Nursing Process NCLEX Questions

Nursing Process NCLEX Questions Related

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A client with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty six-hours later, the client’s urine output suddenly rises above 200mL/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse’s suspicion of diabetes insipidus?

  • A. Above-normal urine and serum osmolality levels
  • B. Below-normal urine and serum osmolality levels
  • C. Above-normal urine osmolality level, below-normal serum osmolality level
  • D. Below- normal urine osmolality level, above-normal serum osmolality level
Correct Answer: D

Rationale: The correct answer is D: Below-normal urine osmolality level, above-normal serum osmolality level. In diabetes insipidus, there is a deficiency of antidiuretic hormone (ADH), leading to the excretion of large volumes of dilute urine. This results in low urine osmolality as the kidneys are unable to concentrate the urine. On the other hand, the serum osmolality increases due to the lack of ADH causing water retention. Therefore, the laboratory findings of low urine osmolality and high serum osmolality support the diagnosis of diabetes insipidus.

Explanation for other choices:
A: Above-normal urine and serum osmolality levels - This does not align with the pathophysiology of diabetes insipidus.
B: Below-normal urine and serum osmolality levels - This is incorrect as low serum osmolality is not characteristic of diabetes insipidus.
C: Above-normal urine osmolality level, below-normal

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The lungs regulate acid-base balance b₃y⁻ all of the following except:

  • A. Excreting HCO into the blood
  • B. Controlling carbon dioxide levels
  • C. Slowing ventilation
  • D. Increasing ventilation
Correct Answer: C

Rationale: The correct answer is C: Slowing ventilation. The lungs regulate acid-base balance by controlling carbon dioxide levels through ventilation. Increasing ventilation helps expel excess carbon dioxide, thus regulating pH. Slowing ventilation would lead to CO2 buildup and an imbalance in acid-base levels. Excreting HCO3- into the blood (choice A) helps maintain pH, while increasing ventilation (choice D) aids in removing excess CO2. Therefore, slowing ventilation is the exception as it would disrupt the acid-base balance by not effectively regulating carbon dioxide levels.

A very popular means of early detection of breast cancer is:

  • A. X-ray
  • B. Both A and B
  • C. Surgical
  • D. Breast self examination
Correct Answer: D

Rationale: The correct answer is D: Breast self-examination. This is because regular breast self-examination allows individuals to become familiar with their own breast tissue and identify any changes or abnormalities early on. X-ray (choice A) and surgical (choice C) are not typically used as early detection methods for breast cancer. Choice B is also incorrect because while mammograms (X-rays) are an important screening tool, self-examination should not be replaced by it, as it is a proactive way for individuals to take charge of their own health.

What would be the most appropriate intervention for a patient with aphasia who state, "I want a ..." and then stops?

  • A. Wait for the patient to complete the sentence.
  • B. Immediately begin showing the patient various objects In the environment.
  • C. Leave the room and come back later.
  • D. Begin naming various objects that the patient could be referring to.
Correct Answer: A

Rationale: The correct answer is A: Wait for the patient to complete the sentence. This is the most appropriate intervention for a patient with aphasia because rushing the patient or providing suggestions can be counterproductive. Waiting allows the patient time to find the words they are looking for and encourages communication. It shows respect for the patient's autonomy and gives them the opportunity to express themselves fully. Choice B may overwhelm the patient, Choice C disrupts the communication process, and Choice D may not align with the patient's intended communication. Patience and support are key in aiding a patient with aphasia.

The nurse is caring for a patient with HIV who has diarrhea. Which of the following would be most therapeutic to teach the patient to avoid in the diet to reduce diarrhea?

  • A. Potassium-rich food
  • B. Liquid nutritional supplements
  • C. Raw fruits and vegetables
  • D. Frozen products
Correct Answer: C

Rationale: The correct answer is C: Raw fruits and vegetables. Patients with HIV and diarrhea should avoid raw fruits and vegetables due to their high fiber content, which can exacerbate diarrhea symptoms. Fiber can increase bowel movements and worsen diarrhea. Therefore, avoiding raw fruits and vegetables can help reduce diarrhea.

Choice A (Potassium-rich food) is not the best answer because potassium-rich foods are important for patients with HIV to maintain electrolyte balance. Choice B (Liquid nutritional supplements) can actually be beneficial in providing essential nutrients to patients with HIV. Choice D (Frozen products) is not directly related to diarrhea management in patients with HIV.

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. During the first phase of the nursing process (assessment), the nurse collects data to establish a comprehensive database of the patient's health status. This information serves as 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 (C) in the third phase (planning), and determining outcomes achieved (D) in the fourth phase (evaluation). Completing a comprehensive database is crucial in the initial assessment phase to gather accurate information for the subsequent steps in the nursing process.

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