Nursing Process Practice Questions

Correct Answer: D

Rationale: The correct answer is D: Diarrhea. Antibiotics can disrupt the normal balance of gut bacteria, leading to diarrhea. This occurs due to the overgrowth of harmful bacteria in the intestines. Monitoring for diarrhea is crucial to prevent dehydration and further complications. Platelet dysfunction (A), stomatitis (B), and oliguria/dysuria (C) are not typically associated with the disruption of normal flora by antibiotics. These symptoms are more likely related to other conditions or side effects of medications, making them incorrect choices in this scenario.

Correct Answer: A

Rationale: Rationale: A: Pressing the system in place for 30 to 60 seconds helps ensure proper adhesion and absorption of the medication. This step is crucial for the effectiveness of the pain management system. B: Choosing a site on the lower torso is not necessary for applying the system. The site selection should be based on guidelines and patient preference. C: Shaving the application site is not recommended unless specifically indicated. It is not a standard step for applying a pain management system. D: Applying the system immediately after removal from a package may not allow the adhesive to fully activate, affecting its efficacy. It is important to follow the recommended steps for proper application.

Correct Answer: B

Rationale: The correct answer is B: Aldosterone. Aldosterone is a hormone produced by the adrenal glands that helps regulate sodium and water balance in the body. It acts on the kidneys to increase reabsorption of sodium, leading to water retention and increased blood volume. This helps maintain blood pressure and electrolyte balance. A: Antidiuretic hormone (ADH) mainly acts on the kidneys to increase water reabsorption, not sodium retention. C: Thyroid hormone does not directly influence sodium retention. D: Insulin regulates blood sugar levels by promoting glucose uptake, it does not have a direct role in sodium retention.

Correct Answer: B

Rationale: The correct answer is B: Focus on the patient�s presenting situation. In the problem-oriented approach, the nurse prioritizes the patient's immediate concerns to address them effectively. By focusing on the presenting situation first, the nurse can gather relevant data and identify key issues. This step ensures that the nurse addresses the most pressing problems promptly. A: Completing questions in chronological order may not be necessary and could delay addressing the immediate concern. C: Making accurate interpretations of data should come after gathering relevant information about the presenting situation. D: Conducting an observational overview is important but should come after focusing on the patient's presenting situation to gather specific data.

Correct Answer: A

Rationale: The correct answer is A: The nurse should practice interviewing strategies. This is the best remedy because improving the nurse's ability to gather comprehensive information during client history will ensure sufficient data for planning interventions. By practicing interviewing strategies, the nurse can learn to ask relevant questions, actively listen, and probe for additional details. Summary: B: Modifying the data collection tool may not address the issue of insufficient information if the problem lies with how the nurse conducts the interview. C: Determining the specific purpose of data collection is important but may not solve the immediate issue of lacking information for intervention planning. D: Updating the database is irrelevant to the problem of inadequate data collection during client history.