ATI RN
Nursing Process NCLEX Questions Questions
Question 1 of 5
or a client with newly diagnosed cancer, the nurse formulates a nursing diagnosis of Anxiety related to the threat of death secondary to cancer diagnosis. Which expected outcome would be appropriate for this client?
Correct Answer: A
Rationale: The correct answer is A because it reflects a measurable and client-centered outcome. Verbalizing feelings of anxiety indicates the client is acknowledging and addressing their emotions, which is essential in managing anxiety. Choice B is incorrect as it focuses on avoidance rather than expression of emotions. Choice C is incorrect as it doesn't specify the use of appropriate coping mechanisms. Choice D is incorrect as it suggests avoidance of seeking information, which may hinder the client's understanding and coping with the diagnosis.
Question 2 of 5
Several hours after returning from surgery, the nurse tells the patient that she is ordered to be ambulated. The patient asks, “Why?” Which of the following complications would the nurse correctly explain can be prevented by early postoperative ambulation?
Correct Answer: C
Rationale: The correct answer is C: Pneumonia. Early postoperative ambulation helps prevent pneumonia by promoting lung expansion, increasing oxygenation, and preventing atelectasis. A: Increased peristalsis is unrelated to ambulation. B: Coughing is important for airway clearance but not directly related to ambulation. D: Wound healing is influenced by various factors, but ambulation primarily impacts respiratory function.
Question 3 of 5
A patient is admitted to a medical unit with a diagnosis of heart failure. The patient reports that she has had increasing fatigue during the past 2 weeks. Which of the following is the most likely cause of this fatigue?
Correct Answer: B
Rationale: The correct answer is B: Decreased cardiac output. Fatigue in heart failure is primarily due to decreased cardiac output, leading to reduced oxygen and nutrient delivery to tissues, causing fatigue. Dyspnea (A) is shortness of breath, not fatigue. Dry cough (C) is more associated with conditions like pulmonary issues, not fatigue. Orthopnea (D) is difficulty breathing while lying down, not specifically related to fatigue. Hence, decreased cardiac output is the most likely cause of fatigue in this patient.
Question 4 of 5
What are the signs of organ rejection a nurse should closely monitor for when caring for a client after heart transplantation? Choose all that apply
Correct Answer: B
Rationale: The correct answer is B: Dyspnea. Dyspnea is a common sign of organ rejection after heart transplantation, indicating possible heart failure. Low white blood cell count (A) is not typically a direct sign of organ rejection. ECG changes (C) may occur but are not specific to organ rejection. Fever (D) is a non-specific symptom and can be caused by various factors. Dyspnea is a key indicator that the transplanted heart is not functioning properly and should be closely monitored.
Question 5 of 5
Which of the ff is a nursing intervention when assessing clients with hypertension?
Correct Answer: B
Rationale: The correct answer is B because teaching the client about both non-pharmacologic and pharmacologic methods for managing hypertension is a crucial nursing intervention to empower the client in their self-care and treatment plan. This intervention helps the client understand the importance of lifestyle modifications and medication adherence in controlling blood pressure. A: The nurse taking the temperature in different positions is not directly related to assessing hypertension. C: Taking BP in different positions is important for orthostatic hypotension, not specifically for hypertension. D: Weighing the client each morning is not a direct nursing intervention for assessing hypertension.