Nursing Process NCLEX Questions

Correct Answer: C

Rationale: Step 1: Repositioning a patient who is on bed rest is a nursing intervention as it involves direct patient care to prevent complications like pressure ulcers. Step 2: Nursing interventions aim to promote patient health, prevent illness, and provide comfort. Step 3: Ordering chest x-ray and prescribing antibiotics are medical interventions, beyond the scope of nursing practice. Step 4: Teaching preoperative exercises falls under nursing education but not a direct nursing intervention involving patient care. Summary: Choice C is correct as it aligns with the essence of nursing interventions focusing on patient care and wellbeing. Choices A, B, and D involve actions that are not within the scope of nursing interventions.

Correct Answer: A

Rationale: The correct answer is A because during the first phase of the nursing process (assessment), the nurse gathers a comprehensive database of information about the patient's health status. This step is crucial for identifying the patient's needs and developing a holistic care plan. Choice B is incorrect because identifying nursing diagnoses typically occurs in the second phase (diagnosis). Choice C is incorrect as intervening based on care priorities happens in the third phase (planning and implementation). Choice D is incorrect as determining outcomes achieved is part of the final phase (evaluation).

Correct Answer: B

Rationale: The correct answer is B: a semi-private room. For a burn patient like Mr. Boy, a semi-private room is preferred to provide a more controlled environment for infection prevention, wound care, and privacy. Strict isolation (A) is not necessary as his burns are not infectious. Liberal visiting (C) can increase the risk of infection and compromise his recovery. Sharing equipment (D) can lead to cross-contamination and is not recommended for burn patients. In summary, a semi-private room balances infection control and patient comfort for burn patients.

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: B

Rationale: Step-by-step rationale for choice B being correct: 1. Blood pressure is vital in this scenario due to prednisone discontinuation. 2. Abruptly stopping prednisone can lead to adrenal insufficiency. 3. Adrenal insufficiency can cause hypotension, a life-threatening condition. 4. Monitoring blood pressure can help detect and manage potential complications. Summary of other choices: A: Breath sounds � Important but not the priority in this specific situation. C: Capillary refill � Useful for assessing circulation but not urgent in this context. D: Butterfly rash � A characteristic of lupus, but not a critical concern in this scenario.