Fundamentals Nursing Process Questions

Correct Answer: B

Rationale: The correct answer is B (10-15 mmHg) because this range is considered safe and effective for suctioning in most cases. Lower suction pressures (such as 2-5 mmHg) may not effectively clear secretions, while higher pressures (20-25 mmHg) can cause tissue damage. Choice C (5-10 mmHg) falls within the safe range but may not provide enough suction for effective clearance. Therefore, the optimal suction pressure for James using the portable suction unit at home is 10-15 mmHg.

Correct Answer: C

Rationale: The correct answer is C: severe dehydration. In HHNK coma, the body tries to eliminate excess glucose through frequent urination, leading to dehydration. This results in decreased blood volume, causing hypotension and tachycardia. Signs include dry mucous membranes, poor skin turgor, and concentrated urine output. Fruity odor of the breath (A) is associated with diabetic ketoacidosis, not HHNK coma. Shallow, deep respirations (B) and profuse sweating (D) are not typically associated with HHNK coma.

Correct Answer: A

Rationale: The correct answer is A: Neutrophil. Neutrophils are the most numerous type of WBC, typically comprising 50-70% of total WBC count. They are key players in the body's immune response, phagocytizing pathogens. Basophils, eosinophils, and lymphocytes are less numerous than neutrophils. Basophils are involved in allergic reactions, eosinophils combat parasitic infections, and lymphocytes play a critical role in adaptive immunity. However, in terms of sheer numbers, neutrophils outnumber the other types of WBC.

Correct Answer: C

Rationale: The correct answer is C: Comparing the patient�s present weight with her last weight. This is the most direct and reliable method to assess volume depletion due to fluid loss. By comparing the patient's current weight with her last weight, you can easily determine if there has been a significant decrease in weight indicating fluid loss and potential hypovolemia. Explanation of why other choices are incorrect: A: Measuring the quantity and specific gravity of her urine output - This method may provide some information about hydration status, but it is not as direct or reliable as comparing weight changes. B: Taking her blood pressure - While blood pressure can indicate hypovolemia, it may not provide immediate insight into volume depletion caused by diarrhea. D: Administering the oral water test - This test is not commonly used to assess volume depletion and may not be as effective or quick as comparing weight changes.

Correct Answer: C

Rationale: The correct answer is C because in Addisonian crisis, the client experiences adrenal insufficiency leading to decreased cortisol levels and impaired stress response. Offering extra blankets and raising room temperature helps prevent hypothermia, as clients in crisis are unable to regulate body temperature. Encouraging independence with ADLs (choice A) and ambulation (choice B) are not priorities as the client is in a critical state. Placing the client in a private room (choice D) is not directly related to managing Addisonian crisis.