Nursing Process Practice Questions

Correct Answer: B

Rationale: The correct answer is B: Use two people to assist the patient. This is the safest option as it provides optimal support and stability for the patient during their first postoperative ambulation. Two people can help prevent falls, ensure proper body mechanics, and offer immediate assistance if needed. Using one person (choice A) may not provide enough support. Encouraging the patient to "dangle" (choice C) may increase the risk of orthostatic hypotension. Giving a narcotic before ambulation (choice D) can impair the patient's balance and coordination, increasing the risk of falls.

Correct Answer: D

Rationale: The correct answer is D: Pallor, tachycardia, and a sore tongue. Pernicious anemia is caused by a deficiency in vitamin B12, leading to symptoms such as pallor (due to decreased red blood cells), tachycardia (as the heart works harder to compensate for decreased oxygen-carrying capacity of the blood), and a sore tongue (due to inflammation of the tongue). Choice A is incorrect because bradycardia would not be expected in pernicious anemia, and reduced pulse is not a typical finding. Choice B is incorrect because weight gain is not a common symptom of pernicious anemia. Choice C is incorrect because angina and double vision are not typical findings of pernicious anemia, and anorexia is more likely due to other causes.

Correct Answer: C

Rationale: The correct answer is C: 1� to 1.5�. When irrigating a colostomy, the client should insert the lubricated catheter about 1� to 1.5� into the stoma. This depth allows for effective irrigation of the colon without causing discomfort or damage. Inserting the catheter too shallow (choice A) may not reach the colon, while inserting it too deep (choices B and D) can cause injury or perforation. Therefore, the optimal depth of 1� to 1.5� ensures proper irrigation while minimizing risks of complications.

Correct Answer: B

Rationale: The correct answer is B because monitoring the site and progress of the infusion every hour is crucial to prevent complications like infiltration or infection in clients with hypertension. Choice A is incorrect as checking BP every hour is excessive. Choice C is incorrect as daily monitoring may not detect issues promptly. Choice D is incorrect as pulse rate monitoring is not directly related to IV fluid administration in this context. Monitoring the site and progress hourly ensures timely intervention if any issues arise.

Correct Answer: A

Rationale: The correct answer is A: A clot can enter the circulation. When a clotted cannula is aggressively flushed, the force can dislodge the clot, allowing it to enter the circulation and potentially leading to serious complications such as embolism. Incorrect choices: B: An air embolism can enter the circulation - In the context of a clotted cannula, air embolism is less likely compared to a clot entering the circulation. C: A painful arterial spasm can occur - Arterial spasm is a potential complication but not directly related to flushing a clotted cannula. D: Fluid extravasation into surrounding tissue can occur - Flushing a clotted cannula may not specifically lead to fluid extravasation, as it is more related to needle dislodgement or improper placement.