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: C

Rationale: The correct response is C: Confronting the denial. Denial is a defense mechanism that can hinder the client's acceptance and coping with the situation. By confronting the denial in a supportive and empathetic manner, the nurse can help the client acknowledge and process their feelings. Accepting (A) or supporting (B) the denial would enable the client to avoid facing reality. Interpreting (D) the denial may lead to miscommunication or misunderstanding. Confronting the denial encourages the client to address their emotions and move towards acceptance and healing.

Correct Answer: B

Rationale: The correct answer is B: The catheter should remain in place for 1-2 days. After litholapaxy surgery, the urethral catheter is typically removed within 1-2 days to prevent infection and promote healing. Keeping the catheter in place for too long can increase the risk of complications such as urinary tract infections. Options A, C, and D suggest longer durations which are not necessary and may lead to unnecessary discomfort and risks for the client. Therefore, the optimal timeframe for catheter removal post-litholapaxy surgery is within 1-2 days.

Correct Answer: A

Rationale: The correct answer is A: Wilma places 2 fingers between the tie and neck. This method ensures that the tracheostomy ties are not too tightly placed by providing a standardized and easily replicable measurement. Placing 2 fingers ensures there is adequate space for proper airflow and movement without causing pressure or constriction. This method is a widely accepted practice in healthcare settings to prevent complications such as skin breakdown or restricted blood flow. Incorrect choices: B: The tracheotomy can be pulled slightly away from the neck - This does not provide a standardized measurement and may not accurately assess the tightness of the ties. C: James� neck veins are not engorged - Monitoring neck veins does not directly correlate with the tightness of tracheostomy ties. D: Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process - This method may not accurately reflect the appropriate tightness of the ties around the neck.

Correct Answer: A

Rationale: Rationale: 1. A: Blood pressure apparatus is essential to monitor for any signs of bleeding or clot formation after carotid angioplasty. 2. B: IV infusion stand is important but not the priority for immediate postoperative monitoring. 3. C: Call bell is important for the client to call for assistance but not the priority for immediate postoperative care. 4. D: Endotracheal intubation is not necessary after a carotid angioplasty and is not a priority item for bedside care. Summary: Monitoring blood pressure is crucial for detecting complications post carotid angioplasty. IV stand, call bell, and endotracheal intubation are important but not the priority in this scenario.