Nursing Process Questions and Answers PDF

Correct Answer: B

Rationale: The correct answer is B: Renal failure. Acute respiratory distress syndrome (ARDS) can lead to hypoxemia and respiratory acidosis, causing decreased perfusion to the kidneys and potentially leading to renal failure. Monitoring for signs of renal failure, such as decreased urine output and elevated creatinine levels, is crucial in managing clients with ARDS. Incorrect choices: A: Chest wall bulging is not a common complication of ARDS. It may be seen in conditions like tension pneumothorax. C: Difficulty swallowing is not a typical complication of ARDS. It may be seen in neurological conditions or esophageal disorders. D: Orthopnea is not a direct complication of ARDS. It is more commonly associated with heart failure or pulmonary edema.

Correct Answer: A

Rationale: The modified Trendelenburg position involves placing the client with their legs elevated higher than their head. This position promotes venous return to the heart, increasing preload and cardiac output, thereby leading to an increase in blood pressure. Elevating the legs helps to reduce peripheral edema and improve circulation. Therefore, the correct answer is A. Choice B is incorrect because the Trendelenburg position does not directly affect the respiratory rate. Choice C is incorrect as the position is not intended to increase heart rate but rather improve venous return. Choice D is also incorrect as the primary goal of the Trendelenburg position is not to decrease blood loss, although it may help in some cases by improving circulation.

Correct Answer: B

Rationale: The correct answer is B: Focused assessment. In this scenario, the client's abdominal pain is a known issue, so a focused assessment would be appropriate to gather specific information related to the current complaint. A focused assessment allows the nurse to concentrate on the particular problem at hand, which in this case is the abdominal pain. A: Initial assessment is not applicable as the client has been seen for this issue before. C: Emergency assessment is not necessary as the situation does not indicate an urgent or life-threatening condition. D: Time-lapsed assessment is not suitable because it involves assessing changes over time, which is not the primary concern in this scenario. In summary, a focused assessment is the most appropriate choice as it allows the nurse to address the client's specific complaint efficiently.

Correct Answer: B

Rationale: The correct answer is B: "Take ferrous sulfate and the antacid at least 2 hours apart." Rationale: 1. Iron absorption is decreased in the presence of antacids due to decreased gastric acidity. 2. Antacids can bind to iron and reduce its absorption. 3. Taking them 2 hours apart allows for optimal iron absorption without interference from the antacid. 4. Taking them together (choice A) would decrease iron absorption. 5. Avoiding antacids altogether (choice C) may not be necessary if spaced apart appropriately. 6. Taking them 1 hour apart (choice D) may still lead to decreased iron absorption due to antacid interference.

Correct Answer: C

Rationale: Rationale: Step 1: Coughing is the primary way TB bacteria are spread. Step 2: By coughing into a handkerchief or tissue, the TB bacteria are contained. Step 3: Washing the handkerchief in hot water or discarding it prevents the bacteria from spreading. Step 4: This method reduces the risk of infecting family members. Summary of Incorrect Choices: A: Wearing gloves does not prevent airborne transmission of TB. B: Keeping windows closed can increase the concentration of bacteria in the air. D: Boiling water is not necessary to prevent TB transmission.