NURSING PROCESS/DIAGNOSES
PRACTICE TEST (NCLEX STYLE) WITH
RATIONALE /PASS GUIDE /GRADED A+
A female client who received general anesthesia returns from surgery.
Postoperatively, which nursing diagnosis takes highest priority for this client?
A. Acute pain R/T surgery
B. Deficient fluid volume R/T blood and fluid loss from surgery
C. Impaired physical mobility R/T surgery
D. Risk for aspiration R/T anesthesia - ANS ✅✅-Answer: D
Rationale- Risk for aspiration takes priority because general anesthesia may
impair gag and swallow reflexes. The other options, although important, are
secondary to this.
A female patient is diagnosed with deep-vein thrombosis. Which nursing
diagnosis should receive the highest priority at this time?
A. Impaired gas exchange related to increased blood flow
B. Fluid volume excess related to peripheral vascular disease
C. Risk for injury related to edema
D. Altered peripheral tissue perfusion related to venous congestion - ANS
✅✅-Answer: D
Rationale: This answer takes highest priority because venous inflammation
and clot formation impede blood flow in a patient with deep-vein thrombosis.
, Option A is incorrect because impaired gas exchange is related to decreased,
not increased, blood flow. Option B is inappropriate because no evidence
suggests that this patient has a fluid volume excess. Option C may be
warranted but is secondary to altered tissue perfusion
A male client is admitted to the hospital with blunt chest trauma after a
motor vehicle accident. The first nursing priority for this client would be to:
A. Assess the client's airway
B. Provide pain relief
C. Encourage deep breathing and coughing
D. Splint the chest wall with a pillow - ANS ✅✅-Answer: A
Rationale- The first priority is to evaluate airway patency. Pain management
and splinting are important for client comfort, but come after an airway
assessment. Coughing and deep breathing may be contraindicated if the
client has internal bleeding and other injuries.
A nurse is assigned to care for a postoperative male client who has diabetes
mellitus. During the assessment interview, the client reports that he's
impotent and says he's concerned about the effect on his marriage. In
planning this client's care, the most appropriate intervention would be to:
A. Encourage the client to ask questions about personal sexuality
B. Provide time for privacy
C. Suggest referral to a sex counselor or other appropriate professional
D. Provide support for the spouse - ANS ✅✅-Answer: C
PRACTICE TEST (NCLEX STYLE) WITH
RATIONALE /PASS GUIDE /GRADED A+
A female client who received general anesthesia returns from surgery.
Postoperatively, which nursing diagnosis takes highest priority for this client?
A. Acute pain R/T surgery
B. Deficient fluid volume R/T blood and fluid loss from surgery
C. Impaired physical mobility R/T surgery
D. Risk for aspiration R/T anesthesia - ANS ✅✅-Answer: D
Rationale- Risk for aspiration takes priority because general anesthesia may
impair gag and swallow reflexes. The other options, although important, are
secondary to this.
A female patient is diagnosed with deep-vein thrombosis. Which nursing
diagnosis should receive the highest priority at this time?
A. Impaired gas exchange related to increased blood flow
B. Fluid volume excess related to peripheral vascular disease
C. Risk for injury related to edema
D. Altered peripheral tissue perfusion related to venous congestion - ANS
✅✅-Answer: D
Rationale: This answer takes highest priority because venous inflammation
and clot formation impede blood flow in a patient with deep-vein thrombosis.
, Option A is incorrect because impaired gas exchange is related to decreased,
not increased, blood flow. Option B is inappropriate because no evidence
suggests that this patient has a fluid volume excess. Option C may be
warranted but is secondary to altered tissue perfusion
A male client is admitted to the hospital with blunt chest trauma after a
motor vehicle accident. The first nursing priority for this client would be to:
A. Assess the client's airway
B. Provide pain relief
C. Encourage deep breathing and coughing
D. Splint the chest wall with a pillow - ANS ✅✅-Answer: A
Rationale- The first priority is to evaluate airway patency. Pain management
and splinting are important for client comfort, but come after an airway
assessment. Coughing and deep breathing may be contraindicated if the
client has internal bleeding and other injuries.
A nurse is assigned to care for a postoperative male client who has diabetes
mellitus. During the assessment interview, the client reports that he's
impotent and says he's concerned about the effect on his marriage. In
planning this client's care, the most appropriate intervention would be to:
A. Encourage the client to ask questions about personal sexuality
B. Provide time for privacy
C. Suggest referral to a sex counselor or other appropriate professional
D. Provide support for the spouse - ANS ✅✅-Answer: C
