Fundamentals Nursing Process Questions

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 the patient expressing fear of going home and being alone indicates apprehension about discharge. This inference is supported by the subjective data provided. Choice A is incorrect because fear of being alone does not necessarily mean the patient can perform dressing changes independently. Choice B is incorrect as resuming all previous medications is not related to the patient's fear of going home. Choice D is incorrect as the subjective data does not provide any information about the success of the surgery.

Correct Answer: D

Rationale: The correct answer is D, decreased body temperature and cold intolerance, because these are classic signs of hypothyroidism due to decreased thyroid hormone levels. The body's metabolism slows down, leading to a lower core body temperature and reduced ability to tolerate cold. Exophthalmos and conjunctival redness (choice A) are associated with hyperthyroidism. Flushed, warm, moist skin (choice B) is indicative of hyperthyroidism as well, due to increased metabolic rate. A systolic murmur at the left sternal border (choice C) is not a common finding in hypothyroidism.

Correct Answer: B

Rationale: The correct answer is B: Sit upright, leaning slightly forward. This position helps to minimize blood flow to the head, reducing the risk of increased bleeding. It also prevents blood from flowing down the throat, reducing the risk of aspiration. A: Lying supine with the neck extended can increase pressure on the blood vessels in the head, potentially worsening the epistaxis. C: Blowing the nose and putting lateral pressure can disrupt any clots that may have formed and increase bleeding. D: Holding the nose while bending forward at the waist can lead to blood flowing down the throat and increase the risk of aspiration.

Correct Answer: D

Rationale: The correct answer is D: Passive immunization. This involves administering pre-formed antibodies to provide immediate protection. In the case of a pregnant client needing temporary protection from chickenpox, passive immunization is necessary as it offers immediate immunity without stimulating the client's immune system. - A (Naturally acquired active immunization): This involves exposure to the pathogen and the body producing its antibodies, which takes time and is not suitable for immediate protection. - B (Artificially acquired passive immunization): This option doesn't involve providing pre-formed antibodies, which are needed for immediate protection. - C (Artificially acquired active immunization): This method requires time for the body to develop its immunity, not providing immediate protection as needed in this scenario.