Nursing Process Practice Questions

Correct Answer: B

Rationale: The correct answer is B because subjective data in a nursing assessment refers to information provided by the patient, such as feelings, perceptions, and symptoms. In this case, the client stating 'I feel nauseated' represents subjective data. This type of information cannot be measured or observed directly. A, C, and D are incorrect: A: Heart rate of 90 beats per minute is an objective measurement that can be directly observed. C: Blood pressure of 130/80 mmHg is also an objective measurement that can be directly observed. D: Skin appears flushed is an objective observation that can be directly seen.

Correct Answer: C

Rationale: The correct answer is C: Stop the transfusion. Lumbar pain during blood administration could indicate a transfusion reaction, such as a hemolytic reaction or fluid overload. Stopping the transfusion is crucial to prevent further harm to the client. Obtaining vital signs (A) is important but not the priority when a transfusion reaction is suspected. Assessing the pain further (B) may delay necessary intervention. Increasing the flow of normal saline (D) is not indicated and may worsen fluid overload. In this situation, stopping the transfusion is the most appropriate action to ensure client safety.

Correct Answer: B

Rationale: The correct answer is B: Resolve the client�s anxiety. Addressing the client's anxiety is the priority because it can impact their overall surgical experience, recovery, and outcomes. Resolving anxiety can improve the client's emotional well-being, enhance cooperation during surgery, and reduce postoperative complications related to stress. Providing emotional support and reassurance should be the initial focus to help the client feel more comfortable and confident about the upcoming surgery. The other choices are not the priority in this situation: A) Evaluating the need for antibiotics can be addressed later in the preoperative process, C) Providing preoperative education is important but not the immediate priority over addressing anxiety, and D) Preparing the client for surgery includes various components, but emotional well-being should be addressed first.

Correct Answer: A

Rationale: The correct answer is A: circulating nurse. The circulating nurse is responsible for maintaining cleanliness, ensuring proper temperature, humidity, and lighting in the operating room. They coordinate activities, manage supplies, and ensure a safe environment for the surgical team. The scrub nurse assists the surgeon with instruments and supplies, not environmental conditions. The surgeon's main focus is on performing the surgery, not environmental management. The anesthesiologist is responsible for administering anesthesia and monitoring the patient's vital signs, not the operating room environment.

Correct Answer: D

Rationale: The correct answer is D: high calorie high protein. In COPD exacerbation, the body requires extra calories and protein for energy and muscle strength. High-calorie foods help combat weight loss and fatigue. High-protein foods aid in muscle repair and maintenance. Low-fat low-cholesterol (A) is not ideal as healthy fats are needed. Low-sodium (B) is not necessary unless there is concurrent heart failure. Bland soft diet (C) is not suitable as it does not provide enough calories and protein needed for COPD exacerbation.