Nursing Process Questions

Correct Answer: D

Rationale: Step 1: A goal should be measurable to track progress effectively. Step 2: The statement "a measurable change in a patient's physical state" indicates a specific and quantifiable outcome. Step 3: This aligns with the SMART criteria for goal setting - Specific, Measurable, Achievable, Relevant, Time-bound. Step 4: Other choices lack the specificity and measurability required for a clear goal. Step 5: Choice A talks about restriction, which is not directly related to understanding a goal. Step 6: Choice B focuses on negative responses, which is not necessarily indicative of understanding the goal. Step 7: Choice C is vague and lacks the specificity of a measurable outcome.

Correct Answer: A

Rationale: The correct answer is A because a nursing diagnosis typically consists of two parts: the problem (Risk for Aspiration) and the related factor (reduced level of consciousness). This format helps clearly identify the client's health issue and its cause. Choice B is incorrect as it refers to a nursing diagnosis focusing on the client's response. Choice C is incorrect as it describes an outcome, not a diagnosis. Choice D is incorrect as a nursing diagnosis should be based on evidence, not made without support. Therefore, the correct choice is A due to the structure and clarity it provides in identifying the client's risk.

Correct Answer: C

Rationale: The correct answer is C because respirations of 16 is an observable and measurable data point that can be quantified. Objective data are factual, measurable, and based on observable phenomena. In contrast, choices A, B, and D are subjective data as they rely on the patient's feelings or experiences, which are not directly measurable or observable by the nurse. Reporting a headache or feeling nauseated are subjective symptoms that are based on the patient's perception and cannot be verified without further assessment. Therefore, only choice C provides objective data that can be accurately reported by the nurse.

Correct Answer: B

Rationale: The correct answer is B: Have patient lie down. When a patient experiences dehiscence (surgical wound separation), lying down helps reduce tension on the wound, minimizing the risk of further tearing. This position also allows the nurse to assess the wound properly. Choice A is incorrect because sitting upright can increase intra-abdominal pressure, worsening the dehiscence. Choice C is incorrect as slowing IV fluids is not a priority in managing dehiscence. Choice D is incorrect because obtaining a sterile suture set should only be done by a healthcare provider and is not the immediate action needed for dehiscence.

Correct Answer: C

Rationale: The correct answer is C (280 to 295mOsm/kg) because serum osmolality is primarily determined by sodium, glucose, and blood urea nitrogen levels. Normal serum sodium range is 135-145 mEq/L, which corresponds to an osmolality range of 280-295 mOsm/kg. Choices A and B are incorrect as they do not align with normal serum sodium levels. Choice D is incorrect as it includes an excessively wide range that is not consistent with normal osmolality values.