Nursing Process NCLEX questions with 100% Verified Solutions
1. The nurse would do which of the fol- B. Analyze data
lowing activities during the diagnos- C. Identify problems, risk, and client
ing phase of the nursing process? strengths
Select all that apply. D. Develop nursing diagnoses
A. Collect and organize client infor- Rationale: The diagnosing phase of
mation the nursing process involves data
B. Analyze data analysis, which leads to identifica-
C. Identify problems, risk, and client tion of problems, risks, and strengths
strengths and the development of nursing di-
D. Develop nursing diagnoses agnoses. Collecting and organizing
E. Develop client goals client data is done in the assess-
ment phase of the nursing process.
Goal setting occurs during the plan-
ning phase.
2. For the nursing diagnostic state- D. Fractured Wrists
ment, Self-care deficit: feeding re-
lated to bilateral fractured wrists in Rationale: The etiology or related fac-
casts, what is the major related fac- tors of a nursing diagnostic statement
tor or risk factor identified by the define one or more probable causes
nurse? of the problem and allow the nurse to
individualize the client's care. In this
A. Discomfort case, the fracture is the cause of the
B. Deficit client's feeding problem.
C. Feeding
D. Fractured wrists
3. The nurse would make which of the A. Client is hypotensive
following inferences after perform-
ing the appropriate client assess- Rationale: An inference is the nurse's
ment? judgment or interpretation of cues
such as judging a blood pressure to
A. Client is hypotensive be lower than normal. A cue is any
B. Respiratory rate of 20 breaths per piece of data information that influ-
minute ences a decision. Options 2, 3, and 4
C. Oxygen saturation of 95% are cues that could lead to inferences.
D. Client relays anxiety about blood
work
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, Nursing Process NCLEX questions with 100% Verified Solutions
4. The nurse would write which of the D. Client will progress to walking a
following outcome statements for a 20-minute mile in one month
client starting an exercise program?
Rationale: Outcome statements must
A. Client will walk quickly three be written in behavioral terms and
times a day identify specific, measurable client
B. Client will be able to walk a mile behaviors. They are stated in terms of
C. Client will have no alteration in the client with an action verb that, un-
breathing during the walk der identified conditions, will achieve
D. Client will progress to walking a the desired behavior. They should
20-minute mile in one month also be realistic and achievable.
5. The nurse informs the physical ther- C. Implementation
apy department that the client is too
weak to use a walker and needs to Rationale: The nurse is responsible
be transported by wheelchair. Which for coordinating the plan of care with
step of the nursing process is the other disciplines to ensure the client's
nurse engaged in at this time? safety. This action represents the im-
plementation phase of the nursing
A. Assessment process. Data gathering occurs dur-
B. Planning ing assessment. Goal setting occurs
C. Implementation during planning. Determining attain-
D. Evaluation ment of client goals occurs as part of
evaluation.
6. A desired outcome for a client im- C. Goal not met: Client able to name
mobilized in a long leg cast reads; only two signs of impaired circulation
Client will state three signs of
impaired circulation prior to dis- Rationale: The goal has not been met
charge. When the nurse evaluates because the client states only two out
the client's progress, the client is of three signs of impaired circulation.
able to state that numbness and tin- By comparing the data with the ex-
gling are signs of impaired circula- pected outcomes, the nurse judges
tion. What would be an appropriate that while there has been progress
evaluation statement for the nurse to toward the goal, it has not been com-
write? pletely met. The care plan may need
to be revised or more effective teach-
A. Client understands the signs of
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1. The nurse would do which of the fol- B. Analyze data
lowing activities during the diagnos- C. Identify problems, risk, and client
ing phase of the nursing process? strengths
Select all that apply. D. Develop nursing diagnoses
A. Collect and organize client infor- Rationale: The diagnosing phase of
mation the nursing process involves data
B. Analyze data analysis, which leads to identifica-
C. Identify problems, risk, and client tion of problems, risks, and strengths
strengths and the development of nursing di-
D. Develop nursing diagnoses agnoses. Collecting and organizing
E. Develop client goals client data is done in the assess-
ment phase of the nursing process.
Goal setting occurs during the plan-
ning phase.
2. For the nursing diagnostic state- D. Fractured Wrists
ment, Self-care deficit: feeding re-
lated to bilateral fractured wrists in Rationale: The etiology or related fac-
casts, what is the major related fac- tors of a nursing diagnostic statement
tor or risk factor identified by the define one or more probable causes
nurse? of the problem and allow the nurse to
individualize the client's care. In this
A. Discomfort case, the fracture is the cause of the
B. Deficit client's feeding problem.
C. Feeding
D. Fractured wrists
3. The nurse would make which of the A. Client is hypotensive
following inferences after perform-
ing the appropriate client assess- Rationale: An inference is the nurse's
ment? judgment or interpretation of cues
such as judging a blood pressure to
A. Client is hypotensive be lower than normal. A cue is any
B. Respiratory rate of 20 breaths per piece of data information that influ-
minute ences a decision. Options 2, 3, and 4
C. Oxygen saturation of 95% are cues that could lead to inferences.
D. Client relays anxiety about blood
work
1/6
, Nursing Process NCLEX questions with 100% Verified Solutions
4. The nurse would write which of the D. Client will progress to walking a
following outcome statements for a 20-minute mile in one month
client starting an exercise program?
Rationale: Outcome statements must
A. Client will walk quickly three be written in behavioral terms and
times a day identify specific, measurable client
B. Client will be able to walk a mile behaviors. They are stated in terms of
C. Client will have no alteration in the client with an action verb that, un-
breathing during the walk der identified conditions, will achieve
D. Client will progress to walking a the desired behavior. They should
20-minute mile in one month also be realistic and achievable.
5. The nurse informs the physical ther- C. Implementation
apy department that the client is too
weak to use a walker and needs to Rationale: The nurse is responsible
be transported by wheelchair. Which for coordinating the plan of care with
step of the nursing process is the other disciplines to ensure the client's
nurse engaged in at this time? safety. This action represents the im-
plementation phase of the nursing
A. Assessment process. Data gathering occurs dur-
B. Planning ing assessment. Goal setting occurs
C. Implementation during planning. Determining attain-
D. Evaluation ment of client goals occurs as part of
evaluation.
6. A desired outcome for a client im- C. Goal not met: Client able to name
mobilized in a long leg cast reads; only two signs of impaired circulation
Client will state three signs of
impaired circulation prior to dis- Rationale: The goal has not been met
charge. When the nurse evaluates because the client states only two out
the client's progress, the client is of three signs of impaired circulation.
able to state that numbness and tin- By comparing the data with the ex-
gling are signs of impaired circula- pected outcomes, the nurse judges
tion. What would be an appropriate that while there has been progress
evaluation statement for the nurse to toward the goal, it has not been com-
write? pletely met. The care plan may need
to be revised or more effective teach-
A. Client understands the signs of
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