Nursing Process Exam Questions

Correct Answer: D

Rationale: The correct answer is D: Calcium. Calcium is necessary for the chemical clotting process because it plays a crucial role in the activation of various clotting factors, leading to the formation of a blood clot. Without sufficient calcium, the clotting cascade would not be able to proceed effectively. Iron (choice A) is essential for red blood cell production, not clotting. Potassium (choice B) and Sodium (choice C) are important for various physiological functions but are not directly involved in the clotting process.

Correct Answer: B

Rationale: The correct answer is B because the assessment findings of pericarditis, photosensitivity, polyarthralgia, and painful mucous membrane ulcers are classic manifestations of systemic lupus erythematosus (SLE). Pericarditis can present as chest pain aggravated by deep breathing or lying flat, photosensitivity refers to skin rashes triggered by sunlight exposure, polyarthralgia involves joint pain in multiple joints, and painful mucous membrane ulcers are common in the mouth or nose. These findings align with the diagnostic criteria for SLE. Choices A, C, and D are incorrect because they do not align with the typical presentation of SLE. Choice A includes facial erythema which is a common symptom, but the presence of profuse proteinuria, pleuritis, fever, and weight loss are not specific to SLE. Choices C and D include symptoms like weight gain, hypothermia, and edema which are not characteristic of SLE. In summary

Correct Answer: B

Rationale: The correct answer is B: Hypotension. Glipizide is a sulfonylurea medication used to treat diabetes by lowering blood sugar levels. Hypotension, or low blood pressure, can be an adverse reaction as glipizide may cause vasodilation leading to a drop in blood pressure. Headache (choice A), constipation (choice C), and photosensitivity (choice D) are not common adverse reactions associated with glipizide use. Headache may occur due to other factors, constipation is more commonly associated with opioids, and photosensitivity is typically seen with certain antibiotics or NSAIDs.

Correct Answer: B

Rationale: The correct answer is B: Positioning the patient on his or her side. This is essential for a lumbar puncture as it helps to open up the spinal spaces, making it easier and safer for the procedure. Positioning the patient on their side also helps prevent complications such as nerve damage or spinal fluid leakage. A: Administering enemas until clear is unnecessary and not directly related to preparing a patient for a lumbar puncture. C: Removing all metal jewelry is important to prevent interference with imaging studies, but it is not directly related to preparing for a lumbar puncture. D: Removing the patient�s dentures is not specifically required for a lumbar puncture procedure.

Correct Answer: A

Rationale: The correct answer is A: Maintenance of a clear airway. In cases of coma or unconsciousness, ensuring a clear airway is crucial to prevent respiratory complications and maintain oxygenation. This involves positioning the patient correctly, suctioning if necessary, and monitoring breathing. Choice B, good nursing care, is too broad and does not address the immediate priority of airway management. Choice C, retention of a catheter, is irrelevant to managing a coma or unconsciousness. Therefore, the correct therapeutic measure in this scenario is to focus on maintaining a clear airway to support respiratory function.