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: D

Rationale: The correct answer is D: "Begin with the highest priority diagnoses, then select appropriate interventions." Rationale: 1. Start with the highest priority diagnoses: Prioritizing care based on the patients' most critical needs ensures their safety and well-being. 2. Identify appropriate interventions: Select interventions that directly address the priority diagnoses to promote effective care delivery. 3. Tailor interventions to individual needs: By focusing on high-priority diagnoses, the nurse can personalize care plans for each patient. 4. Ensure efficient use of resources: Addressing critical issues first optimizes time and resources for the most impactful outcomes. Summary: A: Incorrect. Performing interventions based on time needed may not address the most critical patient needs. B: Incorrect. While scientific rationale is important, it should come after identifying priority diagnoses. C: Incorrect. Setting goals and outcomes should follow the identification of high-priority diagnoses for effective care planning.

Correct Answer: D

Rationale: The correct answer is D: Hyperosmolar solutions used primarily to reverse negative nitrogen balance. Rationale: 1. Hyperalimentation solutions are designed to provide essential nutrients intravenously. 2. Hyperosmolar solutions have a higher osmolarity compared to body fluids, providing concentrated nutrition. 3. Negative nitrogen balance occurs when the body breaks down more protein than it synthesizes, requiring additional protein intake. 4. Hyperosmolar solutions can provide adequate protein and nutrients to reverse negative nitrogen balance. Summary: A: Hypotonic solutions do not increase osmotic pressure, but rather decrease it. B: Hypertonic solutions are not primarily used for hydration in this context. C: Alkalizing solutions are not the primary purpose of hyperalimentation and do not directly address cellular sweating.

Correct Answer: A

Rationale: The correct answer is A: 25 g/day, initially. In this scenario, the client with Hashimoto's thyroiditis and a history of cardiac issues requires a cautious approach due to the risk of exacerbating cardiac conditions with thyroid hormone replacement. Starting with a low dose of 25 �g/day allows for careful monitoring of the client's response and prevents potential adverse effects on the cardiovascular system. Summary: B: Delayed until after thyroid surgery - Not appropriate as the client requires thyroid replacement therapy for Hashimoto's thyroiditis. C: 100 �g/day, initially - Too high of an initial dose and may lead to adverse cardiovascular effects. D: Initiated before thyroid surgery - Not relevant to the client's situation as there is no indication for thyroid surgery mentioned in the question.

Correct Answer: C

Rationale: The correct answer is C: Apply a cream or lotion to the area. This is because radio-dermatitis is a common side effect of radiation therapy, causing skin irritation and dryness. Applying a cream or lotion helps to moisturize the skin, reduce inflammation, and promote healing. Washing the area with soap can further irritate the skin. Leaving the skin alone may prolong discomfort and delay healing. Avoiding creams or lotions can worsen dryness and discomfort. Overall, applying a suitable cream or lotion is the most effective method to alleviate symptoms and support skin recovery in radio-dermatitis.