Nursing Process 1 Test Questions

Correct Answer: B

Rationale: The correct answer is B: Turn on the affected side. This position helps to promote the closure of the puncture site in the lung, reducing the risk of fluid leakage and pneumothorax. Placing the client flat in bed (A) may not allow gravity to assist in the closure of the puncture site. Turning on the unaffected side (C) may not effectively prevent fluid leakage from the puncture site. Bed rest (D) is a general instruction and does not specifically address the prevention of fluid leakage after thoracentesis.

Correct Answer: B

Rationale: The correct answer is B because encouraging the intake of low-sodium liquids like coffee or tea can worsen hyponatremia. Hyponatremia is a condition characterized by low sodium levels in the blood, so encouraging low-sodium liquids would further dilute the sodium levels. The other choices are correct interventions for hyponatremia: A) assessing for symptoms helps in monitoring the patient's condition, C) monitoring neurological status is crucial as hyponatremia can lead to neurological complications, and D) restricting tap water intake helps in managing fluid intake and preventing further dilution of sodium levels.

Correct Answer: D

Rationale: The correct answer is D: To determine clients response to therapy. Evaluating BUN, creatinine, and serum electrolyte levels in a client being treated for acute pyelonephritis helps the nurse assess the effectiveness of the therapy. Changes in these levels indicate how well the kidneys are functioning and how the client is responding to treatment. Monitoring these parameters allows for adjustments in therapy if needed. Incorrect choices: A: To determine the severity of the disorder - While these tests can provide information about the severity of kidney dysfunction, the primary focus is on monitoring the response to therapy. B: To identify signs of fluid retention - While BUN and creatinine levels can indirectly indicate fluid status, the main purpose of evaluating these tests is to assess therapy response. C: To determine the location of discomfort - These tests do not provide information about the location of discomfort but rather focus on kidney function and response to treatment.

Correct Answer: A

Rationale: The correct answer is A: Post-trauma syndrome related to being attacked. This diagnosis accurately reflects the client's symptoms of reliving the traumatic event, crying uncontrollably, and expressing fear. "Post-trauma syndrome" encompasses the psychological and emotional distress following a traumatic event. Choice B: Psychological overreaction simplifies the client's experience and does not capture the severity or ongoing nature of the trauma symptoms. Choice C: Needs assistance coping with attack is vague and does not provide a specific diagnosis or acknowledge the clinical presentation of the client. Choice D: Mental distress related to being attacked is too broad and does not specify the specific syndrome or symptoms experienced by the client.

Correct Answer: A

Rationale: The correct answer is A: Oxygen. Oxygen is primarily transported in the blood bound to hemoglobin within red blood cells, not dissolved in plasma. Carbon dioxide is transported in plasma. Nutrients and hormones are also transported in plasma. Therefore, choice A is incorrect as oxygen is not primarily transported in plasma.