Fundamentals Nursing Process Questions

Correct Answer: D

Rationale: The primary purpose of the outcome identification and planning step of the nursing process (step 3) is to design a plan of care for and with the client. This involves setting specific, measurable, achievable, relevant, and time-bound (SMART) goals to address the client's health problems. By involving the client in the planning process, it promotes client autonomy and ensures that the plan is tailored to their individual needs and preferences. Options A and B focus on data collection and analysis, which are steps 1 and 2 of the nursing process. Option C refers to nursing diagnosis, which is part of step 2 (diagnosis). Therefore, option D is the correct answer as it pertains to the specific purpose of the outcome identification and planning step.

Correct Answer: C

Rationale: The correct answer is C: Cold sensitivity. Severe anemia leads to decreased oxygen delivery to tissues, causing symptoms like pallor, fatigue, and dyspnea on exertion due to the body compensating for low oxygen levels. Cold sensitivity is not a common symptom associated with anemia. The other choices are directly related to severe anemia due to the lack of oxygen delivery to tissues.

Correct Answer: C

Rationale: The correct answer is C: Comparing the patient�s present weight with her last weight. This is the most direct and reliable method to assess volume depletion due to fluid loss. By comparing the patient's current weight with her last weight, you can easily determine if there has been a significant decrease in weight indicating fluid loss and potential hypovolemia. Explanation of why other choices are incorrect: A: Measuring the quantity and specific gravity of her urine output - This method may provide some information about hydration status, but it is not as direct or reliable as comparing weight changes. B: Taking her blood pressure - While blood pressure can indicate hypovolemia, it may not provide immediate insight into volume depletion caused by diarrhea. D: Administering the oral water test - This test is not commonly used to assess volume depletion and may not be as effective or quick as comparing weight changes.

Correct Answer: D

Rationale: The correct answer is D because exhaling deeply before using the spirometer is incorrect. The purpose of the incentive spirometer is to encourage deep inhalation to improve lung function. Exhaling deeply before using the spirometer goes against this goal and may hinder the effectiveness of the device. Choices A, B, and C are all correct actions when using the spirometer. Taking two normal breaths helps to prepare the lungs, sitting upright optimizes lung expansion, and inhaling deeply to reach the target helps to improve lung ventilation.

Correct Answer: C

Rationale: The correct answer is C because administering antiemetic medications like metoclopramide and dexamethasone helps control nausea and vomiting post-chemotherapy. Metoclopramide acts on the gut to reduce nausea, while dexamethasone decreases inflammation and suppresses the vomiting reflex. Choice A focuses on dietary interventions but does not address the physiological cause of nausea. Choice B with breathing exercises may help some clients but does not directly address the nausea and vomiting. Choice D is incorrect as withholding fluids can lead to dehydration, which is not recommended after chemotherapy.