B refers to upper extremities, not the lower extremities affected by lumbar disk herniation. Choice C addresses medication management, not mobility improvement.

Correct Answer: D

Rationale: The correct answer is D: Eight Cranial Nerve (Vestibulocochlear). Mr. Reyea's complaint of hearing ringing noises indicates a potential issue with his auditory function, which is primarily governed by the Vestibulocochlear nerve. This nerve is responsible for transmitting sound and balance information from the inner ear to the brain. The other choices, A: Frontal lobe, B: Six cranial nerve (abducent), and C: Occipital lobe, are not directly associated with auditory function or the perception of ringing noises in the ear.

Correct Answer: B

Rationale: The correct answer is B because it encourages the patient to reflect on the potential causes of their fatigue, leading to a more detailed and insightful response. This open-ended question allows the patient to explore various factors contributing to their fatigue, such as lifestyle habits, medical conditions, or emotional stressors. Choice A focuses on stress, which may not be the primary cause of fatigue for the patient. Choice C is too specific and may not uncover other relevant information. Choice D assumes that sleep duration is the sole factor contributing to fatigue, neglecting other possible causes. Overall, choice B facilitates a more comprehensive discussion and helps the nurse gather valuable information to address the patient's concerns effectively.