PN & Nursing Process NCLEX Style Questions and Answers 100% correct 2023

PN & Nursing Process NCLEX Style Questions and Answers 100% correct 2023 A nurse is caring for a client with a lung disorder. Which nursing actions achieve the primary goal of nursing? Select all that apply. a.) Encouraging the client's healthy habits b.) Communicating with the client c.) Providing a non-individualized nursing care plan d.) Assisting the client in activities of daily living e.) Delaying the participation of the client's family Answer: a, b, d a.) Encouraging the client's healthy habits b.) Communicating with the client d.) Assisting the client in activities of daily living Place the steps of the nursing process in the correct order: Implementation Nursing assessment Nursing diagnosis Evaluation Planning 1.) Nursing assessment 2.) Nursing diagnosis 3.) Planning 4.) Implementation 5.) Evaluation The nurse obtains information regarding health problems from a newly admitted client and documents them systematically. Which step of the nursing process does the nurses' action represent? a.) Implementing care b.) Identifying the goal or plan c.) Evaluating the plan d.) Nursing assessment Answer: d d.) Nursing assessment A client who has met the short-term goals of treatment will be discharged the next day. The nurse is preparing a care plan for the client to meet long-term goals. What factor about the nursing care plan should the nurse keep in mind when preparing it? a.) Experimental b.) Task oriented c.) Generic d.) Client oriented Answer: d d.) Client oriented After measuring a client's vital signs, the nurse determines that the outcome of treatment being provided is not as expected. What nursing intervention should be performed? a.) Change to a trail and error method for solving the problem b.) Adopt a care plan devised for another client with similar challenges c.) Reassess, re-evaluate, and revise the nursing care plan d.) Implement existing care plan and manage adverse reactions Answer: c c.) Reassess, re-evaluate, and revise the nursing care plan The nurse delegates the task of measuring a clients' vital signs to an unlicensed assistive personnel. After receiving the vital signs, what will the nurse do with this data? Select all that apply. a.) Compare how the vital signs were measured. b.) Analyze the vital signs to determine which ones are of high importance. c.) Examine where the client was when the vital signs were assessed. d.) Determine the relationship of the vital signs obtained with the client's condition. e.) Analyze what equipment was used to measure the vital signs. Answer: b & d b.) Analyze the vital signs to determine which ones are of high importance. d.) Determine the relationship of the vital signs obtained with the client's condition. When caring for a client with neuropathic pain the nurse uses ice, heat, pillows, and position changes to try to help reduce the client's pain. The method the nurse is using to help this client is: a.) Critical thinking b.) Scientific method c.) Nursing process d.) Trail and error Answer: d d.) Trail and error Which step of the nursing process is the nurse implementing when identifying the statement of a client's potential and actual problem? a.) Nursing diagnosis b.) Implementation c.) Planning d.) Assessment Answer: a a.) Nursing diagnosis Before providing a client with a prescribe medication the nurse assesses the client's heart rate and blood pressure. This reassessment is an example of which characteristic of the nursing process? a.) Continuous b.) Nursing diagnosis c.) Implementation d.) Goal-oriented Answer: a a.) Continuous Which observation would indicate that interventions to help reduce a client's intake of sodium to control blood pressure have been effective? a.) The client states the importance of reading sodium content on food labels. b.) The client adds salt to the foods on the hospital tray before tasting. c.) The client uses a cane to ambulate safely in the room. d.) The client moves from a sitting to a standing position very slowly. Answer: a a.) The client states the importance of reading sodium content on food labels. A nurse is assigned to asses the condition of a client with hypertension , Which of the following steps for the nursing process should the nurse perform before she develops goals for care and possible activities to meet them? a.) Evaluation b.) Planning c.) Diagnosis d.) Implementation c.) Diagnosis When caring for a client with pneumonia , a nurse follows the nursing care plan ; however , the client is not progressing according to the plan which of the following is the most appropriate nursing intervention in this situation? Reassess, reevaluate and revise the nursing care plan. As part of the care for a client in a healthcare facility, the nurse needs to obtain the client's medical history. This activity comprises which step in the nursing process? Nursing assessment A nurse develops nursing care plans for 2 clients diagnosed with diabetes. One client has a medical history of hypertension. What is the single most appropriate reason for the nurse to prepare two different NCP? The nursing care plan is client-oriented A client is brought to the community health center in an emergency. Using the nursing process, the nurse has to perform an intervention while evaluation its effect and at the same time assessing another factor and planning priorities of what to do next. This method of functioning indicates which aspect of nursing process? It's dynamic nature When caring for a client, the nurse analyzes the client's responses. This action of scientific problem solving is related to which step in the nursing process? Evaluation A nurse who is caring for a particular client in a healthcare facility is leaving for the day. She is confident that the nurse on the next shift will not overlook any detail in the care of the client,. Which factor makes the nurse so confident? Nurses refer to the same care plan with providing care. What are advantages of adopting a nursing care plan? Helps the nurse avert painful complications for the client. Allows the nurse to develop critical thinking skills. Helps the nurse evaluate the nursing care provided. Why is critical thinking important in healthcare? It helps the nurse grasp the meaning of multiple clues. It helps the nurse examine and compare facts with available information. It helps the nurse find quick answers when facing difficult problems. Which step from the scientific problem solving method relate to planning? Formulate tentative solutions A client has been admitted to a healthcare facility and the nurse is conducting a health interview of the client. Which information should the nurse obtain from the client during the health interview? Select all that apply. a.) Type of upbringing of the client b.) Level of education of the client c.) Biographical data of the client d.) Reason for coming to the healthcare facility e.) Activities of daily living performed by the client Answer: c, d, e c.) Biographical data of the client d.) Reason for coming to the healthcare facility e.) Activities of daily living performed by the client The nurse is caring for a client with damage to the olfactory nerve. What intervention would the nurse include in the care plan for the client? a.) Remove trip hazard such as rugs b.) Assure call light is within reach c.) Provide adequate lighting d.) Monitor daily meal intake Answer: d d.) Monitor daily meal intake The nurse is preparing to conduct a health interview of a young adult client who has just been admitted to the healthcare facility for a stomach infection. Which point should the nurse keep in mind when conducting the client's health interview? a.) State that the interview is just a formality b.) Plan for the interview in advance c.) Ask indirect questions instead of direct questions d.) Talk to the client's family before conducting the interview Answer: b b.) Plan for the interview in advance A nurse has conducted the admission interview of a client and assisted in physical examination. Which point should the nurse keep in mind during data analysis? a.) Treat each piece of information individually in isolation. b.) Use critical thinking skills during data collection, not during data analysis. c.) Use critical thinking skills to identify the relevancy of the information obtained. d.) Preserve data collected by not adding new information. Answer: c c.) Use critical thinking skills to identify the relevancy of the information obtained. A client arrives at community health center complaining of abdominal pain. The nurse is required to assess the client. Which is the most appropriate nursing intervention the nurse should perform after the data have been collected and analyzed? a.) Do not do anything until more information is gathered from the client. b.) Provide client referrals to appropriate support groups. c.) Recommend a balanced diet and other health promotional activities. d.) Notify the primary healthcare providers of assessment data. Answer: d d.) Notify the primary healthcare providers of assessment data. The nurse is documenting objective data regarding a client. Which would be considered objective data? a.) Client seems happy with family visit b.) Family appear supportive of client c.) Respirations 16 breaths per minute d.) Pain in left ankle rated at "6" out of 10 Answer: c c.) Respirations 16 breaths per minute The nurse is preparing to complete a health interview with a newly admitted client. Upon entering the room, the nurse notes the client is unable to respond to questions due to chronic dementia and has two adult sons at the bedside. What is the best action of the nurse? a.) Return at the end of the shift to complete the health interview with the cilent. b.) Notify the provider the client is unable to be interviewed and ask the provider to supply the information needed. c.) Document the client cannot respond to health interview questions and continue on with the physical assessment. d.) Ask the family to assist in gathering information needed for the interview. Answer: d d.) Ask the family to assist in gathering information needed for the interview. During the health interview, the client indicates having heart surgery 4 years prior. The nurse notes the absence of a scar on the client during the physical assessment. The nurse would take which action? a.) Validate the data by asking the client a more specific question. b.) Document the absence of a scar. c.) Notify the provider to determine the truth d.) Document that client is telling untruths to the staff Answer: a a.) Validate the data by asking the client a more specific question. The nurse assesses the following data on a client. No BM in 72 hours, abdominal pain and bloating, pulse rate 82, intake of 2100 mL last 24 hours, walks with assist of a cane and reports allergies to poison ivy plants. When the nurse clusters this data, the nurse will address which concern? a.) Bowel elimination b.) Social isolation c.) Fluid imbalance d.) Cardiac muscle function Answer: a a.) Bowel elimination The nurse is assessing the client and determines a nursing diagnosis of Risk for falls related to weakness and unsteady gait. Which data would the nurse include as the "as evidence by" portion of the nursing diagnosis? Select all that apply. a.) The client uses a walker to assist with ambulation b.) The client has a history of a stroke with left sided weakness c.) The client states "I will need help getting out of bed...I am so weak." d.) The client was admitted to the facility 3 weeks ago e.) The client wear bilateral hearing aids and uses a magnifier to read the newspaper. Answer: a, b, c a.) The client uses a walker to assist with ambulation b.) The client has a history of a stroke with left sided weakness c.) The client states "I will need help getting out of bed...I am so weak." During the nursing assessment, the client complains of a lower abdominal pain. Which is the most appropriate nursing action in this situation? Determine whether the client has the necessary strength to cope with the problem A nurse is collecting data on a client's health history. The client's family members are also present. Which intervention should the nurse perform when collecting data regarding the client's medical history? Consult other members of the healthcare team for their analysis of client data A client arrives at a community healthcare center with a wound on his leg as a result of an accident. Which information about the client's condition should the nurse classify as objective data? Size and color of the wound A nurse is monitoring the progress of an Asian client on drug therapy. Which point should the nurse consider when collecting subjective data regarding the client and her response to the therapy? Assess the client's body language and gestures A nurse is assessing a client who has undergone surgery. During the assessment, the nurse observes that the client's skin feels warm; therefore, the nurse measures the client's body temperature. Which type of observation did the nurse make before taking the client's temperature with a thermometer? Tactile observation A nurse is caring for a client who appears to have responded well to the treatment but is looking pale as a result of being confined indoors for the duration of the treatment. When the nurse asked the client how she feels, the client grimaces slightly and responds with an "OK." On further questioning, the nurse finds out that the client is feeling nauseated and has abdominal pain. Which aspect of visual observation did the nurse employ in this case? Facial expression Which is a responsibility of the registered nurse during the admission interview of a client being admitted to a healthcare facility? Work with the team to formulate a nursing diagnosis and plan of care A nurse is collecting data about a client who has been admitted with an ear infection. Which of the following questions should the nurse ask himself as part of the critical thinking skills used to collect objective data? 1. What do the current and previous laboratory reports reveal about the client's condition? 2. What do the healthcare provider's history and progress notes indicate about the client's condition?3. 3. What do the client's vital signs reveal about the client's condition? A nurse is caring for a client with gastrointestinal problems. Which of the following questions should the nurse ask herself to obtain subjective data about the client? Select all that apply 1. What does the client say is the reason for coming to the healthcare facility? 2. Do the client's words and behaviors say the same thing? 3. How is the client coping with the immediate environment? A nurse has conducted the health interview of a client. Which of the following types of information forms a part of the activities of daily living (ADL) section of the nursing history? Select all that apply 1. Sleep patterns of the client 2. Typical diet of the client 3. Exercise regimen followed by the client A nurse is formulating the care plan for a client, prescribes a new respiratory medication and includes a nursing diagnosis of "knowledge deficit related to new prescription medication." What short-term goal would be appropriate for this client? Select all that apply. a.) The nurse will teach the client the side effects of the medication with the first dose b.) The client will not fall or have injuries during admission at the healthcare facility. c.) The client will verbalize the appropriate medication dose within 24 hours d.) The client will verbalize the medication name and purpose within 24 hours e.) The client will demonstrate proper medication administration techniques within 24 hours Answer: c, d, e c.) The client will verbalize the appropriate medication dose within 24 hours d.) The client will verbalize the medication name and purpose within 24 hours e.) The client will demonstrate proper medication administration techniques within 24 hours A nurse is preparing he nursing care plan of a client who had been admitted 5 hours before. Which point should the nurse keep in mind when writing a nursing care plan? a.) Summarize the client's medical history in the nursing care plan b.) Do not make changes to the plan for the duration of the treatment c.) Write the nursing care plan after the nursing care conference d.) The nursing care plan should primarily include only nursing orders Answer: c c.) Write the nursing care plan after the nursing care conference A nurse is formulating the nursing diagnosis of a client who has developed rashes on her skin as a result of an allergy. The nursing facility where the nurse is working requires a three-part statement including the etiology. Which is the most appropriate etiology? a.) "Development of rashes on skin" b.) "Constant feeling of itching" c.) "Soreness near affected area" d.) "Adverse allergic reaction" Answer: d d.) "Adverse allergic reaction" A nurse has prepared a list of nursing diagnoses of a client with respiratory complications. For which diagnosis should the nurse give the highest priority? a.) Activity intolerance b.) Anxiety c.) Ineffective airway clearance d.) Disturbed body image Answer: c c.) Ineffective airway clearance A client is being evaluated at a healthcare facility due to a chicken bone lodged in the client's throat. The client is coughing regularly and drooling but is not experiencing any pain, except when swallowing. Which is an example of a correct diagnostic statement? a.) Throat pain R/T bone lodged in throat b.) Constant drooling R/T foreign object lodged in throat c.) Complication arising out of foreign object lodged in throat d.) Risk of choking R/T foreign object in throat AEB drooling and constant coughing Answer: d d.) Risk of choking R/T foreign object in throat AEB drooling and constant coughing