Nursing Process Exam Questions

Correct Answer: B

Rationale: The correct answer is B: Hypotension. Glipizide is a sulfonylurea medication used to treat diabetes by lowering blood sugar levels. Hypotension, or low blood pressure, can be an adverse reaction as glipizide may cause vasodilation leading to a drop in blood pressure. Headache (choice A), constipation (choice C), and photosensitivity (choice D) are not common adverse reactions associated with glipizide use. Headache may occur due to other factors, constipation is more commonly associated with opioids, and photosensitivity is typically seen with certain antibiotics or NSAIDs.

Correct Answer: A

Rationale: The correct answer is A: Sinusitis. Allergic rhinitis causes inflammation in the nasal passages, leading to congestion and blockage of the sinuses. If the patient does not comply with the treatment regimen, the inflammation can worsen, increasing the risk of developing sinusitis, which is an infection or inflammation of the sinuses. Sinusitis can result in severe pain, pressure, and potentially lead to complications. Summary of other choices: B: Lymphadenopathy - Enlargement of lymph nodes, not directly related to non-compliance with treatment for allergic rhinitis. C: Anaphylaxis - Life-threatening allergic reaction, not a typical consequence of non-compliance with treatment for allergic rhinitis. D: Angioedema - Swelling of deeper layers of skin, usually associated with allergies but not a common outcome of non-compliance with treatment for allergic rhinitis.

Correct Answer: A

Rationale: The correct answer is A because using the client's own words in quotation marks ensures accurate representation of their subjective data. It maintains the integrity of the information provided by the client and improves communication between healthcare providers. Paraphrasing (choice B) may lead to misinterpretation or distortion of the client's statements. Validating with the client's family (choice C) may introduce bias or inaccurate information. Recording with nonspecific words (choice D) decreases the clarity and specificity of the documentation, which is essential for effective communication and decision-making in healthcare.

Correct Answer: C

Rationale: The correct answer is C: Interdependent intervention. This type of nursing intervention involves collaboration with other healthcare professionals to provide holistic care. In this scenario, the nurse is following a protocol set by the health care agency, which likely involves input and guidance from various team members. The nurse's actions require coordination and communication with others to ensure the best outcome for the client. Choice A (Independent intervention) would involve actions that the nurse can perform autonomously without requiring direction from others. Choice B (Dependent intervention) would require an order or prescription from a healthcare provider for the nurse to carry out. Choice D (Collaborative intervention) involves working together with other healthcare professionals on a specific aspect of care, but in this case, the nurse is primarily following a set protocol without necessarily actively collaborating with others during the task.

Correct Answer: A

Rationale: The correct answer is A: immediately administer pain relief. After a lobectomy, the patient may experience significant pain due to the surgical incision and chest tube insertion. Providing prompt pain relief is crucial to ensure the patient's comfort and prevent complications such as shallow breathing or limited mobility. This action will also aid in the patient's early recovery and promote better outcomes. Choice B (keep patient in semi-fowler's position) is not the priority upon arrival from the Post Anesthesia Care Unit as pain management takes precedence. Choice C (turn client every hour) is important for preventing complications but is not the immediate action required upon arrival. Choice D (notify the family to report patient's condition) is important but not as urgent as providing pain relief to the patient.