NCLEX Nursing process with Complete Solutions
1. Offer the client nutritious finger Which intervention should the nurse
foods. include in the plan of care to ensure
adequate nutrition for a very active,
talkative, and easily distractible client
who is unable to sit through meals?
2. The client will demonstrate progress A client experienced the loss of home
in dealing with the grief of losing and beloved family dog in flood wa-
their home and dog. ters 4 months ago. The client states
that since the loss, the client finds
it hard to "feel anything." The client
says they can't concentrate on sim-
ple tasks, thinks about the flood in-
cessantly, and fears losing control.
The client reports becoming extreme-
ly anxious whenever the flood is men-
tioned and must leave the room if peo-
ple talk about it. The admitting nurse
suspects the client has post-traumatic
stress disorder (PTSD). Which nurs-
ing goal would be most appropriate
for this client?
3. Assist the client to the The nurse is administering oxygen by
semi-Fowler's position if possible. face mask to a client. Which action will
the nurse include?
4. establishing a one-on-one relation- A nurse is caring for a client
ship with the client; By establishing with schizotypal personality disorder
a one-on-one relationship, the nurse with impaired verbal communication.
helps the client learn how to interact Which nursing intervention is the pri-
with people in new situations. Help- ority?
ing the client participate in social in-
teractions, establishing alternative
forms of communication, and allow-
ing the client to decide when to com-
municate are appropriate but should
take place only after the nurse-client
relationship has been established.
, NCLEX Nursing process with Complete Solutions
5. risk for injury related to hyperbiliru- At birth, a neonate weighs 7 lb, 3
binemia oz (3,267 g). When assessing the
neonate 1 day later, the nurse obtains
a weight of 7 lb (3,182 g) and an
axillary temperature of 98° F (36.7°
C) and notes that the sclerae are
slightly yellow. The neonate has been
breast-feeding once every 2 to 3
hours. Based on these findings, the
nurse should add which nursing diag-
nosis to the care plan?
6. The client's respirations improve to An adolescent is brought to the emer-
12/min. gency department (ED) after acci-
dentally taking an overdose of hero-
in. The adolescent is semiconscious,
unable to respond appropriately to
questions, slurs words, and has con-
stricted pupils; the client's vital signs
are blood pressure 60/50 mm Hg,
pulse 50 beats/min, and respirations
8 breaths/min. Naloxone is adminis-
tered to temporarily reverse the ef-
fects of the heroin. Which finding
would first indicate that the naloxone
administration has been effective?
7. increases food intake and tolerance A client is recovering from a gas-
gradually. tric resection for peptic ulcer dis-
ease. Which outcome indicates that
the goal of adequate nutritional intake
is being achieved 3 weeks following
surgery? The client:
8. aspirin; Aspirin is implicated in the The client has come to the hospital
development of Reye's syndrome in emergency room reporting lethargy
children with a history of recent and vomiting. The healthcare provider
acute viral infection. makes a tentative diagnosis of Reye's
syndrome. The client's history reveals
1. Offer the client nutritious finger Which intervention should the nurse
foods. include in the plan of care to ensure
adequate nutrition for a very active,
talkative, and easily distractible client
who is unable to sit through meals?
2. The client will demonstrate progress A client experienced the loss of home
in dealing with the grief of losing and beloved family dog in flood wa-
their home and dog. ters 4 months ago. The client states
that since the loss, the client finds
it hard to "feel anything." The client
says they can't concentrate on sim-
ple tasks, thinks about the flood in-
cessantly, and fears losing control.
The client reports becoming extreme-
ly anxious whenever the flood is men-
tioned and must leave the room if peo-
ple talk about it. The admitting nurse
suspects the client has post-traumatic
stress disorder (PTSD). Which nurs-
ing goal would be most appropriate
for this client?
3. Assist the client to the The nurse is administering oxygen by
semi-Fowler's position if possible. face mask to a client. Which action will
the nurse include?
4. establishing a one-on-one relation- A nurse is caring for a client
ship with the client; By establishing with schizotypal personality disorder
a one-on-one relationship, the nurse with impaired verbal communication.
helps the client learn how to interact Which nursing intervention is the pri-
with people in new situations. Help- ority?
ing the client participate in social in-
teractions, establishing alternative
forms of communication, and allow-
ing the client to decide when to com-
municate are appropriate but should
take place only after the nurse-client
relationship has been established.
, NCLEX Nursing process with Complete Solutions
5. risk for injury related to hyperbiliru- At birth, a neonate weighs 7 lb, 3
binemia oz (3,267 g). When assessing the
neonate 1 day later, the nurse obtains
a weight of 7 lb (3,182 g) and an
axillary temperature of 98° F (36.7°
C) and notes that the sclerae are
slightly yellow. The neonate has been
breast-feeding once every 2 to 3
hours. Based on these findings, the
nurse should add which nursing diag-
nosis to the care plan?
6. The client's respirations improve to An adolescent is brought to the emer-
12/min. gency department (ED) after acci-
dentally taking an overdose of hero-
in. The adolescent is semiconscious,
unable to respond appropriately to
questions, slurs words, and has con-
stricted pupils; the client's vital signs
are blood pressure 60/50 mm Hg,
pulse 50 beats/min, and respirations
8 breaths/min. Naloxone is adminis-
tered to temporarily reverse the ef-
fects of the heroin. Which finding
would first indicate that the naloxone
administration has been effective?
7. increases food intake and tolerance A client is recovering from a gas-
gradually. tric resection for peptic ulcer dis-
ease. Which outcome indicates that
the goal of adequate nutritional intake
is being achieved 3 weeks following
surgery? The client:
8. aspirin; Aspirin is implicated in the The client has come to the hospital
development of Reye's syndrome in emergency room reporting lethargy
children with a history of recent and vomiting. The healthcare provider
acute viral infection. makes a tentative diagnosis of Reye's
syndrome. The client's history reveals
