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 because during the first phase of the nursing process (assessment), the nurse gathers a comprehensive database of information about the patient's health status. This includes collecting subjective and objective data to form a baseline for further decision-making. Identifying nursing diagnoses (B) occurs in the second phase (diagnosis), intervening based on priorities of patient care (C) is part of the third phase (planning), and determining outcomes (D) is done in the final phase (evaluation). Therefore, completing a comprehensive database is the most appropriate action in the first phase.
Question 2 of 9
Which type of neuron transmits impulses from the central nervous system to the muscles and glands?
Correct Answer: C
Rationale: The correct answer is C: Efferent neurons transmit impulses from the central nervous system to muscles and glands. This is because efferent neurons are responsible for carrying motor signals away from the central nervous system to control muscle movement and gland secretion. Afferent neurons (choice A) transmit sensory information from the body to the central nervous system. Affective (choice B) is not a term used in neuroscience for describing neuron functions. Effective (choice D) is not a term used in neuroscience and does not describe the specific function of transmitting impulses from the central nervous system to muscles and glands.
Question 3 of 9
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 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
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 because during the first phase of the nursing process (assessment), the nurse gathers a comprehensive database of information about the patient's health status. This step is crucial for identifying the patient's needs and developing a holistic care plan. Choice B is incorrect because identifying nursing diagnoses typically occurs in the second phase (diagnosis). Choice C is incorrect as intervening based on care priorities happens in the third phase (planning and implementation). Choice D is incorrect as determining outcomes achieved is part of the final phase (evaluation).
Question 6 of 9
A nurse is developing nursing diagnoses for a group of patients. Which nursing diagnoses will the nurse use? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Anxiety related to barium enema. This is the correct choice because nursing diagnoses should focus on the patient's actual or potential health problems, not just medical conditions. Anxiety is a common response to medical procedures like a barium enema. It is essential for the nurse to address the patient's emotional and psychological needs. Summary: B: Impaired gas exchange related to asthma is a medical diagnosis, not a nursing diagnosis. Nursing diagnoses focus on the patient's response to the medical condition. C: Impaired physical mobility related to incisional pain is a potential nursing diagnosis, but the focus should be on the patient's response to the pain, not just the pain itself. D: Nausea related to adverse effect of cancer medication is also a medical diagnosis. Nursing diagnoses should address the patient's response to the medication side effects, not just the side effects themselves.
Question 7 of 9
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 8 of 9
Which of the following terms indicates that the patient has a hearing loss caused by aging?
Correct Answer: B
Rationale: The correct answer is B: Presbycusis. Presbycusis refers to age-related hearing loss, commonly affecting higher frequencies. As people age, changes in the inner ear structures can lead to hearing loss. Otoplasty (A) is a surgical procedure to correct ear deformities, not related to aging. Otalgia (C) refers to ear pain, not specifically related to aging. Tinnitus (D) is the perception of ringing or buzzing in the ears, which can occur at any age and is not exclusive to age-related hearing loss.
Question 9 of 9
A factory worker suffered a chemical burn to the eye and arrives at the Emergency department. What is the first action of the nurse?
Correct Answer: D
Rationale: The correct answer is D: flush the eye continuously with sterile solution. This is the first action because it helps to remove the chemical from the eye, preventing further damage. Flushing with sterile solution dilutes and washes away the chemical, reducing the risk of ongoing injury. Applying a cold compress (A) may help with pain but does not address the chemical exposure. Applying a bandage (B) can trap the chemical and worsen the injury. Performing an assessment (C) should come after immediate treatment to ensure proper care but should not delay flushing the eye.