Nursing Process NCLEX Questions

Nursing Process NCLEX Questions Related

Review Nursing Process NCLEX Questions related questions and content

A patient was recently diagnosed with pneumonia. The nurse and the patient have established a goal that the patient will not experience shortness of breath with activity in 3 days with an expected outcome of having no secretions present in the lungs in 48 hours. Which evaluative measure will the nurse use to demonstrate progress toward this goal?

  • A. No sputum or cough present in 4 days
  • B. Congestion throughout all lung fields in 2 days
  • C. Shallow, fast respirations 30 breaths per minute in 1 day
  • D. Lungs clear to auscultation following use of inhaler
Correct Answer: D

Rationale: The correct evaluative measure is D: Lungs clear to auscultation following use of inhaler. This choice aligns with the expected outcome of having no secretions present in the lungs in 48 hours. By using an inhaler to clear the lungs, the nurse can assess if the expected outcome is being met. This measure directly evaluates the presence of secretions in the lungs, in line with the established goal.

Incorrect Choices:
A: No sputum or cough present in 4 days - This measure does not align with the expected outcome of having no secretions present in the lungs in 48 hours.
B: Congestion throughout all lung fields in 2 days - This indicates a worsening condition and does not demonstrate progress towards the goal.
C: Shallow, fast respirations 30 breaths per minute in 1 day - This measure is unrelated to the presence of secretions in the lungs and the goal of avoiding shortness of breath with activity.

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A brain abscess is a collection of pus within the substance of the brain and is caused by:

  • A. Direct invasion of the brain
  • B. Spread of infection by other organs
  • C. Spread infection from nearby sites
  • D. All of the above mechanisms
Correct Answer: D

Rationale: The correct answer is D because a brain abscess can be caused by direct invasion of the brain, spread of infection by other organs, and spread of infection from nearby sites. Direct invasion occurs when bacteria enter the brain tissue directly, such as through trauma or surgery. Infections from other organs, like the lungs or heart, can spread through the bloodstream to the brain. Infections from nearby sites, such as the ears or sinuses, can also spread to the brain. Therefore, all of these mechanisms can lead to the formation of a brain abscess. Choices A, B, and C individually do not cover all the possible causes of a brain abscess, making D the correct choice.

A 72 y.o. man is admitted to a skilled care facility following a stroke. When the nursing assistant is bathing him, he makes a sexual remark and tries to touch her inappropriately. The assistant finishes the bath, then tells the LPN in charge, “I refuse to take care of that dirty old man!” Which response by the nurse is best?

  • A. “The next time he tries to touch you inappropriately, lightly smack his hand and tell him no!”
  • B. “His stroke has made him less inhibited. We’ll see if we can find a male assistant to help him.”
  • C. “We have to take care of all patients equally, even the dirty old men.”
  • D. “He didn’t mean anything by it, just ignore it.”
Correct Answer: B

Rationale: The correct answer is B because it acknowledges the patient's behavior is likely due to the stroke affecting his inhibitions. Finding a male assistant respects both the patient's dignity and the nursing assistant's comfort. Choice A is inappropriate as physical violence is never an acceptable response. Choice C lacks empathy and understanding of the situation. Choice D minimizes the seriousness of the behavior and fails to address the issue. B is the best option for promoting a safe and respectful environment for both the patient and staff.

A client's IV fluid orders for 24 hour's are 1500 ml D5W followed by 1250 ml of NS. The IV tubing has a drop factor of 15 gtt/ml. To administer the required fluids the nurse should set the drip rate at;

  • A. 13 gtt/min
  • B. 29 gtt/min
  • C. 16 gtt/min
  • D. 32 gtt/min Situation 5: Protection of self and patient can be done by supporting the body's immunity.
Correct Answer: B

Rationale: To calculate the drip rate, we first need to find the total volume of IV fluid to be administered, which is 1500 ml + 1250 ml = 2750 ml. Then, we multiply the total volume by the drop factor (2750 ml * 15 gtt/ml = 41250 gtt). Finally, we divide the total number of drops by the time in minutes (24 hours * 60 min = 1440 min) to get the drip rate: 41250 gtt / 1440 min = 28.47 gtt/min, which rounds up to 29 gtt/min. Therefore, choice B is correct. Choices A, C, and D are incorrect because they do not reflect the accurate calculation based on the given parameters.

Which of the ff nursing interventions is essential for a client during the Schilling test?

  • A. Collecting urine 24-48 hrs after the client has received nonradioactive B12
  • B. Collecting blood samples of 50 ml for 24-48 hrs after the client has received the nonradioactive B12
  • C. Not allowing any oral fluid consumption for 24-48 hrs after the client has received nonradioactive B12
  • D. Making the client lie down in the supine position for 24-48 hrs after the client has received nonradioactive B12 CARING FOR CLIENTS WITH DISORDERS OF THE HEMATOPOIETIC SYSTEM
Correct Answer: A

Rationale: The correct answer is A because collecting urine 24-48 hrs after the client has received nonradioactive B12 is essential for the Schilling test to evaluate vitamin B12 absorption. Urine is collected to measure the excretion of radioactive B12, which helps in diagnosing pernicious anemia or malabsorption issues.

Incorrect choices:
B: Collecting blood samples is not necessary for the Schilling test as it primarily involves urine collection.
C: Allowing oral fluid consumption is important to prevent dehydration and is not contraindicated after receiving nonradioactive B12.
D: Making the client lie down in the supine position is unnecessary for the Schilling test and may not affect the test results.

A nurse is updating the care plan of a client whose condition has improved. What is the most appropriate step to take?

  • A. Remove resolved nursing diagnoses from the care plan.
  • B. Continue with the existing care plan until discharge.
  • C. Focus only on interventions for unresolved issues.
  • D. Delegate the task to another nurse or staff member.
Correct Answer: A

Rationale: The correct answer is A because when a client's condition improves, resolved nursing diagnoses should be removed from the care plan to reflect the current status accurately. This ensures the care plan remains relevant and effective. Continuing with the existing plan (choice B) may lead to unnecessary interventions. Focusing only on unresolved issues (choice C) overlooks the importance of updating the care plan comprehensively. Delegating the task to another nurse or staff member (choice D) is not appropriate as the nurse updating the care plan should have a thorough understanding of the client's progress and needs.

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