Nursing Process Test Questions

Correct Answer: B

Rationale: The correct answer is B. Placing the patient on the side with support to the back, pillows for body alignment, and a washcloth to slightly curl the fingers helps prevent contractures, aids in maintaining proper alignment, and provides support for the affected side. This position also promotes optimal blood flow and prevents pressure sores. Choice A is incorrect because tightly holding a rolled washcloth can restrict blood flow and cause discomfort. Choice C is incorrect as lying on the back with pillows under the head and knees does not address the specific needs of right-sided paralysis. Choice D is incorrect as trochanter rolls may not provide adequate support for the paralyzed side, and no pillows can lead to pressure sores and discomfort.

Correct Answer: B

Rationale: The correct answer is B. First, reviewing lab results for potassium level is important in assessing potential electrolyte imbalances that may contribute to the patient's symptoms. This allows for a comprehensive understanding of the patient's condition. Assessing the patient for other symptoms or problems is crucial to gather additional information. Finally, notifying the healthcare provider ensures timely communication and collaboration for appropriate care. Choice A is incorrect as following a clinical protocol for a stroke is premature without a comprehensive assessment. Choice C is incorrect as administering medication without a thorough assessment and provider notification can be dangerous. Choice D is incorrect as notifying the healthcare provider should precede administering any medication.

Correct Answer: B

Rationale: The correct answer is B: IV drugs and chemicals. Thrombophlebitis is inflammation of a vein with blood clot formation, commonly caused by irritants like IV drugs. Impaired mobility (C) and compromised circulation (D) are risk factors for thrombophlebitis, but not specific to older adults with heart and blood vessel diseases. A is incorrect as not all choices apply in this scenario.

Correct Answer: C

Rationale: The correct answer is C: Increased risk of respiratory complications. Clients with myasthenia gravis, Guillain-Barre Syndrome, or amyotrophic lateral sclerosis all experience muscle weakness, including respiratory muscles, leading to a higher risk of respiratory complications such as difficulty breathing or respiratory failure. This is due to the involvement of the neuromuscular system in these conditions. Choices A, B, and D are incorrect because they do not directly correlate with the respiratory complications commonly seen in these specific neuromuscular disorders.

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.