NCLEX-RN
NCLEX RN Predictor Exam Questions
Extract:
Question 1 of 5
Which of the following items of subjective client data would be documented in the medical record by the nurse?
Correct Answer: D
Rationale: The correct answer is 'Client feels nauseated.' Subjective data refers to the client's sensations, feelings, and perception of their health status. It can only be reported by the client as it is based on their personal experiences. The feeling of nausea is a subjective symptom that the client experiences and can provide insight into their health condition.
Choices A and B represent objective data, as they describe observable or measurable findings that can be detected by the nurse.
Choice C involves information reported by someone other than the client, making it indirect and not purely subjective.
Question 2 of 5
During a work shift, how can a nurse best demonstrate the dynamic nature of the nursing process?
Correct Answer: D
Rationale: The nursing process is dynamic as it involves adapting to the changing health status of the client. Rapidly resetting priorities for client care based on changes in the client's condition exemplifies this dynamic nature by responding promptly to evolving circumstances. Collaborating with the client to establish healthcare goals (Option
A), reviewing the client's medical record history (Option
B), and explaining the purpose of administered medications to the client (Option
C) are all essential nursing actions but do not directly showcase the dynamic nature of the nursing process.
Question 3 of 5
The client reports nausea and constipation. Which of the following would be the priority nursing action?
Correct Answer: B
Rationale: The priority nursing action when a client reports symptoms like nausea and constipation is to complete an abdominal assessment. Assessment is crucial as it involves the systematic collection of data to understand the client's condition. By assessing the abdomen, the nurse can gather essential information to make a nursing diagnosis and develop a care plan. Collecting a stool sample (
Choice
A) may be necessary but comes after the assessment to confirm findings. Administering an anti-nausea medication (
Choice
C) addresses symptoms but does not address the underlying cause without a thorough assessment. Notifying the physician (
Choice
D) should come after the assessment to provide a complete picture of the client's condition.
Question 4 of 5
The nurse suspects that a client is withholding health-related information out of fear of discovery and possible legal problems. The nurse formulates nursing diagnoses for the client carefully, being concerned about a diagnostic error resulting from which of the following?
Correct Answer: A
Rationale: In this scenario, the nurse is cautious about potential diagnostic errors due to incomplete data. When a client withholds information, it can lead to incomplete data, which may result in inaccurate nursing diagnoses and care planning.
Therefore, the nurse's primary concern is collecting accurate data to make informed clinical decisions.
Choices B, C, and D are not relevant to the situation described. Generalizing from experience, identifying with the client, and lack of clinical experience do not directly address the issue of incomplete data impacting the diagnostic process.
Question 5 of 5
The client often sighs and says in a monotone voice, 'I'm never going to get over this.' When encouraged to participate in care, the client says, 'I don't have the energy.' These cues are suggestive of which nursing diagnoses? Select all that apply.
Correct Answer: A
Rationale: A nursing diagnosis involves clinical judgment about a response to a health problem. In this scenario, the client's expressions of feeling overwhelmed and lacking energy indicate feelings of hopelessness and powerlessness. While fatigue is mentioned, there is no direct evidence to support an interrupted sleep pattern, making option C incorrect. Similarly, disturbed self-esteem and self-care deficit are not evident from the given cues, making options D and E incorrect.