Nursing Process Final Exam Questions

Correct Answer: A

Rationale: The correct answer is A: Have the patient lie flat for 6 to 8 hours after a lumbar puncture to prevent complications like post-lumbar puncture headache. Lying flat helps maintain CSF pressure and reduce the risk of leakage. B: Keeping the patient from eating or drinking for 4 hours is not necessary after a lumbar puncture. C: Monitoring pedal pulses q4h is irrelevant to post-lumbar puncture care. D: Keeping the head of the bed elevated 30 degrees for 24 hours is not recommended after a lumbar puncture as it may increase the risk of complications.

Correct Answer: B

Rationale: The correct response is B: Notify the physician immediately and expect an order for factor VIII. In a patient with hemophilia A, which is a deficiency of clotting factor VIII, bleeding into a joint can lead to serious complications. The nurse should notify the physician promptly because the patient may need factor VIII replacement therapy to stop the bleeding and prevent further damage. This is a medical emergency requiring timely intervention. Choices A, C, and D are incorrect: A: Palpating the elbow could exacerbate the bleeding and cause further damage. C: Ordering an x-ray would delay the crucial factor VIII replacement therapy needed to manage the bleeding. D: Applying heat can increase blood flow to the joint, worsening the bleeding.

Correct Answer: C

Rationale: The correct answer is C: Apply a cream or lotion to the area. This is because radio-dermatitis is a common side effect of radiation therapy, causing skin irritation and dryness. Applying a cream or lotion helps to moisturize the skin, reduce inflammation, and promote healing. Washing the area with soap can further irritate the skin. Leaving the skin alone may prolong discomfort and delay healing. Avoiding creams or lotions can worsen dryness and discomfort. Overall, applying a suitable cream or lotion is the most effective method to alleviate symptoms and support skin recovery in radio-dermatitis.

Correct Answer:

Rationale: Correct Answer: B: Ask about the chief concerns or problems. Rationale: 1. This step follows setting the agenda to focus on patient's main issues. 2. Allows nurse to gather essential information for effective care. 3. Builds rapport and shows patient-centered approach. Summary of other choices: A: Introductions are typically done at the beginning of the interview. C: Prematurely ending the interview may hinder rapport and information gathering. D: Administering medications is not the immediate priority after setting the agenda.

Correct Answer: C

Rationale: The correct answer is C: severe, unrelieved pain. Compartment syndrome is characterized by increased pressure within a muscle compartment leading to decreased blood flow and tissue damage. Severe, unrelieved pain is a hallmark sign as the pressure builds up. Weak movement of the patient's toes (choice A) could indicate nerve damage but is not specific to compartment syndrome. Decreased pedal pulses (choice B) could suggest vascular compromise but are not specific to compartment syndrome. Presence of foot pallor (choice D) could indicate poor circulation but is not a definitive sign of compartment syndrome.