Fundamentals Nursing Process Questions

Correct Answer: A

Rationale: The correct answer is A: Nystagmus. A phenytoin blood level of 35 mcg/ml is above the therapeutic range (usually 10-20 mcg/ml). Excessive levels can lead to symptoms such as nystagmus, which is an involuntary eye movement commonly seen with phenytoin toxicity. Nystagmus is a known side effect of phenytoin overdose. Choices B and C are incorrect because a level of 35 mcg/ml is not within the normal therapeutic range, so symptoms would be expected. Choice D, Slurred speech, is not typically associated with phenytoin toxicity.

Correct Answer: D

Rationale: The correct answer is D: vasopressin (Pitressin). In diabetes insipidus, there is a deficiency of antidiuretic hormone (ADH), which leads to excessive urination and thirst. Vasopressin is a synthetic form of ADH that helps regulate water balance by reducing urine output. Therefore, administering vasopressin would help manage the symptoms of diabetes insipidus. Insulin (A) is used for diabetes mellitus, not diabetes insipidus. Potassium chloride (B) is used to correct potassium imbalances, not specific to diabetes insipidus. Furosemide (Lasix) (C) is a diuretic that increases urine output, which would worsen the symptoms of diabetes insipidus.

Correct Answer: B

Rationale: Rationale: B is correct because cystoclisis is the process of maintaining patency of a foley catheter by irrigating it with a sterile solution. This prevents blockages and promotes proper drainage. A, C, and D are incorrect because cystoclisis is not related to increasing bladder atony, removing blood clots, or altering urine specific gravity.

Correct Answer: A

Rationale: The correct answer is A because determining whether an intervention is correct and appropriate for the given situation indicates critical thinking in nursing care implementation. This involves assessing the patient's needs, analyzing the situation, and using evidence-based practice to make informed decisions. This process ensures that interventions are tailored to individual patient needs and promotes safe and effective care delivery. Option B is incorrect because performing a procedure without clinical competency can jeopardize patient safety and is not an example of critical thinking. Option C is incorrect as establishing goals without assessment lacks a foundation in data and may lead to inappropriate care planning. Option D is incorrect as evaluating the effectiveness of interventions is a part of the nursing process but does not specifically demonstrate critical thinking in implementation.

Correct Answer: A

Rationale: The correct answer is A because continuous assessment allows for timely identification of changes in the client's condition. This is crucial for providing appropriate and timely interventions. Assessing the client only at specific times (choices B and C) may lead to missing important changes. Choice D is incorrect because assessments should not be limited to physician rounds; they should be ongoing to ensure comprehensive care.