Nursing Process Test Bank

Correct Answer: C

Rationale: The correct answer is C: Receive vaccines against infection. Following a splenectomy, the patient is at an increased risk of infection due to the absence of the spleen's immune function. Vaccines help boost the body's immunity against specific pathogens, reducing the risk of infections. This is crucial for preventing post-splenectomy infections. Now, let's analyze the other choices: A: Avoid showering for 1 week - There is no evidence to support that avoiding showering would prevent infection after a splenectomy. B: Sleep in a semi-fowler�s position - Positioning does not directly impact infection prevention post-splenectomy. D: Stay on antibiotics for life - Long-term antibiotic use can lead to antibiotic resistance and is not recommended unless specifically indicated for a different reason.

Correct Answer: C

Rationale: The correct answer is C: high protein, low residue. For patients with ulcerative colitis, a high protein diet helps in tissue healing and repair. Low residue foods are recommended to reduce bowel irritation. Choice A is incorrect because low protein can impair healing. Choice B is unsuitable as high fiber may worsen symptoms. Choice D is not ideal as high carbohydrate can be difficult to digest for colitis patients.

Correct Answer: A

Rationale: The correct answer is A because playing card games with friends is a low-energy activity suitable for someone with decreased energy due to chemotherapy. This option promotes social interaction and mental stimulation, addressing the deficient diversional activity. B, bowling with a team, involves physical activity and may be too strenuous for someone with decreased energy. C, taking a long trip, requires significant energy and may not be feasible. D, eating lunch in a restaurant, does not address the need for diversional activity and is not specific to the client's energy limitations.

Correct Answer: B

Rationale: The correct answer is B because after developing a plan of care, the nurse must communicate it to all healthcare professionals involved in the patient's care to ensure everyone is aware of the plan and can collaborate effectively. This promotes continuity of care and prevents errors. Choice A is incorrect because the plan of care should not be placed in the chart to avoid tampering; it should be easily accessible for updates. Choice C is incorrect as filing in the administration office is unnecessary for routine care. Choice D is incorrect as sending the plan to quality assurance is not the immediate next step after developing the plan.

Correct Answer: B

Rationale: The correct answer is B: IgE. IgE is specific to allergic responses as it binds to mast cells and basophils, triggering the release of histamine and other inflammatory mediators. IgA is more involved in mucosal immunity, IgG is involved in long-term immunity and opsonization, and IgM is the primary antibody in the primary immune response. IgB is not a known immunoglobulin. Therefore, IgE is the specific immunoglobulin associated with allergic responses due to its role in mediating hypersensitivity reactions.