NCLEX -NURSING PROCESS QUESTIONS &
ANSWERS
During which part of the client interview would it be best for the nurse to ask, "What's
the weather forecast for today?"
A. Introduction
B. Body
C. Closing
D. Orientation - Answers -A. Introduction
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?"
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?"
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
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
, Which of these is a correctly stated outcome goal written by the nurse?
A. The client will walk 2 miles daily by March 19
B. The client will understand how to give insulin by discharge
C. The client will regain their former state of health by April 1
D. The client achieve desired mobility by May 7 - Answers -A. The client will walk 2
miles daily by March 19
The nursing diagnosis is Risk for impaired skin integrity related to immobility and
pressure secondary to pain and presence of a cast. Which of the following desired
outcomes should the nurse include in the care plan?
A. Client will be able to turn self by day 3
B. Skin will remain intact and without redness during hospital stay
C. Client will state pain relieved within 30 minutes after medication
D. Pressure will be prevented by repositioning client every 2 hours - Answers -B. Skin
will remain intact and without redness during hospital stay
While assisting a client from bed to chair, the nurse observes that the client looks pale
and is beginning to perspire heavily. The nurse would then do which of the following
activities as a reassessment?
A. Help client into the chair but more quickly
B. Document client's vital signs taken just prior to moving the client
C. Help client back to bed immediately
D. Observe client's skin color and take another set of vital signs - Answers -D. Observe
client's skin color and take another set of vital signs
After instructing the client on crutch walking technique, the nurse should evaluate the
client's understanding by using which of the following methods?
A. Return demonstration
B. Explanation
C. Achievement of 90 on written test
D. Have client explain produce to the family - Answers -A. Return demonstration
The nurse would do which of the following during the implementation phase of the
nursing process when working with a hospitalized adult?
A. Formulate a nursing diagnosis of impaired gas exchange
B. Record in the medical record the distance a client ambulate in the hall
C. Write individualized nursing orders in the care plan
D. Compare client responses to the desired outcomes for pain relief - Answers -B.
Record in the medical record the distance a client ambulate in the hall
ANSWERS
During which part of the client interview would it be best for the nurse to ask, "What's
the weather forecast for today?"
A. Introduction
B. Body
C. Closing
D. Orientation - Answers -A. Introduction
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?"
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?"
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
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
, Which of these is a correctly stated outcome goal written by the nurse?
A. The client will walk 2 miles daily by March 19
B. The client will understand how to give insulin by discharge
C. The client will regain their former state of health by April 1
D. The client achieve desired mobility by May 7 - Answers -A. The client will walk 2
miles daily by March 19
The nursing diagnosis is Risk for impaired skin integrity related to immobility and
pressure secondary to pain and presence of a cast. Which of the following desired
outcomes should the nurse include in the care plan?
A. Client will be able to turn self by day 3
B. Skin will remain intact and without redness during hospital stay
C. Client will state pain relieved within 30 minutes after medication
D. Pressure will be prevented by repositioning client every 2 hours - Answers -B. Skin
will remain intact and without redness during hospital stay
While assisting a client from bed to chair, the nurse observes that the client looks pale
and is beginning to perspire heavily. The nurse would then do which of the following
activities as a reassessment?
A. Help client into the chair but more quickly
B. Document client's vital signs taken just prior to moving the client
C. Help client back to bed immediately
D. Observe client's skin color and take another set of vital signs - Answers -D. Observe
client's skin color and take another set of vital signs
After instructing the client on crutch walking technique, the nurse should evaluate the
client's understanding by using which of the following methods?
A. Return demonstration
B. Explanation
C. Achievement of 90 on written test
D. Have client explain produce to the family - Answers -A. Return demonstration
The nurse would do which of the following during the implementation phase of the
nursing process when working with a hospitalized adult?
A. Formulate a nursing diagnosis of impaired gas exchange
B. Record in the medical record the distance a client ambulate in the hall
C. Write individualized nursing orders in the care plan
D. Compare client responses to the desired outcomes for pain relief - Answers -B.
Record in the medical record the distance a client ambulate in the hall
