Nursing Process NCLEX Questions

Nursing Process NCLEX Questions Related

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A client in the terminal stage of cancer is receiving continuous infusion of morphine (Duramorph) for pain management. Which assessment finding suggests that the client is experiencing an adverse effect of this drug?

  • A. Voiding of 350mL of concentrated urine in 8 hours
  • B. Respiratory rate of 8breaths/min
  • C. Irregular heart rate of 82 beats/min
  • D. Pupils constricted and equal  A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET J
Correct Answer: B

Rationale: The correct answer is B: Respiratory rate of 8 breaths/min. Morphine is an opioid that can cause respiratory depression as a side effect. A respiratory rate of 8 breaths/min indicates hypoventilation, which is a potential adverse effect of morphine. This is a critical finding that requires immediate intervention to prevent respiratory failure or arrest.

A: Voiding of 350mL of concentrated urine in 8 hours is not directly related to morphine's adverse effects. Morphine can cause urinary retention, not increased voiding.

C: Irregular heart rate of 82 beats/min is within normal range and not a typical adverse effect of morphine. Morphine can cause bradycardia or tachycardia, but not irregular heart rate specifically.

D: Pupils constricted and equal is a common side effect of morphine due to its effect on the central nervous system. This finding does not suggest an adverse effect; it is an expected pharmac

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The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?

  • A. Completes a comprehensive database
  • B. Identifies pertinent nursing diagnoses
  • C. Intervenes based on priorities of patient care
  • D. Determines whether outcomes have been achieved
Correct Answer: A

Rationale: The correct answer is A: Completes a comprehensive database. In the first phase of the nursing process (assessment), the nurse collects data to form a comprehensive database about the patient's health status. This step is crucial as it provides the foundation for identifying nursing diagnoses, planning interventions, and evaluating outcomes. Identifying nursing diagnoses (B) occurs in the second phase (diagnosis), intervening based on priorities of patient care (C) is part of the third phase (planning), and determining whether outcomes have been achieved (D) is in the fourth phase (evaluation). Completing a comprehensive database in the first phase ensures a thorough understanding of the patient's needs before proceeding to the next steps in the nursing process.

Several hours after returning from surgery, the nurse tells the patient that she is ordered to be ambulated. The patient asks, “Why?” Which of the following complications would the nurse correctly explain can be prevented by early postoperative ambulation?

  • A. Increased peristalsis
  • B. Coughing
  • C. Pneumonia
  • D. Wound healing  A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET K
Correct Answer: C

Rationale: The correct answer is C: Pneumonia. Early postoperative ambulation helps prevent pneumonia by promoting lung expansion, increasing oxygenation, and preventing atelectasis. A: Increased peristalsis is unrelated to ambulation. B: Coughing is important for airway clearance but not directly related to ambulation. D: Wound healing is influenced by various factors, but ambulation primarily impacts respiratory function.

A nurse is completing an assessment using the PQRST to obtain data about the patient’s chest pain. Match the questions to the components of the PQRST that the nurse will be using.

  • A. Where is the pain located?
  • B. What causes the pain?
  • C. Does it come and go?
  • D. What does the pain feel like?
Correct Answer: A

Rationale: The correct answer is A: Where is the pain located? This question corresponds to the "P" in PQRST, which stands for Provocation/Palliation. By asking where the pain is located, the nurse is gathering information about what triggers or relieves the pain, aiding in the assessment of the chest pain. The other choices are incorrect because:
B: What causes the pain? - This question corresponds to the "Q" in PQRST, which stands for Quality. It focuses on understanding the characteristics of the pain, not the cause.
C: Does it come and go? - This question corresponds to the "R" in PQRST, which stands for Radiation. It pertains to whether the pain spreads to other areas, not if it comes and goes.
D: What does the pain feel like? - This question corresponds to the "S" in PQRST, which stands for Severity. It relates to the intensity of the pain, not its location.

A few hours before the patient was admitted at the hospital, he complained of fever, nausea and vomiting, and vague abdominal pain. The doctor examined the patient as a case of acute appendicitis and prepared for appendectomy. The nurse anticipates that this type of surgery is classified as:

  • A. emergency
  • B. urgent
  • C. elective
  • D. required
Correct Answer: A

Rationale: The correct answer is A: emergency. Acute appendicitis is a condition that requires immediate surgical intervention to prevent complications like rupture. In an emergency surgery, the procedure must be done urgently to treat a life-threatening condition. In this case, the patient's symptoms indicate an urgent need for surgery to remove the inflamed appendix.

Choice B: urgent, implies that surgery is needed promptly, but not immediately to prevent life-threatening complications. Choice C: elective, refers to a planned, non-urgent surgery that is scheduled in advance. Choice D: required, is a vague term and doesn't specify the urgency of the surgery, hence it is not the best classification for acute appendicitis surgery.

or a client with newly diagnosed cancer, the nurse formulates a nursing diagnosis of Anxiety related to the threat of death secondary to cancer diagnosis. Which expected outcome would be appropriate for this client?

  • A. “Client verbalizes feelings of anxiety.”
  • B. “Client doesn’t guess at prognosis.”
  • C. “Client uses any effective method to reduce tension.”
  • D. “Client stops seeking information.”
Correct Answer: A

Rationale: The correct answer is A because it reflects a measurable and client-centered outcome. Verbalizing feelings of anxiety indicates the client is acknowledging and addressing their emotions, which is essential in managing anxiety. Choice B is incorrect as it focuses on avoidance rather than expression of emotions. Choice C is incorrect as it doesn't specify the use of appropriate coping mechanisms. Choice D is incorrect as it suggests avoidance of seeking information, which may hinder the client's understanding and coping with the diagnosis.

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