Nursing Process Practice Questions

Correct Answer: C

Rationale: The correct answer is C: Airway obstruction. Postoperatively, a nurse must assess for airway patency in a client with a nasal fracture to ensure proper breathing. Any swelling or bleeding in the nasal area can lead to airway obstruction, which is a critical concern that needs immediate intervention. Choices A, B, and D are incorrect because an allergic reaction, extreme sense of smell, and stridor are not typically associated with postoperative assessment of a nasal fracture. It is crucial to prioritize airway assessment to prevent any complications related to breathing difficulties in this situation.

Correct Answer: D

Rationale: Rationale: Acetylcysteine (Mucomyst) is the antidote for acetaminophen overdose. It works by replenishing glutathione, which helps neutralize the toxic metabolite of acetaminophen. Pentostatin, Fludarabine, and Auranofin are not antidotes for acetaminophen overdose and are used for different conditions. Acetylcysteine is the correct choice as it directly counteracts the toxic effects of acetaminophen.

Correct Answer: A

Rationale: The correct answer is A: Infection. After a splenectomy, the client is at risk for infection due to the spleen's role in the immune system. Without the spleen, the body's ability to fight infections is reduced. Infections can be serious and life-threatening. B: Urinary retention is not a typical complication of a splenectomy. C: Congestive heart failure is not directly related to a splenectomy. D: Viral hepatitis is not a common complication of a splenectomy.

Correct Answer: B

Rationale: The correct answer is B - Focus on the patient's presenting situation. This is because in the problem-oriented approach, the nurse must first gather data related to the patient's current issue or concern. This initial focus helps in identifying the primary problem, setting priorities, and developing a care plan. Now, let's analyze the other choices: A: Completing questions in chronological order may not be necessary or relevant to addressing the patient's immediate issue. C: Making accurate interpretations of the data comes after data collection, so it is not the first step. D: Conducting an observational overview is important but should come after focusing on the patient's presenting situation to gather specific and relevant data.

Correct Answer: D

Rationale: The correct answer is D because developing a standard formal nursing diagnosis helps nurses focus on their scope of practice, which involves identifying and addressing the patient's nursing care needs. By formulating a specific nursing diagnosis, nurses can prioritize interventions and provide individualized care. Choice A is incorrect as nursing diagnoses are not exclusive to nurses. Choice B is incorrect because nursing and physician roles overlap. Choice C is incorrect as clinical judgment should be based on evidence and critical thinking, not solely on intuition.