Nursing Process Final Exam Questions

Correct Answer: D

Rationale: The correct answer is D: "I will have my potassium level checked." Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Monitoring potassium levels is crucial to prevent complications such as cardiac arrhythmias. A: Monitoring urine sodium is not typically necessary for furosemide therapy. B: Prothrombin time monitoring is unrelated to furosemide therapy. C: Monitoring calcium levels is not directly affected by furosemide use. In summary, monitoring potassium levels is essential due to the potential for hypokalemia with furosemide, while the other options are not directly relevant to this medication.

Correct Answer: C

Rationale: The nurse would identify platelets at 115,000/ul as an abnormal finding because it is below the normal range of 150,000-450,000/ul. Low platelet count can lead to increased bleeding risk. RBC count and hematocrit levels are within normal ranges, making them normal findings. Option D is incorrect as platelets are abnormal.

Correct Answer: A

Rationale: The correct answer is A: Have the patient lie flat for 6 to 8 hours after a lumbar puncture to prevent complications like post-lumbar puncture headache. Lying flat helps maintain CSF pressure and reduce the risk of leakage. B: Keeping the patient from eating or drinking for 4 hours is not necessary after a lumbar puncture. C: Monitoring pedal pulses q4h is irrelevant to post-lumbar puncture care. D: Keeping the head of the bed elevated 30 degrees for 24 hours is not recommended after a lumbar puncture as it may increase the risk of complications.

Correct Answer: C

Rationale: The correct answer is C: severe, unrelieved pain. Compartment syndrome is characterized by increased pressure within a muscle compartment leading to decreased blood flow and tissue damage. Severe, unrelieved pain is a hallmark sign as the pressure builds up. Weak movement of the patient's toes (choice A) could indicate nerve damage but is not specific to compartment syndrome. Decreased pedal pulses (choice B) could suggest vascular compromise but are not specific to compartment syndrome. Presence of foot pallor (choice D) could indicate poor circulation but is not a definitive sign of compartment syndrome.

Correct Answer: A

Rationale: The correct answer is A: Etiology. Etiology in a nursing diagnosis refers to the cause or contributing factors of the identified problem. In this case, the large scar over the left side of the face is the reason for the disturbed self-esteem. It is the underlying factor that is leading to the self-esteem issue. The problem itself is the disturbed self-esteem, the defining characteristics are the signs and symptoms that support the diagnosis, and client need is the desired outcome or goal for the client. In summary, the presence of the large scar is the cause or etiology of the disturbed self-esteem, making it the correct choice.