Nursing Process NCLEX Questions

Correct Answer: C

Rationale: The correct answer is C: Raw fruits and vegetables. Patients with HIV and diarrhea should avoid raw fruits and vegetables due to their high fiber content, which can exacerbate diarrhea symptoms. Fiber can increase bowel movements and worsen diarrhea. Therefore, avoiding raw fruits and vegetables can help reduce diarrhea. Choice A (Potassium-rich food) is not the best answer because potassium-rich foods are important for patients with HIV to maintain electrolyte balance. Choice B (Liquid nutritional supplements) can actually be beneficial in providing essential nutrients to patients with HIV. Choice D (Frozen products) is not directly related to diarrhea management in patients with HIV.

Correct Answer: A

Rationale: Step-by-step rationale for why answer A is correct: 1. Having intercourse with just the spouse means a monogamous relationship with a trusted partner, minimizing risk of exposure to HIV. 2. It eliminates the risk of contracting HIV from multiple sexual partners. 3. This choice adheres to safer sex practices by reducing the chances of exposure to HIV. 4. This choice also promotes trust and communication within the relationship, further reducing the risk of HIV transmission. Summary: - Choice A is correct as it promotes monogamy and reduces the risk of exposure to HIV. - Choices B, C, and D do not guarantee zero risk of HIV transmission as blood donations, HIV antibodies, and condom use can still pose risks if not used or implemented correctly.

Correct Answer: D

Rationale: Step 1: Proper positioning helps maintain alignment and prevent deformities in muscles and joints. Step 2: It reduces the risk of contractures by ensuring that Mr. Gabatan's lower extremities are in optimal positions. Step 3: This promotes circulation and reduces pressure on bony prominences. Step 4: Active exercise may exacerbate spasticity, tilt board may not address positioning adequately, and deep massage may not prevent contractures effectively.

Correct Answer: C

Rationale: Correct Answer: C - Tracheostomy set Rationale: 1. Immediate airway management: After thyroidectomy, there is a risk of airway compromise due to swelling or bleeding. Tracheostomy set ensures immediate access to secure the airway. 2. Emergency intervention: In case of respiratory distress or airway obstruction post-surgery, a tracheostomy set allows for prompt and effective intervention. 3. Patient safety and priority: Ensuring airway patency is crucial for the client's survival and takes precedence over other equipment. Summary of other choices: A: Indwelling urinary catheter kit - Not directly related to post-thyroidectomy care. B: Cardiac monitor - Important but secondary to airway management in this situation. D: Humidifier - Not essential for immediate post-thyroidectomy care.

Correct Answer: A

Rationale: The correct answer is A because collecting urine 24-48 hrs after the client has received nonradioactive B12 is essential for the Schilling test to evaluate vitamin B12 absorption. Urine is collected to measure the excretion of radioactive B12, which helps in diagnosing pernicious anemia or malabsorption issues. Incorrect choices: B: Collecting blood samples is not necessary for the Schilling test as it primarily involves urine collection. C: Allowing oral fluid consumption is important to prevent dehydration and is not contraindicated after receiving nonradioactive B12. D: Making the client lie down in the supine position is unnecessary for the Schilling test and may not affect the test results.