NCLEX RN Nursing Process Practice
Exam 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026
1. A nurse is caring for a client who reports severe abdominal pain. Which
action should the nurse take first?
A. Administer the prescribed analgesic
B. Assess the client's pain characteristics and vital signs
C. Document the client's complaint
D. Notify the health care provider
Answer: Assess the client's pain characteristics and vital signs
Rationale: Assessment is the first step of the nursing process. The nurse must
collect relevant data before determining appropriate interventions.
2. Which nursing process step involves determining whether the client's
goals have been achieved?
A. Assessment
B. Diagnosis
C. Planning
D. Evaluation
Answer: Evaluation
Rationale: Evaluation determines whether the client's outcomes have been
met and whether the plan of care needs to be continued, modified, or
discontinued.
3. A nurse identifies that a client has impaired physical mobility related to
weakness. Which part of the nursing process is this?
,A. Assessment
B. Nursing diagnosis
C. Planning
D. Implementation
Answer: Nursing diagnosis
Rationale: A nursing diagnosis identifies a client's actual or potential
response to a health condition that nurses can address independently.
4. Which finding is subjective data?
A. Blood pressure of 150/90 mm Hg
B. Temperature of 38.2°C
C. Client states, "I feel nauseated."
D. Respiratory rate of 24/min
Answer: Client states, "I feel nauseated."
Rationale: Subjective data are symptoms or experiences reported by the
client and cannot be directly measured by the nurse.
5. Which finding represents objective data?
A. "My chest feels tight."
B. "I am very tired."
C. "My pain is a 7 out of 10."
D. Oxygen saturation is 89%
Answer: Oxygen saturation is 89%
Rationale: Objective data are observable or measurable findings obtained
through physical assessment, observation, or diagnostic testing.
6. A nurse is collecting a client's health history. Which question is most
appropriate for obtaining subjective information?
A. "What is your current blood pressure?"
B. "What medications are listed on your chart?"
C. "Can you describe how you have been feeling?"
D. "What is your temperature?"
Answer: "Can you describe how you have been feeling?"
,Rationale: Open-ended questions encourage the client to describe symptoms
and experiences in their own words.
7. A nurse receives a report about four clients. Which client should the
nurse assess first?
A. Client with chronic arthritis reporting pain of 6/10
B. Client with pneumonia and an oxygen saturation of 84%
C. Client requesting assistance with bathing
D. Client awaiting discharge instructions
Answer: Client with pneumonia and an oxygen saturation of 84%
Rationale: Airway and breathing take priority. Severe hypoxemia requires
immediate assessment and intervention.
8. Which nursing action is an example of implementation?
A. Identifying impaired skin integrity
B. Establishing a goal for wound healing
C. Repositioning the client every 2 hours
D. Determining whether the wound has improved
Answer: Repositioning the client every 2 hours
Rationale: Implementation is the action phase of the nursing process in which
planned nursing interventions are performed.
9. A nurse develops a goal that states, "The client will ambulate 50 feet
with assistance by the end of the shift." What type of outcome is this?
A. Subjective
B. Measurable
C. Unrelated
D. Long-term only
Answer: Measurable
Rationale: The goal includes a specific distance and time frame, making it
measurable and useful for evaluation.
10.Which outcome is written correctly?
, A. Client will improve mobility.
B. Client will feel better soon.
C. Client will ambulate 100 feet with a walker by 1800.
D. Nurse will encourage ambulation.
Answer: Client will ambulate 100 feet with a walker by 1800.
Rationale: A well-written outcome is client-centered, specific, measurable,
and time limited.
11.A nurse notices that a client has a blood pressure of 88/50 mm Hg. What
should the nurse do first?
A. Document the finding
B. Assess the client for symptoms
C. Call the family
D. Schedule a follow-up appointment
Answer: Assess the client for symptoms
Rationale: Abnormal assessment findings should be validated and interpreted
in the context of the client's clinical condition before further action.
12.Which assessment technique involves tapping the body surface to
produce sounds?
A. Inspection
B. Palpation
C. Percussion
D. Auscultation
Answer: Percussion
Rationale: Percussion involves tapping the body surface to assess underlying
structures based on the sounds produced.
13.Which assessment technique involves listening to internal body sounds?
A. Inspection
B. Palpation
C. Percussion
D. Auscultation
Exam 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026
1. A nurse is caring for a client who reports severe abdominal pain. Which
action should the nurse take first?
A. Administer the prescribed analgesic
B. Assess the client's pain characteristics and vital signs
C. Document the client's complaint
D. Notify the health care provider
Answer: Assess the client's pain characteristics and vital signs
Rationale: Assessment is the first step of the nursing process. The nurse must
collect relevant data before determining appropriate interventions.
2. Which nursing process step involves determining whether the client's
goals have been achieved?
A. Assessment
B. Diagnosis
C. Planning
D. Evaluation
Answer: Evaluation
Rationale: Evaluation determines whether the client's outcomes have been
met and whether the plan of care needs to be continued, modified, or
discontinued.
3. A nurse identifies that a client has impaired physical mobility related to
weakness. Which part of the nursing process is this?
,A. Assessment
B. Nursing diagnosis
C. Planning
D. Implementation
Answer: Nursing diagnosis
Rationale: A nursing diagnosis identifies a client's actual or potential
response to a health condition that nurses can address independently.
4. Which finding is subjective data?
A. Blood pressure of 150/90 mm Hg
B. Temperature of 38.2°C
C. Client states, "I feel nauseated."
D. Respiratory rate of 24/min
Answer: Client states, "I feel nauseated."
Rationale: Subjective data are symptoms or experiences reported by the
client and cannot be directly measured by the nurse.
5. Which finding represents objective data?
A. "My chest feels tight."
B. "I am very tired."
C. "My pain is a 7 out of 10."
D. Oxygen saturation is 89%
Answer: Oxygen saturation is 89%
Rationale: Objective data are observable or measurable findings obtained
through physical assessment, observation, or diagnostic testing.
6. A nurse is collecting a client's health history. Which question is most
appropriate for obtaining subjective information?
A. "What is your current blood pressure?"
B. "What medications are listed on your chart?"
C. "Can you describe how you have been feeling?"
D. "What is your temperature?"
Answer: "Can you describe how you have been feeling?"
,Rationale: Open-ended questions encourage the client to describe symptoms
and experiences in their own words.
7. A nurse receives a report about four clients. Which client should the
nurse assess first?
A. Client with chronic arthritis reporting pain of 6/10
B. Client with pneumonia and an oxygen saturation of 84%
C. Client requesting assistance with bathing
D. Client awaiting discharge instructions
Answer: Client with pneumonia and an oxygen saturation of 84%
Rationale: Airway and breathing take priority. Severe hypoxemia requires
immediate assessment and intervention.
8. Which nursing action is an example of implementation?
A. Identifying impaired skin integrity
B. Establishing a goal for wound healing
C. Repositioning the client every 2 hours
D. Determining whether the wound has improved
Answer: Repositioning the client every 2 hours
Rationale: Implementation is the action phase of the nursing process in which
planned nursing interventions are performed.
9. A nurse develops a goal that states, "The client will ambulate 50 feet
with assistance by the end of the shift." What type of outcome is this?
A. Subjective
B. Measurable
C. Unrelated
D. Long-term only
Answer: Measurable
Rationale: The goal includes a specific distance and time frame, making it
measurable and useful for evaluation.
10.Which outcome is written correctly?
, A. Client will improve mobility.
B. Client will feel better soon.
C. Client will ambulate 100 feet with a walker by 1800.
D. Nurse will encourage ambulation.
Answer: Client will ambulate 100 feet with a walker by 1800.
Rationale: A well-written outcome is client-centered, specific, measurable,
and time limited.
11.A nurse notices that a client has a blood pressure of 88/50 mm Hg. What
should the nurse do first?
A. Document the finding
B. Assess the client for symptoms
C. Call the family
D. Schedule a follow-up appointment
Answer: Assess the client for symptoms
Rationale: Abnormal assessment findings should be validated and interpreted
in the context of the client's clinical condition before further action.
12.Which assessment technique involves tapping the body surface to
produce sounds?
A. Inspection
B. Palpation
C. Percussion
D. Auscultation
Answer: Percussion
Rationale: Percussion involves tapping the body surface to assess underlying
structures based on the sounds produced.
13.Which assessment technique involves listening to internal body sounds?
A. Inspection
B. Palpation
C. Percussion
D. Auscultation
