Nursing Process 1 Test Questions

Correct Answer: A

Rationale: The correct answer is A: Secure the cannula with tape. This is the last step in inserting an IV cannula to ensure it stays in place and prevents dislodgement or movement. Securing the cannula with tape helps maintain proper positioning and prevents accidental removal. Documenting the insertion site, date, and type of cannula used (B) is important but typically done earlier in the process. Assessing the site (C) should be done before securing the cannula to ensure proper placement. Placing a sterile dressing over the insertion site (D) is also important, but it usually comes before securing the cannula with tape to maintain a clean and sterile environment.

Correct Answer: D

Rationale: The correct answer is D: Polyps. Polyps in the colon are precancerous growths that can develop into colorectal cancer over time. Identifying polyps during a medical history interview can raise suspicion for colorectal cancer due to their potential to progress into malignancy. Duodenal ulcer (A) is not directly related to colorectal cancer. Weight gain (B) is a non-specific symptom and does not specifically indicate colorectal cancer. Hemorrhoids (C) are common and usually benign, not directly linked to colorectal cancer.

Correct Answer: C

Rationale: The correct answer is C: liver function tests. Isoniazid and Rifampicin are known to potentially cause hepatotoxicity, leading to abnormal liver function test results. Liver function tests measure enzymes and proteins that indicate liver health. Gallbladder studies (A), thyroid function tests (B), and blood sugar levels (D) are not directly affected by these medications and would not show abnormal results due to their use.

Correct Answer: C

Rationale: The correct answer is C: Glucagon. In a hypoglycemic reaction, glucagon can be administered to raise blood sugar levels quickly. Glucagon works by stimulating the liver to release stored glucose into the bloodstream. This is crucial in emergencies when oral carbohydrates are not feasible. Epinephrine (A) is used for severe allergic reactions, not hypoglycemia. 50% dextrose (B) is an oral carbohydrate used for hypoglycemia but is not always practical. Hydrocortisone (D) is a corticosteroid used for inflammatory conditions, not for hypoglycemic emergencies.

Correct Answer: B

Rationale: The correct answer is B: Focused assessment. In this scenario, the nurse is continuously monitoring specific aspects such as vital signs, pupils, and orientation at regular intervals, which is characteristic of a focused assessment. This type of assessment allows the nurse to gather specific data related to the client's condition and respond promptly to any changes. A: Initial assessment is conducted upon admission to establish baseline data. C: Time-lapsed reassessment involves comparing current data to previous assessments over a longer period. D: Emergency assessment is performed in urgent situations to quickly identify life-threatening issues. By systematically assessing the client's vital signs, pupils, and orientation at frequent intervals, the nurse can provide timely and appropriate care in the intensive care unit setting.