Fundamentals of Nursing Nursing Process Questions

Correct Answer: A

Rationale: The correct answer is A because sharp pain is a subjective cue as it is based on the client's personal experience and perception. The client is the only one who can report the presence and intensity of pain. B: Small bloody drainage is an objective cue that can be observed and measured by the nurse. C: Temperature of 102 degrees F is an objective cue that can be measured using a thermometer. D: Pulse rate of 90 beats per minute is an objective cue that can be measured using a pulse oximeter. In summary, subjective cues are based on the client's feelings and perceptions, while objective cues are observable and measurable by the healthcare provider.

Correct Answer: C

Rationale: The correct answer is C: Performing a physical examination. This method allows the nurse to directly gather data from the patient's body, such as vital signs, appearance, and overall health status. It provides essential information to establish a patient's database, including baseline values and potential health issues. Reviewing current literature (A) helps in decision-making but does not directly establish a patient's database. Checking orders for tests (B) and ordering medications (D) are part of the treatment process and do not focus on gathering initial patient data.

Correct Answer: B

Rationale: The correct answer is B: Maintain strict aseptic technique. This is crucial during thoracentesis to prevent infection. Step 1: Before the procedure, sterile equipment and supplies must be used. Step 2: Proper hand hygiene is essential to reduce the risk of introducing pathogens. Step 3: During the procedure, maintaining a sterile field helps minimize the risk of contamination. Step 4: After the procedure, ensuring proper disposal of all used supplies prevents the spread of infection. Summary: A: Placing the patient in a quiet and cool room may be comforting but is not directly related to the safety of the procedure. C: Advising the patient to sit still is important for accurate needle insertion but does not address infection prevention. D: Applying pressure over the puncture site is important but does not prevent infection if aseptic technique is not maintained.

Correct Answer: A

Rationale: The correct answer is A because it is specific, measurable, achievable, relevant, and time-bound (SMART) - the patient verbalizing a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift. This outcome is immediate, concrete, and directly related to the goal of managing pain. Choice B is incorrect as it lacks specificity and a clear timeframe for evaluation. Choice C is incorrect because the outcome is vague and does not specify when the patient needs to understand the dietary changes. Choice D is incorrect because the timeframe is provided but the outcome is not specific enough and does not directly relate to the goal of pain management.

Correct Answer: B

Rationale: The correct answer is B: Drinking cranberry juice. Cranberry juice is known to help reduce urinary odor due to its acidic nature which can help eliminate bacteria that cause odor. It also helps to maintain urinary tract health. The other choices are incorrect because: A: Eating spicy foods can actually increase body odor and may not have any impact on urinary odor. C: Foods like eggs, asparagus, or cheese may contribute to strong body odor but do not specifically address urinary odor. D: Drinking tea, coffee, and colas can potentially worsen urinary odor due to their caffeine content and impact on urinary tract health.