Nursing Process Questions

Correct Answer: B

Rationale: The correct answer is B: An above-normal anti-deoxyribonucleic acid. In SLE, the body produces antibodies against its own DNA, leading to the presence of anti-dsDNA antibodies. Elevated levels of anti-dsDNA antibodies are specific to SLE, confirming the diagnosis. A: Increased total serum complement levels are seen in SLE due to complement activation but are not specific to SLE. C: Negative antinuclear antibody test is not consistent with SLE, as ANA positivity is common in SLE. D: Negative lupus erythematosus cell test is not specific to SLE as lupus erythematosus cells are not always present.

Correct Answer: A

Rationale: The correct answer is A because assessing the GI tract is crucial before feeding to ensure proper digestion and absorption. Bowel sounds, last BM, and distention indicate GI function. The client's neurologic status and gag reflex are important to prevent aspiration. Option B is not a primary concern before feeding. Option C is incorrect as formula should be warmed to room temperature before feeding.

Correct Answer: B

Rationale: The correct answer is B because having the head of the bed at a 30-degree angle can cause the radioactive material to shift, potentially leading to an uneven distribution of radiation. This could result in harmful exposure to surrounding tissues. A: Maintaining the client on strict bed rest is important to prevent displacement of the radioactive applicator. C: Providing a complete bed bath each morning is necessary for hygiene and does not pose a radiation hazard. D: Checking the applicator's position every 4 hours is essential to ensure proper placement and does not indicate a radiation hazard.

Correct Answer: B

Rationale: The correct answer is B. The nurse should do a quick assessment to confirm the change in the patient's status, then notify the RN or physician. This is the best response because the nurse needs to immediately assess the patient's condition to ensure prompt intervention if needed. By confirming the change in the patient's status, the nurse can provide the necessary information to the healthcare team for appropriate evaluation and management. The other choices are incorrect because: A does not address the urgency of the situation, C involves unnecessary delay by waiting for the speech therapist, and D is not appropriate as the nurse should be the one assessing and notifying the healthcare team.

Correct Answer: C

Rationale: The correct answer is C: 125 mL/h. To calculate the infusion rate per hour, we divide the total volume (1000 mL) by the total time in hours (8 hours). 1000 mL / 8 hours = 125 mL/h. This ensures a consistent and accurate infusion rate throughout the 8-hour period. Choice A (80 mL/h) is incorrect because it underestimates the infusion rate. Choice B (100 mL/h) is incorrect because it does not divide the total volume by the total time correctly. Choice D (150 mL/h) is incorrect because it overestimates the infusion rate.