NURSING PROCESS NCLEX UPDATED QUESTIONS AND
ANSWERSFORFINAL EXAM2025
Which intervention should the nurse include in the plan of care to ensure adequate nutrition for a
very active, talkative, and easily distractible client who is unable to sit through meals? - ANSWER-
Offer the client nutritious finger foods.
A client experienced the loss of home and beloved family dog in flood waters 4 months ago. The client
states that since the loss, the client finds it hard to "feel anything." The client says they can't
concentrate on simple tasks, thinks about the flood incessantly, and fears losing control. The client
reports becoming extremely anxious whenever the flood is mentioned and must leave the room if
people talk about it. The admitting nurse suspects the client has post-traumatic stress disorder (PTSD).
Which nursing goal would be most appropriate for this client? - ANSWER-The client will demonstrate
progress in dealing with the grief of losing their home and dog.
The nurse is administering oxygen by face mask to a client. Which action will the nurse include? -
ANSWER-Assist the client to the semi-Fowler's position if possible.
A nurse is caring for a client with schizotypal personality disorder with impaired verbal
communication. Which nursing intervention is the priority? - ANSWER-establishing a one-on-one
relationship with the client; By establishing a one-on-one relationship, the nurse helps the client learn
how to interact with people in new situations. Helping the client participate in social interactions,
establishing alternative forms of communication, and allowing the client to decide when to
communicate are appropriate but should take place only after the nurse-client relationship has been
established.
At birth, a neonate weighs 7 lb, 3 oz (3,267 g). When assessing the neonate 1 day later, the nurse
obtains a weight of 7 lb (3,182 g) and an axillary temperature of 98° F (36.7° C) and notes that the
sclerae are slightly yellow. The neonate has been breast-feeding once every 2 to 3 hours. Based on
these findings, the nurse should add which nursing diagnosis to the care plan? - ANSWER-risk for
injury related to hyperbilirubinemia
An adolescent is brought to the emergency department (ED) after accidentally taking an overdose of
heroin. The adolescent is semiconscious, unable to respond appropriately to questions, slurs words,
and has constricted pupils; the client's vital signs are blood pressure 60/50 mm Hg, pulse 50
beats/min, and respirations 8 breaths/min. Naloxone is administered to temporarily reverse the
effects of the heroin. Which finding would first indicate that the naloxone administration has been
effective? - ANSWER-The client's respirations improve to 12/min.
A client is recovering from a gastric resection for peptic ulcer disease. Which outcome indicates that
the goal of adequate nutritional intake is being achieved 3 weeks following surgery? The client: -
ANSWER-increases food intake and tolerance gradually.
The client has come to the hospital emergency room reporting lethargy and vomiting. The healthcare
provider makes a tentative diagnosis of Reye's syndrome. The client's history reveals a recent acute
viral infection and the use of several medications. The nurse suspects which medication to be
implicated in the development of Reye's syndrome? - ANSWER-aspirin; Aspirin is implicated in the
development of Reye's syndrome in children with a history of recent acute viral infection.
A nurse is preparing for the discharge of a neonate born 7 weeks premature. The neonate has had
several apneic episodes and will need a home apnea monitor but will require no other specialized
care. Which nursing diagnosis is most appropriate for the neonate's parents? - ANSWER-Deficient
knowledge related to lack of exposure to apnea monitor.
, The nurse is preparing a client for a thoracentesis. How should the nurse position the client for the
procedure? - ANSWER-Sitting forward with the arms supported on the bedside table.
The nurse is teaching an unlicensed assistive personnel (UAP) about the care of clients with self-
mutilation. Which statement by the UAP would indicate teaching about self-mutilation has been
effective? - ANSWER-"It's a way to express anger and rage."
The client with hepatitis A is experiencing fatigue, weakness, and a general feeling of malaise. The
client tires rapidly during morning care. What is the most appropriate goal for this client? - ANSWER-
Gradually increase activity tolerance.
The nurse is caring for a client with a blood pressure of 210/94 mm Hg. The health care provider
prescribes enalapril 20 mg b.i.d. Which nursing action is best when instructing on the new medication
regimen? - ANSWER-State the new medication, including name, use, and reason for the new
medication.
A nurse works with a client diagnosed with bulimia. What is the most appropriate long-term client
goal for this client? - ANSWER-Manage stresses in life without binging or purging.
What short-term goal for a client hospitalized with a stress related disorder is most realistic? -
ANSWER-The client will write a list of strengths and needs; Writing a list of strengths and needs is
short-term, achievable, and measurable. Achieving positive self-esteem would occur over the long
term. Going to school involves complex future steps to a long-term goal. Using skills is likely to be
stressful and is best attempted after the client has done a self-assessment.
A nurse is reviewing arterial blood gas results on an assigned client. The pH is 7.32 with PCO2 of 49
mm Hg and a HCO3−of 28 mEq/L. The nurse reports to the physician which finding? - ANSWER-
respiratory acidosis
A client is admitted to an inpatient psychiatric unit. After the assessment and admission procedures
have been completed, the nurse states, "I'll try to be available to talk with you when needed and will
spend time with you each morning from 10:00 until 10:30 in the corner of the dayroom." What is the
rationale for communicating these planned nursing interventions? - ANSWER-To attempt to establish
a trusting relationship; Availability, reliability, and consistency are critical factors in establishing trust
with a client. Being specific about the time and place of meetings helps establish trust, which is
initially the main objective. Although important, structuring the environment and instilling hope
aren't the primary tasks at this time. Arranging a regular meeting with the client allows the nurse to
plan the workload but isn't the major reason for such scheduling.
Which performance improvement strategy helps prevent adverse reactions to blood products? -
ANSWER-confirming client identification with two qualified health professionals; The client must be
correctly identified to prevent a life-threatening adverse blood reaction. Obtaining vital signs,
instructing the client about the signs and symptoms of a blood reaction, and priming the blood
administration tubing with normal saline solution are key steps in the blood administration procedure;
however, they don't prevent adverse reactions.
For a client with rib fractures and a pneumothorax, the health care provider (HCP) prescribes
morphine sulfate, 1 to 2 mg/h, given IV as needed for pain. The nursing care goal is to provide
adequate pain control so that the client can breathe effectively. Which finding indicates the goal has
been met? - ANSWER-pain rating of 0 on a scale of 0 to 10 by the client
A nurse is caring for a client immediately following an appendectomy. The nurse should assign which
nursing diagnosis the highest priority? - ANSWER-Acute pain
ANSWERSFORFINAL EXAM2025
Which intervention should the nurse include in the plan of care to ensure adequate nutrition for a
very active, talkative, and easily distractible client who is unable to sit through meals? - ANSWER-
Offer the client nutritious finger foods.
A client experienced the loss of home and beloved family dog in flood waters 4 months ago. The client
states that since the loss, the client finds it hard to "feel anything." The client says they can't
concentrate on simple tasks, thinks about the flood incessantly, and fears losing control. The client
reports becoming extremely anxious whenever the flood is mentioned and must leave the room if
people talk about it. The admitting nurse suspects the client has post-traumatic stress disorder (PTSD).
Which nursing goal would be most appropriate for this client? - ANSWER-The client will demonstrate
progress in dealing with the grief of losing their home and dog.
The nurse is administering oxygen by face mask to a client. Which action will the nurse include? -
ANSWER-Assist the client to the semi-Fowler's position if possible.
A nurse is caring for a client with schizotypal personality disorder with impaired verbal
communication. Which nursing intervention is the priority? - ANSWER-establishing a one-on-one
relationship with the client; By establishing a one-on-one relationship, the nurse helps the client learn
how to interact with people in new situations. Helping the client participate in social interactions,
establishing alternative forms of communication, and allowing the client to decide when to
communicate are appropriate but should take place only after the nurse-client relationship has been
established.
At birth, a neonate weighs 7 lb, 3 oz (3,267 g). When assessing the neonate 1 day later, the nurse
obtains a weight of 7 lb (3,182 g) and an axillary temperature of 98° F (36.7° C) and notes that the
sclerae are slightly yellow. The neonate has been breast-feeding once every 2 to 3 hours. Based on
these findings, the nurse should add which nursing diagnosis to the care plan? - ANSWER-risk for
injury related to hyperbilirubinemia
An adolescent is brought to the emergency department (ED) after accidentally taking an overdose of
heroin. The adolescent is semiconscious, unable to respond appropriately to questions, slurs words,
and has constricted pupils; the client's vital signs are blood pressure 60/50 mm Hg, pulse 50
beats/min, and respirations 8 breaths/min. Naloxone is administered to temporarily reverse the
effects of the heroin. Which finding would first indicate that the naloxone administration has been
effective? - ANSWER-The client's respirations improve to 12/min.
A client is recovering from a gastric resection for peptic ulcer disease. Which outcome indicates that
the goal of adequate nutritional intake is being achieved 3 weeks following surgery? The client: -
ANSWER-increases food intake and tolerance gradually.
The client has come to the hospital emergency room reporting lethargy and vomiting. The healthcare
provider makes a tentative diagnosis of Reye's syndrome. The client's history reveals a recent acute
viral infection and the use of several medications. The nurse suspects which medication to be
implicated in the development of Reye's syndrome? - ANSWER-aspirin; Aspirin is implicated in the
development of Reye's syndrome in children with a history of recent acute viral infection.
A nurse is preparing for the discharge of a neonate born 7 weeks premature. The neonate has had
several apneic episodes and will need a home apnea monitor but will require no other specialized
care. Which nursing diagnosis is most appropriate for the neonate's parents? - ANSWER-Deficient
knowledge related to lack of exposure to apnea monitor.
, The nurse is preparing a client for a thoracentesis. How should the nurse position the client for the
procedure? - ANSWER-Sitting forward with the arms supported on the bedside table.
The nurse is teaching an unlicensed assistive personnel (UAP) about the care of clients with self-
mutilation. Which statement by the UAP would indicate teaching about self-mutilation has been
effective? - ANSWER-"It's a way to express anger and rage."
The client with hepatitis A is experiencing fatigue, weakness, and a general feeling of malaise. The
client tires rapidly during morning care. What is the most appropriate goal for this client? - ANSWER-
Gradually increase activity tolerance.
The nurse is caring for a client with a blood pressure of 210/94 mm Hg. The health care provider
prescribes enalapril 20 mg b.i.d. Which nursing action is best when instructing on the new medication
regimen? - ANSWER-State the new medication, including name, use, and reason for the new
medication.
A nurse works with a client diagnosed with bulimia. What is the most appropriate long-term client
goal for this client? - ANSWER-Manage stresses in life without binging or purging.
What short-term goal for a client hospitalized with a stress related disorder is most realistic? -
ANSWER-The client will write a list of strengths and needs; Writing a list of strengths and needs is
short-term, achievable, and measurable. Achieving positive self-esteem would occur over the long
term. Going to school involves complex future steps to a long-term goal. Using skills is likely to be
stressful and is best attempted after the client has done a self-assessment.
A nurse is reviewing arterial blood gas results on an assigned client. The pH is 7.32 with PCO2 of 49
mm Hg and a HCO3−of 28 mEq/L. The nurse reports to the physician which finding? - ANSWER-
respiratory acidosis
A client is admitted to an inpatient psychiatric unit. After the assessment and admission procedures
have been completed, the nurse states, "I'll try to be available to talk with you when needed and will
spend time with you each morning from 10:00 until 10:30 in the corner of the dayroom." What is the
rationale for communicating these planned nursing interventions? - ANSWER-To attempt to establish
a trusting relationship; Availability, reliability, and consistency are critical factors in establishing trust
with a client. Being specific about the time and place of meetings helps establish trust, which is
initially the main objective. Although important, structuring the environment and instilling hope
aren't the primary tasks at this time. Arranging a regular meeting with the client allows the nurse to
plan the workload but isn't the major reason for such scheduling.
Which performance improvement strategy helps prevent adverse reactions to blood products? -
ANSWER-confirming client identification with two qualified health professionals; The client must be
correctly identified to prevent a life-threatening adverse blood reaction. Obtaining vital signs,
instructing the client about the signs and symptoms of a blood reaction, and priming the blood
administration tubing with normal saline solution are key steps in the blood administration procedure;
however, they don't prevent adverse reactions.
For a client with rib fractures and a pneumothorax, the health care provider (HCP) prescribes
morphine sulfate, 1 to 2 mg/h, given IV as needed for pain. The nursing care goal is to provide
adequate pain control so that the client can breathe effectively. Which finding indicates the goal has
been met? - ANSWER-pain rating of 0 on a scale of 0 to 10 by the client
A nurse is caring for a client immediately following an appendectomy. The nurse should assign which
nursing diagnosis the highest priority? - ANSWER-Acute pain
