NCLEX - Type Nursing Process exam Questions and
Correct Answers (100% COMPLETE ANSWERS)
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The client states, "My chest hurts and my left arm feels numb." The nurse interprets that this data is of
which type and source?
A. Subjective data from a primary source
B. Subjective data from a secondary source
C. Objective data from a primary source
D. Objective data from a secondary source - ANSWER-A. Subjective data from a primary source
Rationale: The client states, "My chest hurts and my left arm feels numb." The nurse interprets that this
data is of which type and source?
The nurse feels a client is at risk for skin breakdown because he has only had clear liquids for the last 10
days (and essentially no protein intake). The nurse would formulate which diagnostic statement that
would best reflect this problem?
A. Risk for malnutrition related to clear liquid diet
B. Impaired skin integrity related to no protein intake
C. Risk for impaired skin integrity related to malnutrition
D. Impaired nutrition related to current illness - ANSWER-C. Risk for impaired skin integrity related to
malnutrition
Rationale: This is a risk diagnosis, and the diagnostic statement has two parts: the human response
(impaired skin integrity) and the related/risk factor (malnutrition). Options 1 and 2 do not have related
factors that are under the control of the nurse (i.e., type of diet ordered). The diagnosis in option 4 does
not specify the type of impairment (greater than or less than body requirements) and is therefore
incomplete. It also does not provide direction for development of goals and interventions.
The nurse would place which correctly written nursing diagnostic statement into the client's care plan?
,A. Cancer relater to cigarette smoking
B. Impaired gas exchange related to aspiration of foreign matter as evidenced by oxygen saturation of
91%
C. Imbalance nutrition: more than body requirement related to overweight status
D. Impaired physical mobility related to generalized weakness and pain - ANSWER-B. Impaired gas
exchange related to aspiration of foreign matter as evidence by oxygen saturation of 91%
Rationale: A nursing diagnosis consists of two parts joined by related to. The first part (the human
response) names/labels the problem. The second part (related factors) includes the factors that either
contribute to or are probable etiologies of the human response. Some formats include a third part to
the statement for actual (not risk) diagnoses; this third part consists of the client's signs or symptoms
and is joined to the statement with the label as evidenced by. This type of statement is the most
complete. Option 1 is not a nursing diagnosis but is a medical diagnosis. Options 3 and 4 are vague.
Which of the following outcome goals has the nurse designed correctly for the postoperative client's
plan of care? Select all that apply.
A. Client will state pain is less than or equal to 3 on zero to ten pain scale
B. Client will have no pain
C. Client will state pain is less than or equal to a 3 on a 0-10 pain scale within 24 hours
D. Client will state pain is less than or equal to a 5 on a 0-10 pain scale by the time of discharge
E. Client will be medicated every 4 hours by the nurse - ANSWER-C. Client will state pain is less than or
equal to a 3 on a 0-10 pain scale within 24 hours
D. Client will state pain is less than or equal to a 5 on a 0-10 pain scale by the time of discharge
Rationale: An outcome goal should be SMART: specific, measurable, appropriate, realistic, and timely.
Options 3 and 4 are SMART goals. Options 1 and 2 have no timeframe to achieve the goal and are
therefore incomplete. Option 2 is also unrealistic; the nurse cannot expect a postoperative client to be
pain free. Option 5 is not a client goal.
The nurse questions if the dosage of a medication is unsafe for the client because of the client's weight
and age. The nurse should take which of the following actions?
,A. Administer the medication as ordered by the prescriber
B. Call the prescriber to discuss the order and the nurse's concern
C. Administer the medication, but chart the nurse's concern about the dosage
D. Give the client half the dosage and document accordingly - ANSWER-B. Call the prescriber to discuss
the order and the nurse's concern
Rationale: Client safety is of the utmost importance when implementing any nursing intervention. If the
nurse feels that an order is unsafe or inappropriate for a client, the nurse must act as a client advocate
and collaborate with the appropriate healthcare team member to determine the rationale for the order
and/or modify the order as necessary. A nurse accepts accountability for his or her actions. Options 1, 3,
and 4 are inappropriate and unsafe.
Which activity would be appropriate for the nurse to delegate to an unlicensed assistive person (UAP)?
A. Taking vital signs of clients on the nursing unit
B. Assisting the physician with an invasive procedure
C. Adjusting the rate on an infusion pump
D. Evaluating achievement of client outcome goals - ANSWER-A. Taking vital signs of clients on the
nursing unit
Rationale: Part of the professional nurse's role is to delegate responsibility for activities while
maintaining accountability. The nurse must match the needs of the client with the skills and knowledge
of UAPs. Certain skills and activities, such as those in options 2, 3, and 4, are not within the legal scope
of practice for a UAP.
In giving a change-of-shift report, which type of client information communicated by the nurse is most
appropriate?
A. Vital signs are stable
B. Client is pleasant, alert, and oriented to time, place, and person
C. The chest x-ray results were negative
, D. Client voided 250 mL of urine 2 hours after the urinary catheter removal - ANSWER-D. Client voided
250 mL of urine 2 hours after the urinary catheter removal
Rationale: A change-of-shift report should include significant changes (good or bad) in a client's
condition. The information should be accurate, concise, clear, and complete. Options 1 is vague and
options 2 and 3 are normal data and are therefore of lesser importance to convey in the change-of-shift
report.
Twenty minutes after administering pain medication to the client, the nurse returns to ask if the client's
level of pain has decreased. The nurse documents the client's response as part of which phase of the
nursing process?
A. Diagnosis
B. Planning
C. Implementation
D. Evaluation - ANSWER-D. Evaluation
Rationale: Evaluating is the process of comparing client responses to the outcome goals to determine
whether, or to what degree, goals have been met. Diagnosing identifies health problems, risks, and
strengths. Planning is the formulation of client goals and nursing strategies (interventions) required to
prevent, reduce, or eliminate the client's health problems. Implementing is carrying out or delegating
the nursing interventions.
During which part of the client interview would it be best for the nurse to ask, "What's the weather
forecast for today?"
A. Introduction
B. Body
C. Closing
D. Orientation - ANSWER-A. Introduction
Rationale: Asking about the weather initiates the social or introductory phase of the interview and
allows the nurse to begin an assessment of the client's mental status. The goal is to develop rapport
Correct Answers (100% COMPLETE ANSWERS)
ALREADY GRADED A+ | 100% satisfaction guarantee
with complete solutions,
The client states, "My chest hurts and my left arm feels numb." The nurse interprets that this data is of
which type and source?
A. Subjective data from a primary source
B. Subjective data from a secondary source
C. Objective data from a primary source
D. Objective data from a secondary source - ANSWER-A. Subjective data from a primary source
Rationale: The client states, "My chest hurts and my left arm feels numb." The nurse interprets that this
data is of which type and source?
The nurse feels a client is at risk for skin breakdown because he has only had clear liquids for the last 10
days (and essentially no protein intake). The nurse would formulate which diagnostic statement that
would best reflect this problem?
A. Risk for malnutrition related to clear liquid diet
B. Impaired skin integrity related to no protein intake
C. Risk for impaired skin integrity related to malnutrition
D. Impaired nutrition related to current illness - ANSWER-C. Risk for impaired skin integrity related to
malnutrition
Rationale: This is a risk diagnosis, and the diagnostic statement has two parts: the human response
(impaired skin integrity) and the related/risk factor (malnutrition). Options 1 and 2 do not have related
factors that are under the control of the nurse (i.e., type of diet ordered). The diagnosis in option 4 does
not specify the type of impairment (greater than or less than body requirements) and is therefore
incomplete. It also does not provide direction for development of goals and interventions.
The nurse would place which correctly written nursing diagnostic statement into the client's care plan?
,A. Cancer relater to cigarette smoking
B. Impaired gas exchange related to aspiration of foreign matter as evidenced by oxygen saturation of
91%
C. Imbalance nutrition: more than body requirement related to overweight status
D. Impaired physical mobility related to generalized weakness and pain - ANSWER-B. Impaired gas
exchange related to aspiration of foreign matter as evidence by oxygen saturation of 91%
Rationale: A nursing diagnosis consists of two parts joined by related to. The first part (the human
response) names/labels the problem. The second part (related factors) includes the factors that either
contribute to or are probable etiologies of the human response. Some formats include a third part to
the statement for actual (not risk) diagnoses; this third part consists of the client's signs or symptoms
and is joined to the statement with the label as evidenced by. This type of statement is the most
complete. Option 1 is not a nursing diagnosis but is a medical diagnosis. Options 3 and 4 are vague.
Which of the following outcome goals has the nurse designed correctly for the postoperative client's
plan of care? Select all that apply.
A. Client will state pain is less than or equal to 3 on zero to ten pain scale
B. Client will have no pain
C. Client will state pain is less than or equal to a 3 on a 0-10 pain scale within 24 hours
D. Client will state pain is less than or equal to a 5 on a 0-10 pain scale by the time of discharge
E. Client will be medicated every 4 hours by the nurse - ANSWER-C. Client will state pain is less than or
equal to a 3 on a 0-10 pain scale within 24 hours
D. Client will state pain is less than or equal to a 5 on a 0-10 pain scale by the time of discharge
Rationale: An outcome goal should be SMART: specific, measurable, appropriate, realistic, and timely.
Options 3 and 4 are SMART goals. Options 1 and 2 have no timeframe to achieve the goal and are
therefore incomplete. Option 2 is also unrealistic; the nurse cannot expect a postoperative client to be
pain free. Option 5 is not a client goal.
The nurse questions if the dosage of a medication is unsafe for the client because of the client's weight
and age. The nurse should take which of the following actions?
,A. Administer the medication as ordered by the prescriber
B. Call the prescriber to discuss the order and the nurse's concern
C. Administer the medication, but chart the nurse's concern about the dosage
D. Give the client half the dosage and document accordingly - ANSWER-B. Call the prescriber to discuss
the order and the nurse's concern
Rationale: Client safety is of the utmost importance when implementing any nursing intervention. If the
nurse feels that an order is unsafe or inappropriate for a client, the nurse must act as a client advocate
and collaborate with the appropriate healthcare team member to determine the rationale for the order
and/or modify the order as necessary. A nurse accepts accountability for his or her actions. Options 1, 3,
and 4 are inappropriate and unsafe.
Which activity would be appropriate for the nurse to delegate to an unlicensed assistive person (UAP)?
A. Taking vital signs of clients on the nursing unit
B. Assisting the physician with an invasive procedure
C. Adjusting the rate on an infusion pump
D. Evaluating achievement of client outcome goals - ANSWER-A. Taking vital signs of clients on the
nursing unit
Rationale: Part of the professional nurse's role is to delegate responsibility for activities while
maintaining accountability. The nurse must match the needs of the client with the skills and knowledge
of UAPs. Certain skills and activities, such as those in options 2, 3, and 4, are not within the legal scope
of practice for a UAP.
In giving a change-of-shift report, which type of client information communicated by the nurse is most
appropriate?
A. Vital signs are stable
B. Client is pleasant, alert, and oriented to time, place, and person
C. The chest x-ray results were negative
, D. Client voided 250 mL of urine 2 hours after the urinary catheter removal - ANSWER-D. Client voided
250 mL of urine 2 hours after the urinary catheter removal
Rationale: A change-of-shift report should include significant changes (good or bad) in a client's
condition. The information should be accurate, concise, clear, and complete. Options 1 is vague and
options 2 and 3 are normal data and are therefore of lesser importance to convey in the change-of-shift
report.
Twenty minutes after administering pain medication to the client, the nurse returns to ask if the client's
level of pain has decreased. The nurse documents the client's response as part of which phase of the
nursing process?
A. Diagnosis
B. Planning
C. Implementation
D. Evaluation - ANSWER-D. Evaluation
Rationale: Evaluating is the process of comparing client responses to the outcome goals to determine
whether, or to what degree, goals have been met. Diagnosing identifies health problems, risks, and
strengths. Planning is the formulation of client goals and nursing strategies (interventions) required to
prevent, reduce, or eliminate the client's health problems. Implementing is carrying out or delegating
the nursing interventions.
During which part of the client interview would it be best for the nurse to ask, "What's the weather
forecast for today?"
A. Introduction
B. Body
C. Closing
D. Orientation - ANSWER-A. Introduction
Rationale: Asking about the weather initiates the social or introductory phase of the interview and
allows the nurse to begin an assessment of the client's mental status. The goal is to develop rapport
