ATI RN
Nursing Process NCLEX Questions Questions
Question 1 of 9
The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
Correct Answer: A
Rationale: The correct answer is A: Completes a comprehensive database. During the first phase of the nursing process (assessment), the nurse collects data to establish a comprehensive database of the patient's health status. This information serves as the foundation for identifying nursing diagnoses, planning interventions, and evaluating outcomes. Identifying nursing diagnoses (B) occurs in the second phase (diagnosis), intervening based on priorities (C) in the third phase (planning), and determining outcomes achieved (D) in the fourth phase (evaluation). Completing a comprehensive database is crucial in the initial assessment phase to gather accurate information for the subsequent steps in the nursing process.
Question 2 of 9
A nurse is teaching the staff about the benefits of Nursing Outcomes Classification. Which information should the nurse include in the teaching session? (Select all that apply.)
Correct Answer: C
Rationale: The correct answer is C because Nursing Outcomes Classification adds objectivity to judging a patient's progress by providing standardized criteria for assessing outcomes. This helps in evaluating the effectiveness of interventions and tracking improvements accurately. Other choices are incorrect: A is wrong because Nursing Outcomes Classification includes 7 domains but not necessarily for level 1; B is incorrect as it uses a 5-point Likert scale, not a 3-point scale; and D is inaccurate because Nursing Outcomes Classification guides the selection of interventions based on the identified outcomes, not allowing complete freedom in choosing interventions.
Question 3 of 9
Which of the ff conditions is evident by persistent hoarseness?
Correct Answer: C
Rationale: The correct answer is C: Laryngeal cancer. Persistent hoarseness is a common symptom of laryngeal cancer due to vocal cord involvement. Laryngeal cancer causes changes in voice quality over time. Bacterial infection (A) usually presents with acute symptoms and resolves with treatment. Aphonia (B) is the complete loss of voice, not persistent hoarseness. Peritonsillar abscess (D) causes sore throat and difficulty swallowing, but not persistent hoarseness.
Question 4 of 9
A client who has been taking prednisone to treat lupus erythematosus has discontinued the medication because of lack of funds to buy the drug. When the nurse becomes aware of the situation, which assessment is most important for the nurse to make first?
Correct Answer: B
Rationale: Step-by-step rationale for choice B being correct: 1. Blood pressure is vital in this scenario due to prednisone discontinuation. 2. Abruptly stopping prednisone can lead to adrenal insufficiency. 3. Adrenal insufficiency can cause hypotension, a life-threatening condition. 4. Monitoring blood pressure can help detect and manage potential complications. Summary of other choices: A: Breath sounds – Important but not the priority in this specific situation. C: Capillary refill – Useful for assessing circulation but not urgent in this context. D: Butterfly rash – A characteristic of lupus, but not a critical concern in this scenario.
Question 5 of 9
Which of the ff does the examiner note when auscultating the lungs of a client with pleural effusion?
Correct Answer: D
Rationale: The correct answer is D because pleural effusion is the accumulation of fluid in the pleural space. When auscultating the lungs of a client with pleural effusion, the examiner would note decreased or absent breath sounds over the area where the fluid has accumulated. This is due to the fluid blocking the transmission of sound through the lungs. Pronounced breath sounds (choice A) would not be present due to the fluid obstructing the normal sound transmission. Expiratory wheezes (choice B) are associated with airway obstruction, not fluid accumulation. Friction rub (choice C) is a dry, grating sound heard with inflammation of the pleura, not specifically related to pleural effusion.
Question 6 of 9
When preparing a site for venipunctures with alcohol, how long must the area be cleaned?
Correct Answer: D
Rationale: The correct answer is D: 60 seconds. This is because the area must be cleaned for at least 60 seconds to effectively disinfect the skin and reduce the risk of infection during venipuncture. Cleaning for shorter durations (5, 10, or 30 seconds) may not be sufficient to achieve proper disinfection. Thoroughly cleaning the area for a full minute ensures that the alcohol has enough time to kill bacteria and pathogens on the skin, making it safer for the venipuncture procedure. Shorter cleaning times may leave pathogens behind, increasing the risk of contamination and infection.
Question 7 of 9
A nurse is conducting a health history interview for a woman at an assisted-living facility. The woman says, “I have been so constipated lately.” How should the nurse respond?
Correct Answer: C
Rationale: The correct answer is C. The nurse should respond by asking, “Do you take anything to help your constipation?” This response shows active listening and gathers more information about the woman’s current management of constipation. It allows the nurse to assess the woman's current treatment regimen and potential underlying causes. Choice A is incorrect as it diverts the conversation to chest problems, which is unrelated to the woman's primary concern of constipation. Choice B is incorrect as it suggests a potentially harmful solution without assessing the woman's current treatment or determining the cause of her constipation. Choice D is incorrect as it generalizes bowel problems with aging without addressing the woman's specific issue or management.
Question 8 of 9
A client is in isolation after receiving an internal radioactive implant to treat cancer. Two hours later, the nurse discovers the implant in the bed linens. What should the nurse do first?
Correct Answer: D
Rationale: The correct answer is D. First, the nurse should put the implant back in place using forceps and a shield for self-protection. This is important to limit the exposure to radiation for both the client and the nurse. Second, the nurse should call for help to ensure proper handling and further assistance. Standing away from the implant (choice A) does not address the immediate need to secure the implant. Picking up the implant with long-handled forceps and placing it in a lead-lined container (choice B) should only be done by trained personnel to prevent further exposure. Leaving the room and notifying the radiation therapy department immediately (choice C) delays the immediate action needed to prevent unnecessary radiation exposure.
Question 9 of 9
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.