NCLEX NURSING PROCESS QUESTIONS AND
ANSWERS
The nurse is most likely to collect timely, specific information by asking which of the
following questions?
A. "Would you describe what you are feeling?"
B. "How are you today?"
C. "What would you like to talk about?"
D. "Where does it hurt?" - Answers -A. "Would you describe what you are feeling?"
Rationale: This is an open-ended question that will elicit subjective data. The data
collected will reflect the client's current health status and human response(s) and should
generate specific information that can be used to identify actual and/or potential health
problems. Options 2 and 3 are more likely to elicit general, nonspecific information.
Option 4 may result in a brief, one-word response or nonverbal gesture indicating the
site of the client's pain. A better approach to collect specific information might be,
"Describe any pain you are having."
The nurse should avoid asking the client which of the following leading questions during
a client interview?
A. "What medication do you take at home?"
B. "You are really excited about the plastic surgery, aren't you?"
C. "Were you aware I've has this same type of surgery?"
D. "What would you like to talk about?" - Answers -B. "You are really excited about the
plastic surgery, aren't you?"
Rationale: A leading question directs the client's answer. The phrasing of the question
indicates an expected answer. The client may be influenced by the nurse's expectations
and may give inaccurate responses. This process can result in an error in diagnostic
reasoning.
The nurse needs to validate which of the following statements pertaining to an assigned
client?
A. The client has a hard, raised, red lesion on his right hand.
B. A weight of 185 lbs. is recorded in the chart
C. The client reported an infected toe
D. The client's blood pressure is 124/70. It was 118/68 yesterday. - Answers -C. The
client reported an infected tow
Rationale: Validation is the process of confirming that data are actual and factual. Data
that can be measured can be accepted as factual, as in options 1, 3 and 4. The nurse
should assess the client's toe to validate the statement.
, Which of the following items of subjective client data would be documented in the
medical record by the nurse?
A. Client's face is pale
B. Cervical lymph nodes are palpable
C. Nursing assistant reports client refused lunch
D. Client feel nauseated - Answers -D. Client feel nauseated
Rationale: Subjective data includes the client's sensations, feelings, and perception of
health status. Subjective data can only be verified by the affected person. Options 1, 2,
and 3 represent objective data that can be detected by the nurse or measured against
an accepted norm.
Which desired outcome written by the nurse is correctly written and measurable?
A. Client will have a normal bowel pattern by April 2
B. The client will lose 4 lbs. within next 2 weeks
C. The nurse will provide skin care at least 3 times each day
D. The client will breathe better after resting for 10 minutes - Answers -B. The client will
lose 4 lbs. within next 2 weeks
Rationale: An outcome statement must describe the observable client behavior that
should occur in response to the nursing interventions. It consists of a subject, action
verb, conditions under which the behavior is to be performed, and the level at which the
client will perform the desired behavior. Each of the incorrect options lacks one of these
required elements. Option 1 is not measurable. Option 3 is a nursing goal rather than a
client goal. Option 4 does not include the level at which the behavior should be
performed.
The rehabilitation nurse wishes to make the following entry into a client's plan of care:
"Client will reestablish a pattern of daily bowel movements without straining within two
months." The nurse would write this statement under which section of the plan of care?
A. Nursing diagnosis/problem list
B. Nursing orders
C. Short-term goals
D. Long-term goals - Answers -D. Long-term goals
Rationale: Long-term goals describe changes in client behavior expected over a time
frame greater than one week. They are usually designed to restore normal functioning
in a problem area and are helpful to other healthcare workers who care for the client,
often in a variety of settings.
Which of these is a correctly stated outcome goal written by the nurse?
ANSWERS
The nurse is most likely to collect timely, specific information by asking which of the
following questions?
A. "Would you describe what you are feeling?"
B. "How are you today?"
C. "What would you like to talk about?"
D. "Where does it hurt?" - Answers -A. "Would you describe what you are feeling?"
Rationale: This is an open-ended question that will elicit subjective data. The data
collected will reflect the client's current health status and human response(s) and should
generate specific information that can be used to identify actual and/or potential health
problems. Options 2 and 3 are more likely to elicit general, nonspecific information.
Option 4 may result in a brief, one-word response or nonverbal gesture indicating the
site of the client's pain. A better approach to collect specific information might be,
"Describe any pain you are having."
The nurse should avoid asking the client which of the following leading questions during
a client interview?
A. "What medication do you take at home?"
B. "You are really excited about the plastic surgery, aren't you?"
C. "Were you aware I've has this same type of surgery?"
D. "What would you like to talk about?" - Answers -B. "You are really excited about the
plastic surgery, aren't you?"
Rationale: A leading question directs the client's answer. The phrasing of the question
indicates an expected answer. The client may be influenced by the nurse's expectations
and may give inaccurate responses. This process can result in an error in diagnostic
reasoning.
The nurse needs to validate which of the following statements pertaining to an assigned
client?
A. The client has a hard, raised, red lesion on his right hand.
B. A weight of 185 lbs. is recorded in the chart
C. The client reported an infected toe
D. The client's blood pressure is 124/70. It was 118/68 yesterday. - Answers -C. The
client reported an infected tow
Rationale: Validation is the process of confirming that data are actual and factual. Data
that can be measured can be accepted as factual, as in options 1, 3 and 4. The nurse
should assess the client's toe to validate the statement.
, Which of the following items of subjective client data would be documented in the
medical record by the nurse?
A. Client's face is pale
B. Cervical lymph nodes are palpable
C. Nursing assistant reports client refused lunch
D. Client feel nauseated - Answers -D. Client feel nauseated
Rationale: Subjective data includes the client's sensations, feelings, and perception of
health status. Subjective data can only be verified by the affected person. Options 1, 2,
and 3 represent objective data that can be detected by the nurse or measured against
an accepted norm.
Which desired outcome written by the nurse is correctly written and measurable?
A. Client will have a normal bowel pattern by April 2
B. The client will lose 4 lbs. within next 2 weeks
C. The nurse will provide skin care at least 3 times each day
D. The client will breathe better after resting for 10 minutes - Answers -B. The client will
lose 4 lbs. within next 2 weeks
Rationale: An outcome statement must describe the observable client behavior that
should occur in response to the nursing interventions. It consists of a subject, action
verb, conditions under which the behavior is to be performed, and the level at which the
client will perform the desired behavior. Each of the incorrect options lacks one of these
required elements. Option 1 is not measurable. Option 3 is a nursing goal rather than a
client goal. Option 4 does not include the level at which the behavior should be
performed.
The rehabilitation nurse wishes to make the following entry into a client's plan of care:
"Client will reestablish a pattern of daily bowel movements without straining within two
months." The nurse would write this statement under which section of the plan of care?
A. Nursing diagnosis/problem list
B. Nursing orders
C. Short-term goals
D. Long-term goals - Answers -D. Long-term goals
Rationale: Long-term goals describe changes in client behavior expected over a time
frame greater than one week. They are usually designed to restore normal functioning
in a problem area and are helpful to other healthcare workers who care for the client,
often in a variety of settings.
Which of these is a correctly stated outcome goal written by the nurse?
