Nursing Process NCLEX Questions

Correct Answer: C

Rationale: The correct answer is C: Hypercalcemia. Increased thirst and polyuria are symptoms of hypercalcemia, as excess calcium can lead to dehydration and increased urine output. Decreased muscle tone is also a common symptom of hypercalcemia. The lab value of Ca 8 mg/dl confirms high levels of calcium in the blood. Incorrect choices: A: Hypocalcemia - This is incorrect as the lab value of Ca 8 mg/dl indicates normal to high levels of calcium, ruling out hypocalcemia. B: Hyperkalemia - This is incorrect as the lab value of K 4 mEq/L is within normal range, ruling out hyperkalemia. D: Hypochloremia - This is incorrect as the lab value of Cl 103 mEq/L is within normal range, ruling out hypochloremia.

Correct Answer: A

Rationale: The correct answer is A because completing a comprehensive database is part of the first phase of the nursing process, which is assessment. During assessment, the nurse gathers data about the patient's health status. This information is crucial for identifying health problems, developing nursing diagnoses, planning interventions, and evaluating outcomes. Choice B is incorrect because identifying nursing diagnoses is part of the second phase, which is diagnosis. Choice C is incorrect as intervening based on priorities of patient care is part of the third phase, which is planning. Choice D is incorrect because determining whether outcomes have been achieved is part of the fourth phase, which is evaluation.

Correct Answer: A

Rationale: The correct answer is A, assessment skills. Assessing the client's current condition, including respiratory status, is crucial in determining priorities for care in asthma management. By utilizing assessment skills, the nurse can gather essential information to identify the client's immediate needs and develop an individualized care plan. Nursing books (B) can provide general information but do not provide real-time data on the client's current status. Client's records (C) may contain historical information but may not reflect the client's current condition. Supervisor's advice (D) is important but should supplement rather than replace the nurse's assessment skills in determining immediate care priorities.

Correct Answer: B

Rationale: The correct answer is B: 2 to 3 weeks. Alopecia is a common adverse reaction to chlorambucil, a type of chemotherapy drug that can cause hair loss. Alopecia typically occurs around 2 to 3 weeks after the first administration of chlorambucil. This is because chemotherapy drugs affect rapidly dividing cells, including hair follicles. Hair loss is a well-known side effect of many chemotherapy drugs, and it is important for the nurse to educate the client about this potential side effect. Incorrect choices: A: Immediately - Hair loss does not occur immediately after the first administration of chlorambucil. C: 1 week - Hair loss typically occurs later than 1 week after starting chemotherapy. D: 1 month - While hair loss can occur within a month, it is more likely to happen sooner, around 2 to 3 weeks after starting the medication.

Correct Answer: A

Rationale: The correct answer is A because the first phase of the nursing process is assessment, where the nurse gathers comprehensive data about the patient's health status. This step is crucial in identifying problems and setting priorities for care. Choice B comes in the second phase (diagnosis), C in the third phase (planning), and D in the last phase (evaluation). Assessing the patient's condition is the foundation for the rest of the nursing process.