NURSING PROCESS DIAGNOSES PRACTICE TEST
(NCLEX STYLE) 15 QUESTIONS AND ANSWERS
LATEST VERSION VERIFIED RATIONALE GRADED
A+
A female client who received general anesthesia returns from surgery. Postopera�vely, 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 aspira�on R/T anesthesia - ansAnswer: D
Ra�onale- Risk for aspira�on takes priority because general anesthesia may impair gag and swallow
reflexes. The other op�ons, although important, are secondary to this.
A female pa�ent is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive the
highest priority at this �me?
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 �ssue perfusion related to venous conges�on - ansAnswer: D
Ra�onale: This answer takes highest priority because venous inflamma�on and clot forma�on impede
blood flow in a pa�ent with deep-vein thrombosis.
Op�on A is incorrect because impaired gas exchange is related to decreased, not increased, blood flow.
Op�on B is inappropriate because no evidence suggests that this pa�ent has a fluid volume excess.
Op�on C may be warranted but is secondary to altered �ssue perfusion
A male client is admited to the hospital with blunt chest trauma a�er a motor vehicle accident. The first
nursing priority for this client would be to:
, NURSING PROCESS DIAGNOSES PRACTICE TEST
(NCLEX STYLE) 15 QUESTIONS AND ANSWERS
LATEST VERSION VERIFIED RATIONALE GRADED
A+
A. Assess the client's airway
B. Provide pain relief
C. Encourage deep breathing and coughing
D. Splint the chest wall with a pillow - ansAnswer: A
Ra�onale- The first priority is to evaluate airway patency. Pain management and splin�ng are important
for client comfort, but come a�er 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 postopera�ve 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 interven�on would be to:
A. Encourage the client to ask ques�ons about personal sexuality
B. Provide �me for privacy
C. Suggest referral to a sex counselor or other appropriate professional
D. Provide support for the spouse - ansAnswer: C
Ra�onale- Making appropriate referrals is a valid part of planning the client's care. The nurse normally
does not provide sex counseling. While providing �me 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 revising a client's care plan. During which step of the nursing process does such a revision take
place?
A. Assessment
B. Planning
(NCLEX STYLE) 15 QUESTIONS AND ANSWERS
LATEST VERSION VERIFIED RATIONALE GRADED
A+
A female client who received general anesthesia returns from surgery. Postopera�vely, 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 aspira�on R/T anesthesia - ansAnswer: D
Ra�onale- Risk for aspira�on takes priority because general anesthesia may impair gag and swallow
reflexes. The other op�ons, although important, are secondary to this.
A female pa�ent is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive the
highest priority at this �me?
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 �ssue perfusion related to venous conges�on - ansAnswer: D
Ra�onale: This answer takes highest priority because venous inflamma�on and clot forma�on impede
blood flow in a pa�ent with deep-vein thrombosis.
Op�on A is incorrect because impaired gas exchange is related to decreased, not increased, blood flow.
Op�on B is inappropriate because no evidence suggests that this pa�ent has a fluid volume excess.
Op�on C may be warranted but is secondary to altered �ssue perfusion
A male client is admited to the hospital with blunt chest trauma a�er a motor vehicle accident. The first
nursing priority for this client would be to:
, NURSING PROCESS DIAGNOSES PRACTICE TEST
(NCLEX STYLE) 15 QUESTIONS AND ANSWERS
LATEST VERSION VERIFIED RATIONALE GRADED
A+
A. Assess the client's airway
B. Provide pain relief
C. Encourage deep breathing and coughing
D. Splint the chest wall with a pillow - ansAnswer: A
Ra�onale- The first priority is to evaluate airway patency. Pain management and splin�ng are important
for client comfort, but come a�er 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 postopera�ve 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 interven�on would be to:
A. Encourage the client to ask ques�ons about personal sexuality
B. Provide �me for privacy
C. Suggest referral to a sex counselor or other appropriate professional
D. Provide support for the spouse - ansAnswer: C
Ra�onale- Making appropriate referrals is a valid part of planning the client's care. The nurse normally
does not provide sex counseling. While providing �me 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 revising a client's care plan. During which step of the nursing process does such a revision take
place?
A. Assessment
B. Planning
