Nursing Process NCLEX Questions

Correct Answer: B

Rationale: Step-by-step rationale for choice B: Footboard and splint: 1. Footboard helps prevent foot drop by maintaining proper alignment and preventing pressure ulcers. 2. Splint helps stabilize and support Franco's limbs to prevent contractures and maintain proper positioning. 3. Both items are essential for Franco's safety, comfort, and prevention of complications. 4. Hand bell and extra bed linen (Choice A) are not crucial for Franco's immediate care needs. 5. Sandbag and trochanter rolls (Choice C) are not directly relevant to Franco's specific conditions. 6. Suction machine and gloves (Choice D) are important for airway management but not the priority for bedside equipment in this case.

Correct Answer: A

Rationale: The correct answer is A: Where is the pain located? In the PQRST mnemonic, "P" stands for provocation, "Q" for quality, "R" for region/radiation, "S" for severity, and "T" for timing. The question "Where is the pain located?" corresponds to the "R" component, which is region/radiation. This question helps the nurse identify the specific area where the pain is localized, which can provide valuable information for diagnosis. Explanation of other choices: B: What causes the pain? This question relates more to the "P" component, which is provocation, rather than the region/radiation aspect. C: Does it come and go? This question pertains to the "T" component, which is timing, focusing on the pattern of the pain rather than the specific location. D: What does the pain feel like? This question is more aligned with the "Q" component, which is quality,

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: C

Rationale: The correct answer is C: Slowing ventilation. The lungs regulate acid-base balance by controlling carbon dioxide levels through ventilation. Increasing ventilation helps expel excess carbon dioxide, thus regulating pH. Slowing ventilation would lead to CO2 buildup and an imbalance in acid-base levels. Excreting HCO3- into the blood (choice A) helps maintain pH, while increasing ventilation (choice D) aids in removing excess CO2. Therefore, slowing ventilation is the exception as it would disrupt the acid-base balance by not effectively regulating carbon dioxide levels.

Correct Answer: A

Rationale: The correct answer is A because observing for signs of brain injury is crucial in assessing a possible skull fracture. Signs may include altered mental status, headache, nausea, vomiting, and unequal pupil size. Choice B is incorrect as hemorrhaging from the oral cavity may not always be present in skull fractures. Choice C is incorrect as elevating the foot of the bed is not recommended for a possible skull fracture. Choice D is incorrect as decreased intracranial pressure and temperature are not typical symptoms of a skull fracture.