"NCLEX" - Type Nursing Process, Exam Questions
and Correct Answers With Rationale. 2024/2025.
(Answer: ) B
(Rationale- The nurse identifies human responses to actual or potential health
problems during the nursing diagnoses step of the nursing process. During the
assessment step, the nurse collects data. During the planning step, the nurse
develops strategies to resolve or decrease the patient's problem. During
evaluation, the nurse determines the effectiveness of the plan of care.)
The nurse in charge identifies a patient's responses to actual or potential health
problems during which step of the nursing process?
A. Assessing
B. Diagnosing
C. Planning
D. Evaluating
(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 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
(Answer: ) D
(Rationale: During the evaluation step of the nursing process the nurse
determines whether the goals established have been achieved, and evaluates the
success of the plan. Answer A involves data collection. Answer B involves
setting priorities, and Answer C is the actual intervention.)
A nurse is revising a client's care plan. During which step of the nursing process does
such a revision take place?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
,(Answer: ) D
(Rationale: You should begin with the simplest interventions. Answer A is
incorrect because medications should be avoided whenever possible. Answer B
would be a thorough sleep assessment, and should be done only after common
sense interventions fail. Answer C would be appropriate only after common
sense interventions fail.)
Which intervention should the nurse in charge try first for a client that exhibits signs of
sleep disturbance?
A. Administer sleeping medication before bedtime
B. Ask the client each morning to describe the quantity of sleep the night before
C. Teach the client relaxation techniques, such as guided imagery and progressive
muscle relaxation
D. Provide the client normal sleep aids, such as pillows, back rubs, and snacks
(Answer: ) C
(Rationale- Making appropriate referrals is a valid part of planning the client's
care. The nurse normally does not provide sex counseling. While providing time
for privacy and providing support for the spouse is important, it is not as
important as referring the client to a sex counselor/appropriate professional)
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
(Answer: ) A
(Rationale - According to Maslow, elimination is a first-level or physiological
need. Security and safety are second-level needs, and belonging is a third-level
need.)
Using Maslow's hierarchy of needs, a nurse assigns the highest priority to which client
need?
A. Elimination
B. Security
C. Safety
D. Belonging
(Answer: ) A
(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 client who received general anesthesia returns from surgery. Postoperatively,
which nursing diagnosis takes highest priority for this client?
A. Risk for aspiration R/T anesthesia
B. Deficient fluid volume R/T blood and fluid loss from surgery
C. Impaired physical mobility R/T surgery
D. Acute pain R/T surgery
(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 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
(Answer: ) C
(Rationale- The first thing a nurse should do to differentiate is to compare the
data collected to the major and minor defining characteristics of each of the
nursing diagnoses being considered.)
When two nursing diagnoses appear closely related, what should the nurse do first to
determine which diagnosis most accurately reflects the needs of a patient?
A. Reassess the patient
B. Examine the related to factors
C. Review the defining characteristics,
D. Analyze the secondary to factors
(Answer: ) B
(Rationale- This is the primary purpose of a nursing admission assessment.)
The nurse performs an assessment of a newly admitted patient. The nurse understands
that this admission assessment is conducted primarily to:
A. Diagnose if the patient is at risk for falls.
B. Identify important data
C. Establish a therapeutic relationship
D. Ensure that the patient's skin is intact
(Answer: ) D
(Rationale- A nursing diagnosis is a statement about a patient's actual or
and Correct Answers With Rationale. 2024/2025.
(Answer: ) B
(Rationale- The nurse identifies human responses to actual or potential health
problems during the nursing diagnoses step of the nursing process. During the
assessment step, the nurse collects data. During the planning step, the nurse
develops strategies to resolve or decrease the patient's problem. During
evaluation, the nurse determines the effectiveness of the plan of care.)
The nurse in charge identifies a patient's responses to actual or potential health
problems during which step of the nursing process?
A. Assessing
B. Diagnosing
C. Planning
D. Evaluating
(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 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
(Answer: ) D
(Rationale: During the evaluation step of the nursing process the nurse
determines whether the goals established have been achieved, and evaluates the
success of the plan. Answer A involves data collection. Answer B involves
setting priorities, and Answer C is the actual intervention.)
A nurse is revising a client's care plan. During which step of the nursing process does
such a revision take place?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
,(Answer: ) D
(Rationale: You should begin with the simplest interventions. Answer A is
incorrect because medications should be avoided whenever possible. Answer B
would be a thorough sleep assessment, and should be done only after common
sense interventions fail. Answer C would be appropriate only after common
sense interventions fail.)
Which intervention should the nurse in charge try first for a client that exhibits signs of
sleep disturbance?
A. Administer sleeping medication before bedtime
B. Ask the client each morning to describe the quantity of sleep the night before
C. Teach the client relaxation techniques, such as guided imagery and progressive
muscle relaxation
D. Provide the client normal sleep aids, such as pillows, back rubs, and snacks
(Answer: ) C
(Rationale- Making appropriate referrals is a valid part of planning the client's
care. The nurse normally does not provide sex counseling. While providing time
for privacy and providing support for the spouse is important, it is not as
important as referring the client to a sex counselor/appropriate professional)
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
(Answer: ) A
(Rationale - According to Maslow, elimination is a first-level or physiological
need. Security and safety are second-level needs, and belonging is a third-level
need.)
Using Maslow's hierarchy of needs, a nurse assigns the highest priority to which client
need?
A. Elimination
B. Security
C. Safety
D. Belonging
(Answer: ) A
(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 client who received general anesthesia returns from surgery. Postoperatively,
which nursing diagnosis takes highest priority for this client?
A. Risk for aspiration R/T anesthesia
B. Deficient fluid volume R/T blood and fluid loss from surgery
C. Impaired physical mobility R/T surgery
D. Acute pain R/T surgery
(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 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
(Answer: ) C
(Rationale- The first thing a nurse should do to differentiate is to compare the
data collected to the major and minor defining characteristics of each of the
nursing diagnoses being considered.)
When two nursing diagnoses appear closely related, what should the nurse do first to
determine which diagnosis most accurately reflects the needs of a patient?
A. Reassess the patient
B. Examine the related to factors
C. Review the defining characteristics,
D. Analyze the secondary to factors
(Answer: ) B
(Rationale- This is the primary purpose of a nursing admission assessment.)
The nurse performs an assessment of a newly admitted patient. The nurse understands
that this admission assessment is conducted primarily to:
A. Diagnose if the patient is at risk for falls.
B. Identify important data
C. Establish a therapeutic relationship
D. Ensure that the patient's skin is intact
(Answer: ) D
(Rationale- A nursing diagnosis is a statement about a patient's actual or
