Nursing Process NCLEX Questions

Questions 75

ATI RN

Home > ATI RN > Nursing Process > Nursing Process NCLEX Questions
ATI RN Test Bank

Nursing Process NCLEX Questions Questions

Question 1 of 5

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.

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.

Question 2 of 5

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?

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.

Question 3 of 5

The best way to tell whether or not a patient is breathing, is for the nurse to watch the movement of the:

Correct Answer: D

Rationale: The correct answer is D, "Chest and nostrils." This is because observing the movement of the chest and nostrils is the most reliable way to determine if a patient is breathing. The chest rises and falls with each breath, and the nostrils may flare or move as air is inhaled and exhaled. Monitoring these areas provides a direct indication of respiratory effort. Choices A, B, and C are incorrect because they do not directly reflect the act of breathing. Extremities, head, and eyeball movements are not reliable indicators of breathing function.

Question 4 of 5

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

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.

Question 5 of 5

The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?

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.

Similar Questions

The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
A client is in isolation after receiving an internal radioactive implant to treat cancer. Two hours later, the nurse discovers the implant in the bed linens. What should the nurse do first?
At health fair, an oncology nurse answers questions about risk factors for various types of cancer. One person with a family history of colon cancer asks the nurse to identify risk factors for this type of cancer. The nurse should identify:
The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
A client with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty six-hours later, the client�s urine output suddenly rises above 200mL/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse�s suspicion of diabetes insipidus?

Join Our Community Today!

Join Over 10,000+ nursing students using Nurselytic. Access Comprehensive study Guides curriculum for ATI-RN and 3000+ practice questions to help you pass your ATI-RN exam.

Call to Action Image