Nursing Process Practice Questions

Correct Answer: B

Rationale: Severe and extensive hemolysis leads to the release of large amounts of hemoglobin into the bloodstream, causing hemoglobinemia. This can result in hemoglobinuria, leading to acute renal failure and ultimately shock. Shock is the correct answer as it is a severe consequence of extensive hemolysis. Leg ulcers (A) may occur in conditions like peripheral arterial disease. Priapism (C) is unrelated to hemolysis. Compromised growth (D) is not a common consequence of hemolysis.

Correct Answer: B

Rationale: The correct answer is B because subjective data in a nursing assessment refers to information provided by the patient, such as feelings, perceptions, and symptoms. In this case, the client stating 'I feel nauseated' represents subjective data. This type of information cannot be measured or observed directly. A, C, and D are incorrect: A: Heart rate of 90 beats per minute is an objective measurement that can be directly observed. C: Blood pressure of 130/80 mmHg is also an objective measurement that can be directly observed. D: Skin appears flushed is an objective observation that can be directly seen.

Correct Answer: D

Rationale: The correct answer is D: �You must avoid hyperextending your neck after surgery.� This is because hyperextending the neck can put excessive strain on the surgical site, leading to potential complications such as bleeding or injury to the incision. Keeping the neck in a neutral position helps promote healing and reduces the risk of complications. A: �The head of your bed must remain flat for 24 hours after surgery.� - Incorrect. Elevating the head of the bed can help reduce swelling and promote drainage after thyroidectomy. B: �You should avoid deep breathing and coughing after surgery.� - Incorrect. Deep breathing and coughing are important to prevent respiratory complications such as pneumonia. C: �You won�t be able to swallow for the first day or two.� - Incorrect. Swallowing may be difficult initially but should improve gradually after surgery.

Correct Answer: C

Rationale: The correct next step after identifying nursing diagnoses is planning. Planning involves setting goals and creating a plan of care to address the patient's needs based on the identified nursing diagnoses. This step helps in determining interventions and outcomes for the patient. Assessment has already been completed, and diagnosis is the step where nursing diagnoses are identified. Implementation comes after planning, where the nurse carries out the planned interventions. Therefore, the logical next step in the nursing process after identifying nursing diagnoses is planning.

Correct Answer: A

Rationale: The correct answer is A because it meets the goal of maintaining a heart rate of 78 beats/min. This specific date ensures the consistency of the heart rate within the desired range. Choices B, C, and D do not align with the goal as they either have a different heart rate or occur on a different date. Therefore, A is the only option that accurately reflects the goal being met on the specified date.