Fundamentals of Nursing Nursing Process Questions

Correct Answer: C

Rationale: The correct answer is C: Performing a physical examination. This method allows the nurse to gather comprehensive data about the patient's health status, including vital signs, physical appearance, and potential health issues. It provides valuable information for developing an individualized care plan. Reviewing literature (A) is important but not for establishing a patient's database. Checking orders (B) and ordering medications (D) are part of the treatment process and do not directly contribute to establishing the initial patient database.

Correct Answer: B

Rationale: The correct answer is B - Avoid traumatic injuries and exposure to any infection. For a client with pancytopenia caused by chemotherapy, their immune system is compromised, making them more susceptible to infections and bleeding. By avoiding traumatic injuries and exposure to infections, the client can reduce the risk of complications. Option A is incorrect because aggressive mouth care may further damage the already compromised oral mucosa. Option C is incorrect because excessive fluid intake may not be necessary and could worsen electrolyte imbalances. Option D is incorrect because muscle cramps and tingling sensations are not directly related to the main concern of infection and bleeding in pancytopenia.

Correct Answer: B

Rationale: The correct answer is B: Efferent. Efferent neurons transmit signals from the central nervous system to muscles and glands, controlling movement and secretion. Afferent neurons carry signals from sensory receptors to the central nervous system, not towards muscles or glands. "Affective" relates to emotions, not neural function. "Effective" does not describe the direction of signal transmission in the nervous system. Therefore, B is the correct choice.

Correct Answer: C

Rationale: The correct answer is C: Performing a physical examination. This method allows the nurse to directly gather data from the patient's body, such as vital signs, appearance, and overall health status. It provides essential information to establish a patient's database, including baseline values and potential health issues. Reviewing current literature (A) helps in decision-making but does not directly establish a patient's database. Checking orders for tests (B) and ordering medications (D) are part of the treatment process and do not focus on gathering initial patient data.

Correct Answer:

Rationale: Correct Answer: A: The patient will ambulate in the hallway twice this shift using crutches correctly. Rationale: 1. This choice outlines a specific nursing intervention - ambulating with crutches. 2. It includes clear actions for the patient to ambulate and specifies using crutches correctly. 3. It addresses the patient's physical mobility needs actively. 4. It focuses on promoting independence and functional ability. Summary of other choices: B: This choice includes the nursing diagnosis and the plan but lacks the specificity of the correct answer. C: This choice includes the nursing diagnosis and specifies the use of crutches but lacks the clarity of correct implementation. D: This choice only identifies the patient's condition without providing a specific nursing intervention.