NURS 403 Practice Questions Exam #1, Fundamentals of
Nursing, 11th edition NCLEX questions - exam 1 Questions
With Complete Solutions
A female client who received general anesthesia returns from
surgery. Postoperatively, 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 aspiration R/T anesthesia
Answer: D
Rationale- Risk for aspiration takes priority because general
anesthesia may impair gag and swallow reflexes. The other
options, although important, are secondary to this.
A male client is admitted to the hospital with blunt chest trauma
after a motor vehicle accident. The first nursing priority for this
client would be to:
A. Assess the client's airway
B. Provide pain relief
,C. Encourage deep breathing and coughing
D. Splint the chest wall with a pillow
Answer: A
Rationale- The first priority is to evaluate airway patency. Pain
management and splinting are important for client comfort, but
come after an airway assessment. Coughing and deep breathing
may be contraindicated if the client has internal bleeding and
other injuries.
When two nursing diagnoses appear closely related, what should
the nurse do first to determine which diagnosis most accurately
reflects the needs of a patient?
A. Reassess the patient
B. Examine the related to factors
C. Analyze the secondary to factors
D. Review the defining characteristics
Answer: D
Rationale- The first thing a nurse should do to differentiate is to
compare the data collected to the major and minor defining
characteristics of each of the nursing diagnoses being
considered.
,The nurse performs an assessment of a newly admitted patient.
The nurse understands that this admission assessment is
conducted primarily to:
A. Diagnose if the patient is at risk for falls.
B. Ensure that the patient's skin is intact
C. Establish a therapeutic relationship
D. Identify important data
Answer: D
Rationale- This is the primary purpose of a nursing admission
assessment.
The guidelines for writing an appropriate nursing diagnosis
include all of the following except:
A. State the diagnosis in terms of a problem, not a need
B. Use nursing terminology to describe the patient's response
C. Use statements that assist in planning independent nursing
interventions
D. Use medical terminology to describe the probable cause of
the patient's response
Answer- D
Rationale- A nursing diagnosis is a statement about a patient's
actual or potential health problem that is within the scope of
independent nursing intervention. Medical terminology is never
part of the nursing diagnosis.
, Independent nursing interventions commonly used for patients
with pressure ulcers include:
A. changing the patient's position regularly to minimize pressure
B. Applying a drying agent such as an antacid to decrease
moisture at the ulcer site
C. Debriding the ulcer to remove necrotic tissue, which can
impede healing
D. Placing the patient in a whirlpool bath containing povidone-
iodine solution as tolerated
Answer: A
Rationale- Independent nursing interventions for a patient with
pressure ulcers commonly include changing positions. B, C, &
D all require a physician's order. Additionally, a drying agent
(answer B) would be contraindicated because the wound needs
moisture to heal.
While the nurse is providing a patient personal hygiene, she
observes that his skin is excessively dry. During the procedure,
he tells her that he is very thirsty. An appropriate nursing
diagnosis would be:
A. Potential for impaired skin integrity R/T altered gland
function
B. Potential for impaired skin integrity R/T dehydration
C. Impaired skin integrity R/T dehydration
D. Impaired skin integrity R/T altered circulation
Nursing, 11th edition NCLEX questions - exam 1 Questions
With Complete Solutions
A female client who received general anesthesia returns from
surgery. Postoperatively, 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 aspiration R/T anesthesia
Answer: D
Rationale- Risk for aspiration takes priority because general
anesthesia may impair gag and swallow reflexes. The other
options, although important, are secondary to this.
A male client is admitted to the hospital with blunt chest trauma
after a motor vehicle accident. The first nursing priority for this
client would be to:
A. Assess the client's airway
B. Provide pain relief
,C. Encourage deep breathing and coughing
D. Splint the chest wall with a pillow
Answer: A
Rationale- The first priority is to evaluate airway patency. Pain
management and splinting are important for client comfort, but
come after an airway assessment. Coughing and deep breathing
may be contraindicated if the client has internal bleeding and
other injuries.
When two nursing diagnoses appear closely related, what should
the nurse do first to determine which diagnosis most accurately
reflects the needs of a patient?
A. Reassess the patient
B. Examine the related to factors
C. Analyze the secondary to factors
D. Review the defining characteristics
Answer: D
Rationale- The first thing a nurse should do to differentiate is to
compare the data collected to the major and minor defining
characteristics of each of the nursing diagnoses being
considered.
,The nurse performs an assessment of a newly admitted patient.
The nurse understands that this admission assessment is
conducted primarily to:
A. Diagnose if the patient is at risk for falls.
B. Ensure that the patient's skin is intact
C. Establish a therapeutic relationship
D. Identify important data
Answer: D
Rationale- This is the primary purpose of a nursing admission
assessment.
The guidelines for writing an appropriate nursing diagnosis
include all of the following except:
A. State the diagnosis in terms of a problem, not a need
B. Use nursing terminology to describe the patient's response
C. Use statements that assist in planning independent nursing
interventions
D. Use medical terminology to describe the probable cause of
the patient's response
Answer- D
Rationale- A nursing diagnosis is a statement about a patient's
actual or potential health problem that is within the scope of
independent nursing intervention. Medical terminology is never
part of the nursing diagnosis.
, Independent nursing interventions commonly used for patients
with pressure ulcers include:
A. changing the patient's position regularly to minimize pressure
B. Applying a drying agent such as an antacid to decrease
moisture at the ulcer site
C. Debriding the ulcer to remove necrotic tissue, which can
impede healing
D. Placing the patient in a whirlpool bath containing povidone-
iodine solution as tolerated
Answer: A
Rationale- Independent nursing interventions for a patient with
pressure ulcers commonly include changing positions. B, C, &
D all require a physician's order. Additionally, a drying agent
(answer B) would be contraindicated because the wound needs
moisture to heal.
While the nurse is providing a patient personal hygiene, she
observes that his skin is excessively dry. During the procedure,
he tells her that he is very thirsty. An appropriate nursing
diagnosis would be:
A. Potential for impaired skin integrity R/T altered gland
function
B. Potential for impaired skin integrity R/T dehydration
C. Impaired skin integrity R/T dehydration
D. Impaired skin integrity R/T altered circulation
