ATI RN
Nursing Process NCLEX Questions Questions
Question 1 of 5
A client is brought to the emergency department unconscious after a fall. What is the primary source of information in this case?
Correct Answer: A
Rationale: The correct answer is A: Client's spouse. In the case of an unconscious client, the spouse is the primary source of information about the client's medical history, medications, allergies, and recent events. This information is crucial for providing appropriate care. Medical records may not be immediately accessible. Diagnostic tests provide limited historical information. Nursing assessment relies on the client's condition, which may not provide comprehensive information.
Question 2 of 5
A nurse is assigned to care for a client diagnosed with asthma who has just been admitted to the health care facility. The nurse determines the client’s priorities for care using which of the following?
Correct Answer: A
Rationale: The correct answer is A, assessment skills. Assessing the client's current condition, including respiratory status, is crucial in determining priorities for care in asthma management. By utilizing assessment skills, the nurse can gather essential information to identify the client's immediate needs and develop an individualized care plan. Nursing books (B) can provide general information but do not provide real-time data on the client's current status. Client's records (C) may contain historical information but may not reflect the client's current condition. Supervisor's advice (D) is important but should supplement rather than replace the nurse's assessment skills in determining immediate care priorities.
Question 3 of 5
A nurse is updating the care plan of a client whose condition has improved. What is the most appropriate step to take?
Correct Answer: A
Rationale: The correct answer is A because when a client's condition improves, resolved nursing diagnoses should be removed from the care plan to reflect the current status accurately. This ensures the care plan remains relevant and effective. Continuing with the existing plan (choice B) may lead to unnecessary interventions. Focusing only on unresolved issues (choice C) overlooks the importance of updating the care plan comprehensively. Delegating the task to another nurse or staff member (choice D) is not appropriate as the nurse updating the care plan should have a thorough understanding of the client's progress and needs.
Question 4 of 5
A man with a history of diabetes and chronic lung disease is admitted to the hospital with prostate cancer. He has all the following symptoms. Which should the nurse address first?
Correct Answer: C
Rationale: The correct answer is C: Respiratory rate 36/min. In this case, the nurse should address the respiratory rate first due to the patient's chronic lung disease, indicating potential respiratory distress. High respiratory rate may signify hypoxia, infection, or worsening lung function, posing immediate life-threatening risks. Addressing this symptom promptly is crucial to prevent respiratory failure. Fever (A) and difficulty urinating (B) are important but not as urgent as addressing potential respiratory distress. Painful legs and feet (D) may indicate peripheral neuropathy related to diabetes, which is important but not as critical as addressing the respiratory issue.
Question 5 of 5
. A female client experiences trauma to her urinary tract during an accident. Which of the ff factors should the nurse consider while assessing the client?
Correct Answer: B
Rationale: The correct answer is B: Assessment and recognition of abnormal findings. This is crucial as trauma to the urinary tract can lead to various complications such as urinary retention, infection, or injury to surrounding structures. By assessing and recognizing abnormal findings, the nurse can promptly identify any issues and initiate appropriate interventions. Choice A (Assessment of sexual habits) may be important for assessing risk factors for urinary tract trauma, but it is not directly related to assessing the client's current condition post-accident. Choice C (Assessment of allergies to seafood) is irrelevant in this scenario as it does not impact the assessment of urinary tract trauma. Choice D (Assessment of insurance coverage) is not a priority when assessing a client's immediate health status post-accident.