Nursing Process Quizlet Questions

Correct Answer: B

Rationale: The correct answer is B: Pink, frothy sputum. This is because pink, frothy sputum is a classic sign of pulmonary edema, indicating fluid in the lungs. Furosemide IV is a diuretic that helps remove excess fluid from the body, including the lungs. Resolving pink, frothy sputum indicates that the treatment is effectively reducing the fluid in the lungs. Incorrect choices: A: Pedal edema - This refers to swelling in the feet and ankles, which is not directly related to pulmonary edema. C: Jugular vein distention - This is a sign of heart failure, not specifically pulmonary edema. D: Bradycardia - This is a slow heart rate and not a direct indicator of pulmonary edema resolution.

Correct Answer: A

Rationale: The correct answer is A: Bleeding precautions. With low platelets (50,000/ul), the client is at risk for bleeding. Platelets help with blood clotting, so precautions to prevent bleeding are essential. This includes avoiding activities that can cause injury, using a soft toothbrush, and reporting any signs of bleeding. Summary: B: Isolation to prevent infection - This is not related to the client's lab values. C: Seizure precautions - Not relevant to the client's lab values. D: Control of pain with analgesics - Pain management is not the priority given the client's lab values indicating a risk of bleeding.

Correct Answer: B

Rationale: The correct answer is B: 2.0mEq/L. Severe vomiting can lead to hypokalemia, characterized by flat T waves and ST segment depression on ECG. This is due to decreased potassium levels affecting cardiac repolarization. A potassium level of 2.0mEq/L is dangerously low and consistent with the ECG findings in this scenario. Choices A, C, and D have potassium levels that are not reflective of severe hypokalemia, therefore they are incorrect. Option A (4.0mEq/L) is within the normal range, option C (8.0mEq/L) is elevated, and option D (2.6mEq/L) is higher than the correct value of 2.0mEq/L.

Correct Answer: B

Rationale: Step 1: Activity intolerance is defined as insufficient physiological or psychological energy to endure or complete required or desired daily activities. Step 2: In the scenario, the patient experiences shortness of breath when getting out of bed, indicating decreased ability to tolerate physical activity. Step 3: This shortness of breath is a defining characteristic of activity intolerance as it reflects the patient's limited ability to perform activities of daily living. Step 4: Other symptoms like decreased oral intake, decreased oxygen saturation, and productive cough may be related to other health issues but are not specific to activity intolerance. Step 5: Therefore, choice B is the correct answer as it includes a key defining characteristic of activity intolerance, while other choices do not directly relate to the concept.

Correct Answer: D

Rationale: The correct answer is D because asking the patient about their usual sleep patterns and onset of difficulty resting is crucial to understand the situation fully. This helps to identify any potential underlying issues contributing to the sleep disturbance. Choice A is incorrect as it dismisses the patient's concerns. Choice B is not as effective as directly addressing the patient's sleep issues. Choice C delays the assessment, potentially missing important information. By choosing answer D, the nurse can gather valuable information to address the patient's sleep problem effectively.