Nursing Process Practice Questions

Correct Answer: A

Rationale: The correct initial action for the nurse to take is A: Try to have the client breathe slower. This is because the client may be experiencing respiratory distress, and slowing down their breathing can help improve oxygenation. Giving O2 via nasal cannula (B) should be considered if the client's oxygen saturation is low after trying to slow down their breathing. Administering sodium bicarbonate (C) is not the appropriate initial action unless the client is experiencing severe acidosis. Monitoring the client's fluid balance (D) is important but not the best initial action in this scenario where respiratory distress is the concern.

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: The correct answer is D: �You must avoid hyperextending your neck after surgery.� This is because hyperextending the neck can put excessive strain on the surgical site, leading to potential complications such as bleeding or injury to the incision. Keeping the neck in a neutral position helps promote healing and reduces the risk of complications. A: �The head of your bed must remain flat for 24 hours after surgery.� - Incorrect. Elevating the head of the bed can help reduce swelling and promote drainage after thyroidectomy. B: �You should avoid deep breathing and coughing after surgery.� - Incorrect. Deep breathing and coughing are important to prevent respiratory complications such as pneumonia. C: �You won�t be able to swallow for the first day or two.� - Incorrect. Swallowing may be difficult initially but should improve gradually after surgery.

Correct Answer: A

Rationale: The correct answer is A: A clot can enter the circulation. When a clotted cannula is aggressively flushed, the force can dislodge the clot, allowing it to enter the circulation and potentially leading to serious complications such as embolism. Incorrect choices: B: An air embolism can enter the circulation - In the context of a clotted cannula, air embolism is less likely compared to a clot entering the circulation. C: A painful arterial spasm can occur - Arterial spasm is a potential complication but not directly related to flushing a clotted cannula. D: Fluid extravasation into surrounding tissue can occur - Flushing a clotted cannula may not specifically lead to fluid extravasation, as it is more related to needle dislodgement or improper placement.

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.