Fundamentals Nursing Process Questions

Correct Answer: B

Rationale: The correct answer is B: Pathologic bone fractures. In multiple myeloma, there is an increase in osteoclast activity leading to bone destruction, making patients prone to pathologic fractures. Chronic liver failure (A), acute heart failure (C), and hypoxemia (D) are not directly associated with multiple myeloma pathophysiology. This highlights the importance of understanding the disease process to determine the correct answer.

Correct Answer: A

Rationale: Step-by-step rationale for why choice A is correct: 1. The American Cancer Society recommends yearly mammograms after age 40 for early breast cancer detection. 2. Mammograms are most effective for women aged 40 and older in detecting breast cancer. 3. Regular mammograms can help detect breast cancer at an early stage, improving treatment outcomes. Summary of why other choices are incorrect: B: Mammograms should start at age 40, not after the birth of the first child. C: Mammograms are not recommended after the first menstrual period; they should start at age 40. D: Mammograms should be done annually after age 40, not every 3 years between ages 20 and 40.

Correct Answer: B

Rationale: The correct answer is B: 17 drops per minute. To calculate the correct drip rate, you need to use the formula: (Volume to be infused in mL / Time in minutes) x Drop factor. In this case, if the volume to be infused is 100 mL and the time is 60 minutes with a drop factor of 20, the calculation would be: (100 / 60) x 20 = 33.33 drops per minute. Since we cannot deliver fractional drops, the closest whole number is 17 drops per minute. This ensures the correct delivery rate for the medication. Choice A (6 drops per minute) is incorrect as it would be too slow and may not deliver the medication effectively. Choice C (50 drops per minute) and Choice D (100 drops per minute) are incorrect as they would both deliver the medication too quickly, potentially causing harm to the patient. The correct answer, 17 drops per minute, ensures a safe and accurate delivery rate

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen therapy. This is the priority intervention because a high temperature and diaphoresis indicate potential respiratory distress. Oxygen therapy can help improve oxygenation and support respiratory function. Providing frequent linen changes (B) is important for hygiene but not the priority. Fluid intake (C) is essential but not as urgent as addressing respiratory distress. Maintaining complete bed rest (D) may be necessary but addressing oxygenation takes precedence in this case.

Correct Answer: D

Rationale: The correct answer is D: Evaluation. In the nursing process, evaluation involves determining if the patient's condition has improved and if the expected outcomes have been met. The nurse assesses the patient's progress, compares it to the expected outcomes set during planning, and determines the effectiveness of the interventions implemented. This step ensures that the care provided is meeting the patient's needs and helps in making any necessary adjustments to the care plan. Incorrect choices: A: Assessment - This step involves gathering information about the patient's condition and needs at the beginning of the nursing process. B: Planning - Involves setting goals and developing a plan of care based on the assessment data. C: Implementation - Involves carrying out the interventions outlined in the care plan to meet the patient's goals.