Nursing Process 1 Test Questions

Correct Answer: D

Rationale: The correct answer is D: Loss of peripheral vision. Macular degeneration affects the central vision, specifically the macula, which is responsible for central vision and sharp detail. Loss of peripheral vision is not a typical symptom of macular degeneration. The macula is located in the center of the retina, so symptoms would relate to central vision impairments such as decreased ability to distinguish colors, loss of central vision, and loss of near vision. Peripheral vision is not primarily affected by macular degeneration, hence it is not an expected symptom.

Correct Answer: D

Rationale: The correct answer is D: To determine clients response to therapy. Evaluating BUN, creatinine, and serum electrolyte levels in a client being treated for acute pyelonephritis helps the nurse assess the effectiveness of the therapy. Changes in these levels indicate how well the kidneys are functioning and how the client is responding to treatment. Monitoring these parameters allows for adjustments in therapy if needed. Incorrect choices: A: To determine the severity of the disorder - While these tests can provide information about the severity of kidney dysfunction, the primary focus is on monitoring the response to therapy. B: To identify signs of fluid retention - While BUN and creatinine levels can indirectly indicate fluid status, the main purpose of evaluating these tests is to assess therapy response. C: To determine the location of discomfort - These tests do not provide information about the location of discomfort but rather focus on kidney function and response to treatment.

Correct Answer: D

Rationale: The correct answer is D. In bronchiectasis, worsening cough with position changes is an assessment finding due to increased sputum production and airway obstruction. This occurs because of the pooling of secretions in the affected bronchi. Choices A, B, and C are incorrect because in bronchiectasis, there is typically increased sputum production over time, productive cough with expectoration of large amounts of sputum, and cough that worsens with activity or physical exertion, rather than with position changes.

Correct Answer: B

Rationale: The correct answer is B because it follows the SMART approach: Specific (monitor heart rhythm), Measurable (continuously this shift), Achievable (feed self at all mealtimes), Relevant (shortness of breath), and Time-bound (today). Choice A lacks specificity and measurability. Choice C focuses on the nurse's action, not patient outcomes. Choice D lacks specificity and measurability, focusing on the nurse's actions rather than patient outcomes.

Correct Answer: D

Rationale: Step 1: Monitoring Mrs. GC's color, pulse, and respiration is important to assess for any signs of distress during the procedure. Step 2: Labeling all laboratory specimens in numerical order ensures accurate identification and prevents errors in specimen handling. Step 3: Positioning Mrs. GC on her side with knees drawn up to her chest helps maintain proper spinal alignment and reduces the risk of complications. Summary: Option D is correct because all the interventions mentioned are crucial for ensuring patient safety and procedural success. Options A, B, and C are incorrect individually as they each address only one aspect of the procedure, whereas the correct answer encompasses all necessary interventions.