Nursing Process Exam Questions

Correct Answer: B

Rationale: The correct answer is B because a Snellen chart reading of 20/80 means the patient can see at 20 feet what a normal eye can see at 80 feet. This indicates that the patient's vision is below average. Choice A is incorrect because it reverses the numerator and denominator. Choice C is incorrect because it does not accurately represent the Snellen chart findings. Choice D is incorrect because 20/80 is not considered normal vision.

Correct Answer: A

Rationale: The correct answer is A: Diagnosis. After reviewing the patient's database and identifying concerning signs such as not voiding for over 8 hours, abnormal kidney function, and decreased oral intake, the nurse must move to the diagnosis step. In this step, the nurse will analyze the data collected to identify the patient's actual and potential health problems. This will help the nurse formulate appropriate nursing diagnoses and develop a plan of care to address the identified issues. Choice B (Planning) comes after the diagnosis step, where specific goals and interventions are established; Choice C (Implementation) follows planning and involves executing the planned interventions; Choice D (Evaluation) is the final step where the nurse assesses the effectiveness of the interventions. In this scenario, the nurse must first determine the patient's health problems before proceeding to planning, implementing, and evaluating care.

Correct Answer: A

Rationale: The correct answer is A: Physiologic. Impaired Gas Exchange pertains to the basic physiological need for oxygenation, which is fundamental for survival. Maslow's hierarchy states that physiological needs are the most fundamental and must be met before progressing to higher-level needs. Safety, love and belonging, and self-actualization are higher-level needs compared to physiological needs. Therefore, Impaired Gas Exchange aligns with the physiological level of needs in Maslow's hierarchy.

Correct Answer: B

Rationale: The correct answer is B: Halos around lights. Digoxin toxicity can cause visual disturbances like seeing halos around lights, which is a common symptom. This is due to its effect on the eyes. Poor appetite (choice A) is a common side effect but not specific to toxicity. Constipation (choice C) is not a typical sign of digoxin toxicity. Tachycardia (choice D) is more commonly associated with digoxin toxicity, but visual disturbances like halos around lights are more specific and should be explained to the patient.

Correct Answer: A

Rationale: The correct answer is A because gathering and organizing needed supplies is a crucial step before performing a complex dressing change. By ensuring all necessary supplies are readily available, the nurse can streamline the process, minimize interruptions, and promote efficiency. This step also helps maintain aseptic technique and prevent the spread of infection. Deciding on goals and outcomes (B) is important but typically done as part of the care planning process, not immediately before a dressing change. Assessing the patient's readiness (C) is also important but can be done concurrently with gathering supplies. Calling for assistance (D) may be necessary in some situations, but it is not the immediate step required just before changing the dressing.