Nursing Process Exam Questions

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Nursing Process Exam Questions Questions

Question 1 of 5

The nursing diagnosis Impaired Gas Exchange, prioritized by Maslow�s hierarchy of basic human needs, is appropriate for what level of needs?

Correct Answer: A

Rationale: The correct answer is A: Physiologic. Impaired Gas Exchange pertains to the basic physiological need for oxygenation, which is fundamental for survival. Maslow's hierarchy states that physiological needs are the most fundamental and must be met before progressing to higher-level needs. Safety, love and belonging, and self-actualization are higher-level needs compared to physiological needs. Therefore, Impaired Gas Exchange aligns with the physiological level of needs in Maslow's hierarchy.

Question 2 of 5

In the presence of coma or unconsciousness, the major therapeutic measure includes:

Correct Answer: A

Rationale: The correct answer is A: Maintenance of a clear airway. In cases of coma or unconsciousness, ensuring a clear airway is crucial to prevent respiratory complications and maintain oxygenation. This involves positioning the patient correctly, suctioning if necessary, and monitoring breathing. Choice B, good nursing care, is too broad and does not address the immediate priority of airway management. Choice C, retention of a catheter, is irrelevant to managing a coma or unconsciousness. Therefore, the correct therapeutic measure in this scenario is to focus on maintaining a clear airway to support respiratory function.

Question 3 of 5

A patient with abnormal sodium losses is receiving a house diet. To provide 1,600mg sodium daily, the nurse could supplement the patient�s diet with:

Correct Answer: D

Rationale: The correct answer is D because 1 beef cube contains about 1,000mg of sodium. To reach 1,600mg, the patient needs an additional 600mg. 12oz of tomato juice contains approximately 600mg of sodium, making it the right choice. A: Not enough sodium from the beef cube and tomato juice. B: Too much sodium from the 16oz of tomato juice. C: Too much sodium from the 4 beef cubes.

Question 4 of 5

When caring for Mr. Reyes, the nurse should assess for

Correct Answer: B

Rationale: The correct answer is B, Altered level of consciousness, because it is a critical assessment in determining Mr. Reyes's neurological status and overall well-being. Assessing for altered level of consciousness helps identify potential neurological issues, such as brain injury or stroke, which require immediate intervention. A: Decreased carotid pulses - This is related to cardiovascular assessment, not specific to Mr. Reyes's neurological status. C: Bleeding from oral cavity - While important to assess for, it is not directly related to Mr. Reyes's neurological status. D: Absence of deep tendon-reflexes - This is a specific neurological assessment, but altered level of consciousness takes priority in this scenario.

Question 5 of 5

The nurse is assigned to a client with acquired immunodeficiency syndrome (AIDS). When handling the client�s blood and body fluids, the nurse uses standard precautions, which include:

Correct Answer: A

Rationale: The correct answer is A. Standard precautions include wearing gloves when there is a potential for contact with blood or body fluids. Emptying a bedpan involves contact with bodily fluids, thus gloves are necessary to prevent exposure to pathogens. Choice B is incorrect because wearing a gown and protective eyewear is not necessary for obtaining a urine specimen via catheterization unless there is a risk of splashing or spraying of fluids. Choice C is incorrect as needles should always be disposed of in a proper sharps container with the cap secured to prevent accidental needlestick injuries. Choice D is incorrect because applying eyedrops does not involve contact with blood or body fluids, so wearing gloves is not necessary according to standard precautions.

Similar Questions

The nurse is assigned to a client with acquired immunodeficiency syndrome (AIDS). When handling the client�s blood and body fluids, the nurse uses standard precautions, which include:
When teaching a client about insulin administration, the nurse should include which instruction?
A nurse changes a client�s wound dressing according to the protocol outlined by the health care agency. What type of nursing intervention is this?
A client has an abnormal result on a Papanicolaou test. After admitting that she read her chart while the nurse was out of the room, the client asks what dysplasia means. Which definition should the nurse provide?
The nurse is reviewing a patient�s database for significant changes and discovers that the patient has not voided in over 8 hours. The patient�s kidney function lab results are abnormal, and the patient�s oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review?

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