Nursing Process NCLEX Questions

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Nursing Process NCLEX Questions Questions

Question 1 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 during the first phase of the nursing process (assessment), the nurse gathers a comprehensive database of information about the patient's health status. This includes collecting subjective and objective data to form a baseline for further decision-making. Identifying nursing diagnoses (B) occurs in the second phase (diagnosis), intervening based on priorities of patient care (C) is part of the third phase (planning), and determining outcomes (D) is done in the final phase (evaluation). Therefore, completing a comprehensive database is the most appropriate action in the first phase.

Question 2 of 5

A client is receiving a blood transfusion. If this client experiences an acute hemolytic reaction, which nursing intervention is the most important?

Correct Answer: D

Rationale: The correct answer is D: Immediately stop the transfusion, infuse normal saline solution, notify the blood bank. Rationale: 1. Stop the transfusion immediately to prevent further complications from the hemolytic reaction. 2. Infuse normal saline solution to maintain adequate hydration and support kidney function. 3. Notify the blood bank to report the adverse reaction and to return the blood products for further investigation and testing. Summary of other choices: A: Incorrect because infusing dextrose 5% in water (D5W) is not indicated for treating a hemolytic reaction. Calling the physician is important, but stopping the transfusion and notifying the blood bank are more critical. B: Incorrect because slowing the transfusion may not be sufficient to manage the acute hemolytic reaction effectively. C: Incorrect because administering antihistamines is not the appropriate treatment for a hemolytic reaction. Stopping the transfusion and notifying the blood bank are more urgent actions.

Question 3 of 5

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?

Correct Answer: D

Rationale: The correct answer is D: Below-normal urine osmolality level, above-normal serum osmolality level. In diabetes insipidus, there is a deficiency of antidiuretic hormone (ADH), leading to the excretion of large volumes of dilute urine. This results in low urine osmolality as the kidneys are unable to concentrate the urine. On the other hand, the serum osmolality increases due to the lack of ADH causing water retention. Therefore, the laboratory findings of low urine osmolality and high serum osmolality support the diagnosis of diabetes insipidus. Explanation for other choices: A: Above-normal urine and serum osmolality levels - This does not align with the pathophysiology of diabetes insipidus. B: Below-normal urine and serum osmolality levels - This is incorrect as low serum osmolality is not characteristic of diabetes insipidus. C: Above-normal urine osmolality level, below-normal

Question 4 of 5

A client has cancer that has me tastasized to her bones. She is complaining of increased thirst, polyuria and decreased muscle tone. Her lab values are: Na 139mEq/L, k 4 mEq/L, Cl 103 mEq/L, and Ca 8 mg/dl. What electrolyte imbalance is present?

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.

Question 5 of 5

Mr. Boy, a 65-year old man, has been admitted wth severe flame burns resulting from smoking in bed. The nurse can expect his room environment to include:

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.

Similar Questions

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