Nursing Process Test Questions

Correct Answer: D

Rationale: The correct answer is D: Draw up clear insulin first when mixing two types of insulin in one syringe. This is important because mixing insulin requires drawing up the clear (short-acting) insulin first to prevent contamination. This ensures accurate dosing and prevents clouding of the insulin. Drawing up cloudy insulin first can lead to inaccurate dosing and potential mixing errors. Administering insulin after the first meal (choice A) is not the focus of this question. Administering insulin at a 45-degree angle into the deltoid muscle (choice B) is not recommended for insulin injections. Vigorously shaking the vial of insulin before withdrawal (choice C) can cause bubbles and affect the accuracy of the dose.

Correct Answer: B

Rationale: The correct answer is B because air conduction is less efficient than bone conduction due to the sound waves traveling through the air in the ear canal, which can be hindered by factors like blockages or obstructions. This results in a weaker and less clear sound transmission compared to bone conduction, where sound waves are transmitted directly through the bones of the skull, bypassing any potential obstructions in the ear canal. Incorrect choices: A: This statement is incorrect as air conduction of sound in the ear is not caused by the vibration of bones in the skull. C: This statement is incorrect as air conduction is typically heard for a shorter duration than bone conduction. D: This statement is incorrect as air conduction of sound in the ear is not caused by the transmission of heat through the air, but rather by sound waves traveling through the ear canal.

Correct Answer: A

Rationale: The correct answer is A because postural hypotension is defined as a drop in systolic blood pressure of greater than 20 mmHg or a drop in diastolic blood pressure of greater than 10 mmHg within 3 minutes of standing from a sitting or supine position. Therefore, a drop in systolic pressure greater than 10 mmHg when changing from lying to sitting is indicative of postural hypotension. Choice B is incorrect as postural hypotension is primarily defined by changes in systolic blood pressure, not diastolic. Choice C is incorrect because a drop in diastolic pressure greater than 10 mmHg is not the defining characteristic of postural hypotension. Choice D is not provided.

Correct Answer: B

Rationale: The correct answer is B: Use pressure relieving devices when the client is in bed. This is because pressure ulcers are a common risk for individuals with neuromuscular disorders due to immobility. Pressure relieving devices such as special mattresses or cushions help redistribute pressure and prevent skin breakdown. Incorrect choices: A: Preventing strenuous exercises is not directly related to preventing skin breakdown in this case. C: Placing the client in Fowler's position may be beneficial for respiratory issues but does not directly address skin integrity. D: Avoiding daily baths with soaps may lead to poor hygiene and does not specifically address the risk of skin breakdown.

Correct Answer: C

Rationale: The correct answer is C: increased serum ammonia levels. In hepatic encephalopathy, the liver is unable to metabolize ammonia, leading to its accumulation in the bloodstream, causing altered thought processes. This results in confusion and asterixis. Massive ascites formation (choice A) is related to fluid accumulation in the peritoneal cavity, not directly linked to altered thought processes. Fluid volume excess (choice B) is a general fluid imbalance issue, not specific to hepatic encephalopathy. Altered clotting mechanism (choice D) is more associated with hepatic dysfunction leading to impaired clotting factors, not directly linked to altered thought processes.