Clients who will go through operations and who have undergone surgery need the proper observation, treatment and care. Implementing the nursing process to these patients will help reduce complications. Nurse Maria checks on Mr. Alberto who had abdominal surgery, and finds that the edges of the incision have separated. Also, a small portion of the bowel is sticking out through the incision. Nurse Maria would:

Questions 75

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Fundamentals of Nursing Nursing Process Questions Questions

Question 1 of 9

Clients who will go through operations and who have undergone surgery need the proper observation, treatment and care. Implementing the nursing process to these patients will help reduce complications. Nurse Maria checks on Mr. Alberto who had abdominal surgery, and finds that the edges of the incision have separated. Also, a small portion of the bowel is sticking out through the incision. Nurse Maria would:

Correct Answer: A

Rationale: Correct Answer: A: Cover wound with moist sterile dressing Rationale: 1. Covering the wound with a moist sterile dressing helps maintain a clean and moist environment, promoting wound healing. 2. Moist dressing prevents the wound from drying out and minimizes the risk of infection. 3. The moist environment supports healing by promoting cell growth and preventing tissue damage. 4. It protects the exposed bowel from further injury and contamination. Summary: B: Finding out how this happened is important but not an immediate priority for patient care. C: Placing sterile dry gauze can lead to the wound drying out and hinder healing. D: Pouring sterile water into the wound is not recommended as it can introduce contaminants and is not considered standard care for this situation.

Question 2 of 9

In giving health instructions, the nurse should infrom the client about the risk fsctors associated with coronary artery disease. Which of the following controllable risk factors is closely linked to the development of MI?

Correct Answer: B

Rationale: Step 1: High cholesterol levels contribute to the buildup of plaque in arteries, leading to atherosclerosis and increasing the risk of coronary artery disease. Step 2: Atherosclerosis can result in a blockage of blood flow to the heart, causing a myocardial infarction (MI). Step 3: Age is a risk factor for CAD but not directly linked to MI development. Step 4: Medication usage may impact risk factors but is not a direct cause of MI. Step 5: Gender can influence risk but is not the primary factor in MI development.

Question 3 of 9

A diabetic client develops sinusitis and otitis media accompanied by a fever of 100.8○0 F (38.2○0 C). What effect may this have on his need for insulin?

Correct Answer: D

Rationale: The correct answer is D: It will increase the need for insulin. Infections like sinusitis and otitis media can lead to increased stress on the body, causing insulin resistance and higher blood sugar levels. This leads to an increased demand for insulin to regulate blood sugar levels effectively. Therefore, the diabetic client's need for insulin will likely increase in this scenario. Incorrect choices: A: It will have no effect - Incorrect because infections and fever can impact insulin requirements. B: It will cause wide fluctuations in the need for insulin - Incorrect as infections generally lead to increased insulin needs, not fluctuations. C: It will decrease the need for insulin - Incorrect as infections and fever typically increase insulin requirements due to increased stress on the body.

Question 4 of 9

The nurse is teaching a client who will be discharged soon how to change a sterile dressing on the right leg. During the teaching session, the nurse notices redness, swelling and induration at the wound site. What do these signs suggest?

Correct Answer: A

Rationale: The presence of redness, swelling, and induration at the wound site are indicative of infection. Redness and swelling suggest inflammation, while induration indicates tissue hardening and can be a sign of infection spreading. Infection can delay healing and lead to complications if not treated promptly. Evisceration refers to wound opening with protrusion of internal organs, not indicated by the symptoms. Dehiscence is the partial or complete separation of wound layers, not represented by the symptoms. Hemorrhage involves excessive bleeding, which is not described in the scenario. Therefore, choice A is correct as it aligns with the signs observed and is the most appropriate response for the situation.

Question 5 of 9

A client with uterine cancer asks the nurse, “Which is the most common type of cancer in women?” The nurse replies that it’s breast cancer. Which type of cancer causes the most deaths in women?

Correct Answer: B

Rationale: The correct answer is B: Lung cancer. Lung cancer causes the most deaths in women due to its high mortality rate. It is often diagnosed at an advanced stage, leading to poorer outcomes. Breast cancer, although common, has a lower mortality rate compared to lung cancer. Brain cancer is relatively rare in comparison. Colon and rectal cancer, while significant, do not surpass lung cancer in terms of causing the most deaths in women.

Question 6 of 9

The nurse is using a systematic approach to the collection of assessment data. The nurse uses an assessment guide that uses a hierarchy of five life requirements universal to all persons. What model for organizing the assessment data is the nurse using?

Correct Answer: A

Rationale: The correct answer is A: Human Needs (Maslow) model. The nurse is using a systematic approach based on Maslow's Hierarchy of Needs, which includes physiological, safety, love/belonging, esteem, and self-actualization needs. This model organizes assessment data by prioritizing these universal life requirements. Incorrect choices: B: Functional Health Patterns model - This model focuses on 11 functional health patterns, not the hierarchy of universal life requirements. C: Human Response Patterns model - This model focuses on the individual's response to stressors, not prioritizing universal life requirements. D: Body System model - This model focuses on assessing specific body systems, not the holistic approach of addressing all life requirements.

Question 7 of 9

Through which of the ff body fluids has transmission of HIV been established? Choose all that apply

Correct Answer: C

Rationale: The correct answer is C: Tears and F: Breastmilk. HIV transmission has been established through breastmilk due to the presence of the virus in the milk. Tears can also transmit HIV if they contain blood from an HIV-positive individual. Saliva, sweat, and urine do not typically contain enough HIV to transmit the virus. Blood is a well-known mode of HIV transmission due to the high viral load present in blood. Therefore, choices A, B, D, and G are incorrect as they do not have sufficient levels of the virus to transmit HIV.

Question 8 of 9

During chemotherapy, an oncology client has a nursing diagnosis of impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis?

Correct Answer: B

Rationale: Step 1: Providing a solution of hydrogen peroxide and water as a mouth rinse helps in reducing the pain of stomatitis by promoting oral hygiene and preventing infections. Step 2: Hydrogen peroxide has antimicrobial properties that can help in reducing bacteria in the mouth, which can worsen stomatitis. Step 3: Rinsing with this solution can also help in cleansing the oral mucosa and reducing inflammation, thereby decreasing pain. Step 4: This intervention directly addresses the nursing diagnosis of impaired oral mucous membrane and is focused on symptom management. Summary: A: Recommending the client to discontinue chemotherapy is not a feasible option as it is essential for treating cancer. C: Monitoring platelet and leukocyte counts is important but does not directly address the pain of stomatitis. D: Checking for signs and symptoms is necessary but does not provide direct relief for the pain of stomatitis.

Question 9 of 9

Tic douloureux is a (n) ___ cranial nerve disorder characterized by paroxysms of pain and burning sensations.

Correct Answer: C

Rationale: The correct answer is C: 5th cranial nerve. Tic douloureux, also known as trigeminal neuralgia, is characterized by severe facial pain. The trigeminal nerve, the 5th cranial nerve, is responsible for sensory input from the face. This nerve is commonly affected in cases of tic douloureux, leading to sharp, shooting pain in the face. Choices A, B, and D are incorrect because the 1st cranial nerve (olfactory nerve), 7th cranial nerve (facial nerve), and 8th cranial nerve (vestibulocochlear nerve) are not typically associated with the symptoms of tic douloureux.

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