Fundamentals of Nursing Nursing Process Questions

Correct Answer: A

Rationale: The correct answer is A: Ensure client safety. This is the nurse's primary legal responsibility as it aligns with the ethical principle of beneficence, prioritizing the well-being and safety of the client. Ensuring client safety is essential to prevent harm and promote positive health outcomes. Following physician orders precisely (B) is important but not the primary legal responsibility of the nurse. Documenting care comprehensively (C) is crucial for accountability and continuity of care but is not the primary legal responsibility. Providing client-centered education (D) is essential for empowering clients but is not the primary legal responsibility in terms of legal accountability and duty of care.

Correct Answer: A

Rationale: The correct answer is A because it is specific, measurable, achievable, relevant, and time-bound (SMART) - the patient verbalizing a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift. This outcome is immediate, concrete, and directly related to the goal of managing pain. Choice B is incorrect as it lacks specificity and a clear timeframe for evaluation. Choice C is incorrect because the outcome is vague and does not specify when the patient needs to understand the dietary changes. Choice D is incorrect because the timeframe is provided but the outcome is not specific enough and does not directly relate to the goal of pain management.

Correct Answer: C

Rationale: The correct answer is C: Performing a physical examination. This method allows the nurse to collect objective data directly from the patient, which is crucial in establishing a comprehensive patient database. By assessing the patient's physical condition, the nurse can gather vital information such as vital signs, overall health status, and potential areas of concern. Reviewing literature (A) and checking orders for tests (B) may provide additional insights but are not direct data collection methods. Ordering medications (D) is a treatment intervention, not a data collection method.

Correct Answer: B

Rationale: The correct answer is B: Potato. Potatoes are high in potassium, which is essential for various bodily functions. Potatoes can help increase potassium intake in patients who require it. Bread, eggs, and cereal are not as rich in potassium as potatoes. Increasing intake of these foods won't provide the necessary boost in potassium levels needed for the patient.

Correct Answer: C

Rationale: The correct answer is C: Tears and F: Breastmilk. HIV transmission has been established through breastmilk due to the presence of the virus in the milk. Tears can also transmit HIV if they contain blood from an HIV-positive individual. Saliva, sweat, and urine do not typically contain enough HIV to transmit the virus. Blood is a well-known mode of HIV transmission due to the high viral load present in blood. Therefore, choices A, B, D, and G are incorrect as they do not have sufficient levels of the virus to transmit HIV.