Fundamentals of Nursing Nursing Process Questions

Correct Answer: A

Rationale: The correct answer is A. 1. Change in level of consciousness is crucial in assessing neurological status. 2. Tachypnea indicates possible respiratory distress or oxygenation issues. 3. Tachycardia may suggest a cardiovascular problem or inadequate perfusion. 4. Petechiae can be a sign of bleeding disorders or sepsis. Option B is incorrect because chest pain, diaphoresis, and nausea/vomiting are more indicative of a cardiac event rather than monitoring for J.E.'s signs and symptoms. Option C is incorrect because loss of consciousness, bradycardia, and leg pain do not align with the signs and symptoms to monitor for J.E. Option D is incorrect because bradycardia, chest pain, and oliguria are not as comprehensive as the signs and symptoms listed in option A for monitoring J.E.

Correct Answer: C

Rationale: The correct answer is C: Urine output increases. This indicates digoxin's effectiveness as it improves cardiac output by enhancing contraction strength. Increased urine output signifies improved kidney perfusion due to enhanced cardiac function. Option A is incorrect as decreased urine output indicates poor kidney perfusion. Option B is incorrect as digoxin aims to regulate heart rate, not necessarily make it higher than 95. Option D is incorrect as a heart rate lower than 50 could indicate digoxin toxicity.

Correct Answer: B

Rationale: The correct answer is B: Ineffective airway clearance related to obstruction by a tumor or secretions. This takes highest priority as compromised airway can lead to respiratory distress and potential respiratory failure. Maintaining clear airways is essential for oxygenation and ventilation. Choices A, C, and D are important but do not pose immediate life-threatening risks compared to compromised airway. Disturbed body image, anxiety, and imbalanced nutrition can be addressed once the airway clearance is stabilized.

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: B

Rationale: The correct answer is B, a high protein, vitamin, and iron diet, as it directly addresses the nutritional deficiencies associated with anemia. Proteins aid in the production of red blood cells, while iron and vitamins are essential for hemoglobin synthesis. Medical therapy (A) typically involves medications or blood transfusions, not dietary changes. Fluid therapy (C) may be used for certain types of anemia, but it is not a primary intervention. Chemotherapy (D) is not indicated for the treatment of anemia, as it is used for cancer treatment. Therefore, choice B is the most appropriate intervention for anemia.