Fundamentals Nursing Process Questions

Correct Answer: B

Rationale: The correct answer is B: A hypothermia blanket. This is important because hypothermia can lead to complications such as shivering, increased risk of infection, and altered drug metabolism. Checking for the hypothermia blanket ensures Mrs. Zeno's temperature is regulated, promoting safety. A: A tracheostomy set is not directly related to Mrs. Zeno's immediate safety unless she has a tracheostomy in place. C: An intravenous set-up is important for administering medications, fluids, or blood products, but it is not directly related to Mrs. Zeno's safety at the bedside. D: A syringe and edrophonium HCl(Tensilon) is specific to a diagnostic test for myasthenia gravis, which may not be relevant to Mrs. Zeno's current condition or safety.

Correct Answer: C

Rationale: The correct answer is C: Collaborative problem. In the given diagnostic statement, "Impaired physical mobility related to tibial fracture as evidenced by patient�s inability to ambulate," the nurse needs to revise the mention of collaborative problem. The collaborative problem is a health issue that requires the expertise of multiple healthcare providers, whereas the statement provided focuses on a nursing diagnosis related to physical mobility impairment. The etiology (cause), nursing diagnosis, and defining characteristic are all relevant to the nursing diagnostic statement and do not need revision. The collaborative problem aspect is not appropriate in this context as it does not fit the criteria for a collaborative problem.

Correct Answer: C

Rationale: The correct answer is C because asking if the client has strained their voice recently is the most relevant question to assess the issue of hopelessness. Voice strain can be a symptom of underlying emotional distress or mental health concerns, which could be contributing to the client's feelings of hopelessness. Choices A, B, and D are unrelated to the client's presenting issue and would not provide valuable information in addressing the problem at hand.

Correct Answer: B

Rationale: The correct answer is B because a client's medical history of allergy to iodine or seafood is crucial for urinary diversion assessment to prevent potential adverse reactions during procedures involving contrast media or seafood-based medications. It is essential to ensure the client's safety and avoid any allergic reactions. Choice A is incorrect because assessing sexual function is not directly related to urinary diversion assessment. Choice C is also incorrect as urinary diversion does not typically affect nervous control. Choice D is irrelevant to the assessment of a client undergoing urinary diversion.

Correct Answer: D

Rationale: The correct answer is D: Assess swallowing reflex. This is crucial for a patient with Bell's Palsy as it can affect their ability to swallow properly, leading to inadequate nutrition intake. By assessing the swallowing reflex, the nurse can determine if the patient is at risk of aspiration or difficulty in eating, which directly impacts their nutrition status. Monitoring meal trays (A) may not provide accurate information on actual food intake. Checking weights (B) only gives limited information on nutrition status. Measuring intake and output (C) is important for fluid balance but may not directly reflect adequate nutrition intake.