Nursing Process NCLEX

The nurse sees an unauthorized person reading a client's medical record outside a client's room. Which action should the nurse take?

2. Notify the nursing supervisor and approach the individual.

When assisting in developing a plan of care for an older adult, the nurse should consider which challenges faced by clients in this age-group?

4. Adjusting to retirement, deaths of family members, and decreased physical strength

A client has a nursing diagnosis of Risk for injury related to adverse effects of potassium-wasting diuretics. What is a correctly written client outcome for this nursing diagnosis?

1. "Before discharge, the client correctly identifies three potassium-rich food sources."

A client is admitted with the following vital signs: temperature, 102° F (38.9° C); heart rate, 144 beats/minute and irregular; and respiratory rate, 22 breaths/minute. Which nursing diagnosis takes highest priority when planning this client's care?

1. Decreased cardiac output

What is the most appropriate nursing diagnosis for a client with acute pancreatitis?

1. Deficient fluid volume

A client is scheduled for surgery under general anesthesia. The night before surgery, the client tells the nurse, "I can't wait to have breakfast tomorrow." Based on this statement, the nurse should formulate which nursing diagnosis?

1. Deficient knowledge related to food restrictions associated with anesthesia

The parents of a pediatric client are waiting in the surgical family lounge while their son undergoes emergency surgery. A physician enters the family lounge and tells another family that surgery for their family member was unsuccessful. What should the nurse do to best serve these families?

1. Escort the family who received the discouraging news to a private area.

Which type of evaluation occurs continuously throughout the teaching and learning process?

1. Formative

Which statement best describes an expected outcome?

1. Goals that the client should reach as a result of planned nursing interventions

A geriatric client is admitted to the facility after fainting while gardening on a hot summer day. Which nursing diagnosis takes highest priority for this client?

1. Hyperthermia

A client is hospitalized with Pneumocystis carinii pneumonia. The nurse notes that the client has had no visitors, seems withdrawn, avoids eye contact, and refuses to take part in conversation. In a loud and angry voice, the client demands that the nurse leave the room. The nurse formulates a nursing diagnosis of Social isolation. Based on this diagnosis, what is an appropriate goal of care for this client?

1. Identifying one way to increase social interaction

A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis carinii pneumonia. Which nursing diagnosis has the highest priority?

1. Impaired gas exchange

After collecting data on a client, the nurse helps formulate relevant nursing diagnoses. Which of the following is a complete nursing diagnosis statement?

1. Ineffective airway clearance related to mucus plugs and nonproductive cough

The nurse discovers a fire in the client's bedside trash can. Which action should the nurse take first?

1. Move the client from the immediate fire scene.

A client has the following arterial blood gas values: pH, 7.30; PaO2, 89 mm Hg; PaCO2, 50 mm Hg; and HCO3-, 26 mEq/L. Based on these values, the nurse should suspect which condition?

1. Respiratory acidosis

After her shift, a nurse remembers that she failed to document a medication that she administered. What should the nurse do?

1. Return to the client care area and document the medication as given.

While caring for a client who's immobile, the nurse documents the following information in the client's chart: "Turned client from side to back every 2 hours." "Skin intact; no redness noted." "Client up in chair three times today." "Improved skin turgor noted." Which nursing diagnosis accurately reflects this information?

1. Risk for impaired skin integrity related to immobility

A nurse who's assigned the care of six clients is administering a tube feeding to a client when breakfast trays arrive. A client who needs assistance with meals helps herself to her tray and spills hot coffee on her chest and abdomen. How should the nurse intervene?

1. Stop administering the tube feeding and assist the client with changing her wet clothing, assess the burns, and notify the charge nurse.

The nurse refers a client with terminal cancer to a local hospice. What is the goal of this referral?

1. To provide support for the client and family in coping with terminal illness

A client complains of severe abdominal pain. To elicit as much information as possible about the pain, the nurse should ask:

2. "Can you describe the pain?"

A client is placed on a low-sodium (500 mg/day) diet. Which client statement indicates that the nurse's nutrition teaching plan has been effective?

2. "I chose broiled chicken with a baked potato for dinner."

A client has been receiving an I.V. solution. What is an appropriate expected outcome for this client?

2. "The client remains free of signs and symptoms of phlebitis."

Which intervention is an example of primary prevention?

2. Administering a measles, mumps, and rubella immunization to an infant

A client who underwent surgery 1 day ago is complaining of worsening incisional pain and isn't scheduled to receive pain medication for 2 hours. Which action by the nurse is most appropriate?

2. Assess the incision and then notify the charge nurse of the client's worsening pain.

The nurse is taking the health history of an 85-year-old client. Which information will be most useful to the nurse for planning care?

2. Current health promotion activities

A client is admitted to the health care facility with bowel obstruction secondary to colon cancer. The nurse obtains a health history, measures vital signs, and auscultates for bowel sounds. Which step of the nursing process is the nurse performing?

2. Data collection

During the planning step of the nursing process, the nurse performs which activity?

2. Develops goals of care

When collecting data, the nurse identifies these signs and symptoms: impaired coordination, decreased muscle strength, limited range of motion, and reluctance to move. These signs and symptoms indicate which nursing diagnosis?

2. Impaired physical mobility

While caring for a client, the nurse hears someone call for help. What should the nurse do?

2. Make sure the client is safe and then go see who's calling for help.

A client who underwent surgical repair of a herniated lumbar disk has a physician's order to ambulate during the immediate postoperative period. The client complains of numbness, weakness, and pain in his leg. How should the nurse intervene?

2. Notify the physician of the client's complaints.

A physician becomes angry when he sees no recent vital signs documented on the client's graphic vital sign record. How should the nurse intervene?

2. Obtain vital signs and report the findings to the physician.

A client admitted with a high fever complains that his mouth is very dry. Scheduled diagnostic testing restricts him from consuming anything by mouth. Which action by the nurse is best?

2. Performing mouth care

A client returns to the client care area after undergoing abdominal surgery. As the nurse inspects the client's dressing, she notes that it's completely saturated with bright-red blood. Which action should the nurse take?

2. Reinforce the dressing and contact the physician.

What is a common goal of discharge planning in all care settings?

2. Teaching the client how to perform self-care activities

The nurse is changing a client's dressing. Which observation of the wound warrants immediate physician notification?

2. Yellow, purulent drainage

The following statement appears on a client's plan of care: "Client will ambulate in the hall without assistance within 4 days." This statement is an example of:

2. a client outcome.

One aspect of implementation related to drug therapy is:

2. documenting drugs given.

The nurse is caring for a client with a history of falls. The first priority when caring for a client at risk for falls is:

2. keeping the bed in the lowest possible position.

A client is admitted with acute chest pain. When obtaining the health history, which question would be most helpful for the nurse to ask?

3. "How would you rate your pain on a scale of one to ten, with ten being the worst pain imaginable?"

A client with a weak left leg is learning how to ambulate with a cane; however, he has difficulty remembering to hold the cane with his right arm. Which statement by the nurse would be most helpful to this client?

3. "Remember to hold the cane with the hand on the opposite side of your weak leg."

The nurse should include which instruction in the teaching plan for a client who is scheduled to undergo an ultrasound of the gallbladder and biliary system?

3. Avoiding smelling greasy foods before the test

A 65-year-old client comes to the physician's office for a follow-up appointment after having a basal cell lesion removed from his face. The nurse teaches the client to inspect his skin for signs of melanoma. For which sign should the nurse tell him to look?

3. Black or purple irregularly shaped nodules

A blind client is admitted for treatment of gastroenteritis. Which nursing diagnosis takes highest priority for this client?

3. Deficient fluid volume

A client is admitted to the health care facility after 3 days of nausea, vomiting, and fever. Which nursing diagnosis takes highest priority for this client?

3. Deficient fluid volume related to nausea and vomiting

A client with chronic renal failure is admitted with a heart rate of 122 beats/minute, a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, neck vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client?

3. Excess fluid volume

While assessing a home care client, the nurse notices a family member smoking near the client's oxygen. Which action by the nurse is best?

3. Explaining to the family member that oxygen is flammable and smoking must be avoided

Which aspect of drug therapy is most important when planning nursing care for an elderly client?

3. Noncompliance

A nurse is seen accessing a client's medical record in an area where she doesn't provide care. Which action by the nurse is best?

3. Notify the charge nurse and nursing supervisor of the incident.

Which clinical characteristic affects client compliance?

3. The nurse-client relationship

Which option serves as a framework for nursing education and clinical practice?

3. Theoretical and conceptual models

When prioritizing a client's plan of care based on Maslow's hierarchy of needs, the nurse's first priority would be:

3. administering pain medication.

During the planning step of the nursing process, the nurse:

3. establishes short- and long-term goals.

The nurse assists in developing a list of nursing diagnoses for a client. This list should include:

3. factors influencing the client's problem.

The nurse is collecting data on a client. She notes clubbed fingers. This finding indicates:

3. hypoxia.

The nurse is providing care for a client who underwent heart surgery. The best example of a measurable outcome goal is for the client to:

3. walk from his room to the end of the hall and back before discharge.

Which statement reflects appropriate documentation in the medical record of a hospitalized client?

4. "Client's skin is moist and cool."

A client is provided two treatment options by his physician. During morning care, the client asks the nurse for her opinion about which treatment to undergo. Which response by the nurse is most appropriate?

4. "It sounds like you need more time to make a decision. Would you like me to contact your physician for you?"

The nurse assesses capillary refill in a client admitted with pneumonia and dehydration. Which capillary refill duration is considered abnormal and should be reported?

4. 4 seconds

Each morning, the nurse-manager assigns clients and additional tasks for the staff nurses to complete that day. During the shift, a crisis develops and one staff nurse doesn't complete the additional tasks. The next day, the nurse-manager reprimands this nurse. When the nurse tries to explain, the nurse-manager interrupts, saying that the tasks should have been completed anyway. Which leadership style is the nurse-manager exhibiting?

4. Authoritarian

A client who speaks and understands minimal English has emergency gallbladder surgery. During discharge preparation, which nursing action would best help this client understand wound care instructions?

4. Demonstrating the procedure and having the client perform a return demonstration

A client is to be discharged from an acute care facility after treatment for right leg thrombophlebitis. The nurse notes that the client's leg is pain-free, without redness or edema. The nurse's actions reflect which step of the nursing process?

4. Evaluation

A client receives morphine, 4 mg I.V., for relief of surgical pain. Thirty minutes later, the nurse asks the client to rate his level of pain using a pain scale. Which step of the nursing process is the nurse using?

4. Evaluation

The nurse is revising a client's plan of care. During which step of the nursing process does such revision take place?

4. Evaluation

Which of the following is an approved nursing diagnosis?

4. Impaired gas exchange

After a stroke, a client develops aphasia. Which data collection finding is most typical in aphasia?

4. Inability to speak clearly

A client is diagnosed with deep vein thrombosis. Which nursing diagnosis should receive highest priority at this time?

4. Ineffective peripheral tissue perfusion related to venous congestion

A nurse discovers that a stat dose of potassium chloride that was prescribed by the physician was never administered. Which action should the nurse take?

4. Notify the charge nurse so she can notify the physician of the missed dose.

What should the nurse do with linens that have been soiled by a client with hepatitis?

4. Place them in a plastic bag that has a contamination symbol.

A client complains that he's uncomfortable lying in the hospital bed and can't sleep. The nurse checks the client's medication administration record and there's no sleep medication prescribed. How can the nurse best help this client?

4. Provide a gentle backrub to promote relaxation and sleep.

A client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client?

4. Risk for aspiration related to general anesthesia

A nurse is caring for a client with a diagnosis of Impaired gas exchange. Which outcome is most appropriate based upon this nursing diagnosis?

4. The client has normal breath sounds in all lung fields.

A client admitted with deep vein thrombosis of the left leg is prescribed bed rest. The client complains that she's unable to void in the bedpan. Which action should the nurse take?

4. When the client has the urge to void, assist her to a sitting position on the bedpan.

When documenting information in a client's medical record, the nurse should:

4. end each entry with the nurse's signature and title.