Nursing Process NCLEX Questions

Nursing Process NCLEX Questions Related

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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? In the PQRST mnemonic, "P" stands for provocation, "Q" for quality, "R" for region/radiation, "S" for severity, and "T" for timing. The question "Where is the pain located?" corresponds to the "R" component, which is region/radiation. This question helps the nurse identify the specific area where the pain is localized, which can provide valuable information for diagnosis.

Explanation of other choices:
B: What causes the pain? This question relates more to the "P" component, which is provocation, rather than the region/radiation aspect.
C: Does it come and go? This question pertains to the "T" component, which is timing, focusing on the pattern of the pain rather than the specific location.
D: What does the pain feel like? This question is more aligned with the "Q" component, which is quality,

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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.

When preparing a site for venipunctures with alcohol, how long must the area be cleaned?

  • A. 5 seconds
  • B. 10 seconds
  • C. 30 seconds
  • D. 60 seconds
Correct Answer: D

Rationale: The correct answer is D: 60 seconds. This is because the area must be cleaned for at least 60 seconds to effectively disinfect the skin and reduce the risk of infection during venipuncture. Cleaning for shorter durations (5, 10, or 30 seconds) may not be sufficient to achieve proper disinfection. Thoroughly cleaning the area for a full minute ensures that the alcohol has enough time to kill bacteria and pathogens on the skin, making it safer for the venipuncture procedure. Shorter cleaning times may leave pathogens behind, increasing the risk of contamination and infection.

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 matches with the "Location" component of the PQRST. This question helps determine the specific area where the pain is occurring, providing crucial information for diagnosis and treatment. This step is important in identifying potential underlying issues related to the pain.

Summary of other choices:
B: What causes the pain? - This question relates to the "Provocation/Palliation" component, not the location.
C: Does it come and go? - This question corresponds to the "Quality" component, focusing on the characteristics of the pain.
D: What does the pain feel like? - This question aligns with the "Severity" component, concentrating on the intensity of the pain.

A nurse is developing nursing diagnoses for a group of patients. Which nursing diagnoses will the nurse use? (Select all that apply.)

  • A. Anxiety related to barium enema
  • B. Impaired gas exchange related to asthma
  • C. Impaired physical mobility related to incisional pain
  • D. Nausea related to adverse effect of cancer medication
Correct Answer: A

Rationale: The correct answer is A: Anxiety related to barium enema. This is the correct choice because nursing diagnoses should focus on the patient's actual or potential health problems, not just medical conditions. Anxiety is a common response to medical procedures like a barium enema. It is essential for the nurse to address the patient's emotional and psychological needs.

Summary:
B: Impaired gas exchange related to asthma is a medical diagnosis, not a nursing diagnosis. Nursing diagnoses focus on the patient's response to the medical condition.
C: Impaired physical mobility related to incisional pain is a potential nursing diagnosis, but the focus should be on the patient's response to the pain, not just the pain itself.
D: Nausea related to adverse effect of cancer medication is also a medical diagnosis. Nursing diagnoses should address the patient's response to the medication side effects, not just the side effects themselves.

Which of the following intravenous solutions is hypotonic?

  • A. Normal saline
  • B. Ringer’s lactate
  • C. 0.45% saline
  • D. 5% dextrose in normal saline  A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET F
Correct Answer: C

Rationale: The correct answer is C: 0.45% saline. This solution is hypotonic because it has a lower osmolarity compared to the intracellular fluid. It contains fewer solutes than the cells, causing water to move into the cells by osmosis, potentially causing them to swell.

Normal saline (A) and Ringer's lactate (B) are isotonic solutions, meaning they have a similar osmolarity to the intracellular fluid and do not cause significant water shifts.

5% dextrose in normal saline (D) is a hypertonic solution, containing more solutes than the cells, leading to water movement out of the cells.

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