Nursing Process NCLEX Questions

Correct Answer: C

Rationale: Rationale for Correct Answer (C): A complete blood count (CBC) is used to identify abnormalities in red blood cells, white blood cells, and platelets. Hematocrit (HCT) and hemoglobin (Hb) levels are part of a CBC and indicate the oxygen-carrying capacity of the blood. Abnormally low HCT and Hb levels can signify conditions like anemia, which can impact a client's ability to undergo surgery due to potential complications related to oxygen delivery. Summary of Incorrect Choices: A: Potential hepatic dysfunction is not directly related to a CBC, and BUN/creatinine levels are markers for kidney function, not liver function. B: Low levels of urine constituents are not assessed in a CBC, which focuses on blood components. D: Electrolyte imbalance is not specifically tested in a CBC; it is usually evaluated through separate blood tests. Coagulation factors are not directly measured in a CBC.

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: Step-by-step rationale for why answer A is correct: 1. Having intercourse with just the spouse means a monogamous relationship with a trusted partner, minimizing risk of exposure to HIV. 2. It eliminates the risk of contracting HIV from multiple sexual partners. 3. This choice adheres to safer sex practices by reducing the chances of exposure to HIV. 4. This choice also promotes trust and communication within the relationship, further reducing the risk of HIV transmission. Summary: - Choice A is correct as it promotes monogamy and reduces the risk of exposure to HIV. - Choices B, C, and D do not guarantee zero risk of HIV transmission as blood donations, HIV antibodies, and condom use can still pose risks if not used or implemented correctly.

Correct Answer: C

Rationale: The correct answer is C because Nursing Outcomes Classification adds objectivity to judging a patient's progress by providing standardized criteria for assessing outcomes. This helps in evaluating the effectiveness of interventions and tracking improvements accurately. Other choices are incorrect: A is wrong because Nursing Outcomes Classification includes 7 domains but not necessarily for level 1; B is incorrect as it uses a 5-point Likert scale, not a 3-point scale; and D is inaccurate because Nursing Outcomes Classification guides the selection of interventions based on the identified outcomes, not allowing complete freedom in choosing interventions.

Correct Answer: A

Rationale: Step 1: Orthopnea is a classic symptom of congestive heart failure (CHF) due to fluid accumulation in the lungs when lying flat. Step 2: This symptom occurs because when lying down, the fluid redistributes, making it harder to breathe. Step 3: Fever (choice B) is not typically associated with CHF unless there is an underlying infection. Step 4: Weight loss (choice C) is more indicative of conditions like cancer or malnutrition, not CHF. Step 5: Calf pain (choice D) is more commonly associated with deep vein thrombosis, not CHF. Summary: Orthopnea is the best assessment finding indicating CHF, while the other choices are more likely related to different health conditions.