Nursing Process 1 Test Questions

Correct Answer: A

Rationale: The correct answer is A: New set of tracheostomy tubes and Oxygen tank. Rationale: 1. New set of tracheostomy tubes: Essential for reinserting the cannulas to secure the airway. 2. Oxygen tank: To ensure James has a stable oxygen supply while the tracheostomy tubes are being reinserted. Summary of incorrect choices: B: Theophylline and Epinephrine - These medications are not directly related to managing a dislodged tracheostomy. C: Obturator and Kelly clamp - While these are useful tools for tracheostomy care, they are not the immediate equipment needed in this emergency situation. D: Sterile saline dressing - This is not relevant for a dislodged tracheostomy; the priority is securing the airway.

Correct Answer: C

Rationale: The correct answer is C: �Nurses use evaluation to determine the effectiveness of nursing care.� Evaluation in nursing is essential to assess the outcomes of nursing interventions and determine the effectiveness of the care provided. It helps in identifying areas for improvement, making informed decisions, and ensuring quality patient care. Choice A is incorrect because evaluation is not solely about checking completion of tasks but rather assessing the impact of those interventions on patient outcomes. Choice B is incorrect as evaluation is not related to staffing decisions but focuses on assessing the quality of care delivery. Choice D is incorrect as evaluation is not about eliminating paperwork but rather about improving care outcomes.

Correct Answer: C

Rationale: The correct answer is C: Glucagon. In a hypoglycemic reaction, glucagon can be administered to raise blood sugar levels quickly. Glucagon works by stimulating the liver to release stored glucose into the bloodstream. This is crucial in emergencies when oral carbohydrates are not feasible. Epinephrine (A) is used for severe allergic reactions, not hypoglycemia. 50% dextrose (B) is an oral carbohydrate used for hypoglycemia but is not always practical. Hydrocortisone (D) is a corticosteroid used for inflammatory conditions, not for hypoglycemic emergencies.

Correct Answer: C

Rationale: The most pertinent nursing diagnosis for this patient is acute pain (Choice C). This is because the patient's right femur fracture would likely cause significant pain and discomfort, which is a priority to address for optimal recovery and comfort. Managing pain effectively is crucial in promoting healing and preventing complications. Posttrauma syndrome (Choice A) is not as immediate a concern in this scenario. While constipation (Choice B) and anxiety (Choice D) are important considerations, addressing acute pain takes precedence in the initial plan of care to ensure the patient's comfort and well-being.

Correct Answer: D

Rationale: The correct answer is D: To determine clients response to therapy. Evaluating BUN, creatinine, and serum electrolyte levels in a client being treated for acute pyelonephritis helps the nurse assess the effectiveness of the therapy. Changes in these levels indicate how well the kidneys are functioning and how the client is responding to treatment. Monitoring these parameters allows for adjustments in therapy if needed. Incorrect choices: A: To determine the severity of the disorder - While these tests can provide information about the severity of kidney dysfunction, the primary focus is on monitoring the response to therapy. B: To identify signs of fluid retention - While BUN and creatinine levels can indirectly indicate fluid status, the main purpose of evaluating these tests is to assess therapy response. C: To determine the location of discomfort - These tests do not provide information about the location of discomfort but rather focus on kidney function and response to treatment.