Nursing Process Exam Questions

Correct Answer: A

Rationale: The correct answer is A. Standard precautions include wearing gloves when there is a potential for contact with blood or body fluids. Emptying a bedpan involves contact with bodily fluids, thus gloves are necessary to prevent exposure to pathogens. Choice B is incorrect because wearing a gown and protective eyewear is not necessary for obtaining a urine specimen via catheterization unless there is a risk of splashing or spraying of fluids. Choice C is incorrect as needles should always be disposed of in a proper sharps container with the cap secured to prevent accidental needlestick injuries. Choice D is incorrect because applying eyedrops does not involve contact with blood or body fluids, so wearing gloves is not necessary according to standard precautions.

Correct Answer: A

Rationale: The correct answer is A. Standard precautions include wearing gloves when there is a potential for contact with blood or body fluids. Emptying a bedpan involves contact with bodily fluids, thus gloves are necessary to prevent exposure to pathogens. Choice B is incorrect because wearing a gown and protective eyewear is not necessary for obtaining a urine specimen via catheterization unless there is a risk of splashing or spraying of fluids. Choice C is incorrect as needles should always be disposed of in a proper sharps container with the cap secured to prevent accidental needlestick injuries. Choice D is incorrect because applying eyedrops does not involve contact with blood or body fluids, so wearing gloves is not necessary according to standard precautions.

Correct Answer: A

Rationale: The correct answer is A: immediately administer pain relief. After a lobectomy, the patient may experience significant pain due to the surgical incision and chest tube insertion. Providing prompt pain relief is crucial to ensure the patient's comfort and prevent complications such as shallow breathing or limited mobility. This action will also aid in the patient's early recovery and promote better outcomes. Choice B (keep patient in semi-fowler's position) is not the priority upon arrival from the Post Anesthesia Care Unit as pain management takes precedence. Choice C (turn client every hour) is important for preventing complications but is not the immediate action required upon arrival. Choice D (notify the family to report patient's condition) is important but not as urgent as providing pain relief to the patient.

Correct Answer: B

Rationale: The correct answer is B because it indicates a confrontational and possibly disrespectful attitude towards the nurse. This can hinder effective communication and collaboration. A: Shows understanding of hallucinations. C: Demonstrates assistance to the father. D: Reflects consideration for the father's needs. B is incorrect as it does not promote positive interaction.

Correct Answer: C

Rationale: The correct answer is C because flushing the central venous catheter with a heparinized solution before blood withdrawal is essential to maintain catheter patency and prevent clot formation. This step ensures the catheter is clear of any blockages, allowing for accurate blood sampling. Choice A is incorrect because assembling supplies should come after preparing the catheter. Choice B is incorrect as discarding blood before flushing the catheter may lead to inaccurate test results. Choice D is incorrect as replacing the catheter cap without flushing may lead to clot formation and catheter malfunction.