Nursing Process Questions

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Dressing changes twice a day help maintain a clean wound environment, reducing the risk of infection. 2. Regular dressing changes promote proper wound healing by facilitating moisture balance and removal of dead tissue. 3. It is a direct intervention that addresses the patient's poor wound healing. 4. Teaching the patient about signs of infection (B) is important but does not directly address the wound healing process. 5. Instructing the family on dressing changes (C) is helpful but should not substitute direct patient care. 6. Refocusing the patient from body image changes (D) is not directly related to improving wound healing.

Correct Answer: C

Rationale: The correct answer is C. Washing feet in hot water is not part of diabetic foot care as it can lead to burns or skin damage. A: Properly fitting shoes help prevent injuries. B: Trimming toenails straight reduces risk of ingrown nails. D: Wearing shoes on hot surfaces protects feet from burns or injuries. Overall, C is incorrect due to its potential harm to the client's feet.

Correct Answer: A

Rationale: Correct Answer: A: Respiratory acidosis Rationale: 1. Respiratory acidosis is caused by inadequate ventilation leading to increased PCO? and decreased pH. 2. Low pH indicates acidosis, and high PCO? indicates respiratory component. 3. Metabolic acidosis (B) results from non-respiratory causes. 4. Respiratory alkalosis (C) is characterized by high pH and low PCO?. 5. Metabolic alkalosis (D) is caused by non-respiratory factors with high pH.

Correct Answer: C

Rationale: The correct answer is C because a decreased number of functioning acetylcholine receptor sites would result in the disease. Acetylcholine is a neurotransmitter that transmits signals between nerves and muscles. If there are fewer receptor sites for acetylcholine to bind to, this can lead to impaired nerve-muscle communication, causing the disease. Choice A is incorrect because a genetic defect in acetylcholine production would not directly affect the receptor sites. Choice B is incorrect because a reduced amount of acetylcholine would still be able to bind to the available receptor sites. Choice D is incorrect because inhibiting the enzyme Ache would not directly impact the receptor sites.

Correct Answer: C

Rationale: Objective data are measurable and observable, such as vital signs. Respirations of 16 are a specific numerical measurement that can be quantified. This makes choice C the correct answer as it is factual and quantifiable. Choices A, B, and D are subjective data, as they rely on the patient's feelings or experiences, which are open to interpretation and not measurable. Therefore, the nurse should report choice C as objective data as it provides concrete information for assessment and decision-making.