Nursing Process 1 Test Questions

Correct Answer: A

Rationale: The correct answer is A: Fasciculations. Fasciculations are involuntary muscle twitches commonly seen with neurological conditions like motor neuron disease. In this case, the patient's muscle weakness and frequent muscle twitching indicate possible nerve damage. Chorea (B) is characterized by involuntary, jerky movements, not twitching. Atrophy (C) refers to muscle wasting, not twitching. Neuropathy (D) is a general term for nerve damage and does not specifically describe the muscle twitching seen in this patient.

Correct Answer: A

Rationale: The correct answer is A: Vision changes. This is crucial to report immediately because tamoxifen can cause serious eye problems such as retinopathy. Vision changes could indicate a potentially serious adverse reaction that requires prompt medical attention to prevent permanent damage. Headache, hearing loss, and anorexia are not typically associated with tamoxifen use and are less urgent in nature. Reporting vision changes promptly can help prevent irreversible harm and ensure timely intervention.

Correct Answer: D

Rationale: Step 1: Monitoring Mrs. GC's color, pulse, and respiration is important to assess for any signs of distress during the procedure. Step 2: Labeling all laboratory specimens in numerical order ensures accurate identification and prevents errors in specimen handling. Step 3: Positioning Mrs. GC on her side with knees drawn up to her chest helps maintain proper spinal alignment and reduces the risk of complications. Summary: Option D is correct because all the interventions mentioned are crucial for ensuring patient safety and procedural success. Options A, B, and C are incorrect individually as they each address only one aspect of the procedure, whereas the correct answer encompasses all necessary interventions.

Correct Answer: C

Rationale: The correct answer is C: Glucagon. In a hypoglycemic reaction, glucagon can be administered to raise blood sugar levels quickly. Glucagon works by stimulating the liver to release stored glucose into the bloodstream. This is crucial in emergencies when oral carbohydrates are not feasible. Epinephrine (A) is used for severe allergic reactions, not hypoglycemia. 50% dextrose (B) is an oral carbohydrate used for hypoglycemia but is not always practical. Hydrocortisone (D) is a corticosteroid used for inflammatory conditions, not for hypoglycemic emergencies.

Correct Answer: A

Rationale: The correct answer is A: 2 and 5. Diminished breath sounds indicate possible atelectasis or pneumonia post-operatively, making coughing and deep breathing (2) and ambulation (5) crucial to prevent complications. Decreasing fluid intake (iv) can lead to dehydration, worsening the situation. Administering antibiotics (i) without further assessment may not be necessary at this point. Acetaminophen (iii) can help with fever but does not address the underlying respiratory issue.