Nursing Process Test Questions

Correct Answer: A

Rationale: The correct answer is A because hanging the chest drainage system on the top of the wheelchair backrest ensures that the system remains upright and secured during transportation, reducing the risk of accidental disconnection or leakage. Placing it on the patient's feet (B), hanging it with the IV pole (C), or placing it in the patient's lap (D) can lead to potential complications such as pulling or kinking the drainage tubing, increasing the risk of infection or injury to the patient.

Correct Answer: C

Rationale: The correct answer is C: Increased risk of respiratory complications. Clients with myasthenia gravis, Guillain-Barre Syndrome, or amyotrophic lateral sclerosis all experience muscle weakness, including respiratory muscles, leading to a higher risk of respiratory complications such as difficulty breathing or respiratory failure. This is due to the involvement of the neuromuscular system in these conditions. Choices A, B, and D are incorrect because they do not directly correlate with the respiratory complications commonly seen in these specific neuromuscular disorders.

Correct Answer: D

Rationale: The correct answer is D, Leucovorin. Leucovorin is administered with methotrexate to protect normal cells from methotrexate toxicity by acting as a "rescue" agent. Methotrexate inhibits dihydrofolate reductase, leading to decreased levels of tetrahydrofolate needed for DNA synthesis. Leucovorin bypasses this step by directly providing the reduced form of folic acid, thus preventing toxicity in normal cells. Probenecid (choice A) is not used to protect normal cells during methotrexate therapy. Cytarabine (choice B) and Thioguanine (choice C) are not rescue agents for methotrexate toxicity.

Correct Answer: D

Rationale: The correct answer is D because pupil size is not typically a part of a routine neurological examination. A: Eye movements are assessed to evaluate cranial nerve functions. B: Reflexes help determine the integrity of the spinal cord and peripheral nervous system. C: Nuchal rigidity is important to assess for signs of meningitis or other neurological conditions. In contrast, pupil size is more relevant in ophthalmological examinations or when assessing response to specific medications affecting the pupil size.

Correct Answer: A

Rationale: The correct answer is A because evaluating a nursing intervention involves collecting data to determine if the goals set for the intervention were achieved. This process helps in assessing the effectiveness of the intervention in meeting the desired outcomes. Option B is incorrect as it refers to the identification of nursing diagnoses for new problems, which is part of the nursing assessment phase, not evaluation. Option C is incorrect as adjusting the care plan to include collaborative interventions is part of the implementation phase, not evaluation. Option D is incorrect as performing client care tasks as per protocol is part of the implementation phase, not evaluation.