The Nursing
Process NCLEX
3000 (73
questions and
answers)
What is the most appropriate nursing
diagnosis for a client with acute pancreatitis?
- answer 1. Deficient fluid volume
A client is admitted with the following vital
signs: temperature, 102° F (38.9° C); heart
rate, 144 beats/minute and irregular; and
respiratory rate, 22 breaths/minute. Which
nursing diagnosis takes highest priority when
planning this client's care? - answer 1.
Decreased cardiac output
,The nurse is taking the health history of an
85-year-old client. Which information will be
most useful to the nurse for planning care? -
answer 2. Current health promotion
activities
Which aspect of drug therapy is most
important when planning nursing care for an
elderly client? - answer 3. Noncompliance
A client with acquired immunodeficiency
syndrome (AIDS) develops Pneumocystis
carinii pneumonia. Which nursing diagnosis
has the highest priority? - answer 1.
Impaired gas exchange
Which clinical characteristic affects client
compliance? - answer 3. The nurse-client
relationship
Which statement reflects appropriate
documentation in the medical record of a
hospitalized client? - answer 4. "Client's skin
is moist and cool."
, The nurse is changing a client's dressing.
Which observation of the wound warrants
immediate physician notification? - answer
2. Yellow, purulent drainage
A 65-year-old client comes to the physician's
office for a follow-up appointment after
having a basal cell lesion removed from his
face. The nurse teaches the client to inspect
his skin for signs of melanoma. For which
sign should the nurse tell him to look? -
answer 3. Black or purple irregularly shaped
nodules
The nurse assesses capillary refill in a client
admitted with pneumonia and dehydration.
Which capillary refill duration is considered
abnormal and should be reported? - answer
4. 4 seconds
When collecting data, the nurse identifies
these signs and symptoms: impaired
coordination, decreased muscle strength,
limited range of motion, and reluctance to
move. These signs and symptoms indicate
Process NCLEX
3000 (73
questions and
answers)
What is the most appropriate nursing
diagnosis for a client with acute pancreatitis?
- answer 1. Deficient fluid volume
A client is admitted with the following vital
signs: temperature, 102° F (38.9° C); heart
rate, 144 beats/minute and irregular; and
respiratory rate, 22 breaths/minute. Which
nursing diagnosis takes highest priority when
planning this client's care? - answer 1.
Decreased cardiac output
,The nurse is taking the health history of an
85-year-old client. Which information will be
most useful to the nurse for planning care? -
answer 2. Current health promotion
activities
Which aspect of drug therapy is most
important when planning nursing care for an
elderly client? - answer 3. Noncompliance
A client with acquired immunodeficiency
syndrome (AIDS) develops Pneumocystis
carinii pneumonia. Which nursing diagnosis
has the highest priority? - answer 1.
Impaired gas exchange
Which clinical characteristic affects client
compliance? - answer 3. The nurse-client
relationship
Which statement reflects appropriate
documentation in the medical record of a
hospitalized client? - answer 4. "Client's skin
is moist and cool."
, The nurse is changing a client's dressing.
Which observation of the wound warrants
immediate physician notification? - answer
2. Yellow, purulent drainage
A 65-year-old client comes to the physician's
office for a follow-up appointment after
having a basal cell lesion removed from his
face. The nurse teaches the client to inspect
his skin for signs of melanoma. For which
sign should the nurse tell him to look? -
answer 3. Black or purple irregularly shaped
nodules
The nurse assesses capillary refill in a client
admitted with pneumonia and dehydration.
Which capillary refill duration is considered
abnormal and should be reported? - answer
4. 4 seconds
When collecting data, the nurse identifies
these signs and symptoms: impaired
coordination, decreased muscle strength,
limited range of motion, and reluctance to
move. These signs and symptoms indicate
