1. When the nurse explains to the patient that together they will plan the patient’s care and set
goals to achieve by discharge, the patient says, “How is that different from what the doctor
does?” Which response by the nurse is most appropriate?
a. “The role of the nurse is to provide prescribed patient care.”
b. “The nurse helps the doctor to diagnose and treat patients.”
c. “Nurses perform many of the procedures done by physicians.”
d. “Nursing is focused on the human response to health problems.”
Correct Answer: D
Rationale: This response is consistent with the American Nursing Association (ANA) definition
of nursing, which states that nursing is focused on the human response to health problems. The
other responses describe some of the dependent and collaborative functions of the nursing role
but do not accurately describe the nurse’s role in the health care system.
Cognitive Level: Comprehension Text Reference: p. 3
Nursing Process: Implementation
NCLEX: Safe and Effective Care Environment
2. When providing patient care using evidence-based practice, the nurse uses
a. clinical judgment based on experience.
b. evidence from a clinical research study.
c. evidence-based guidelines coupled with clinical expertise.
d. evaluation of data showing that the patient outcomes are met.
Correct Answer: C
Rationale: Evidence-based practice (EBP) is use of the best research-based evidence combined
with clinician expertise. Clinical judgment based on the nurse’s clinical experience is part of
EBP, but clinical decision making should also incorporate current research and research-based
guidelines. Evidence from one clinical research study does not provide an adequate
substantiation for interventions. Evaluation of patient outcomes is important, but interventions
should be based on research from randomized control studies with a large number of subjects.
Cognitive Level: Comprehension Text Reference: p. 5
Nursing Process: Planning
NCLEX: Safe and Effective Care Environment
,3. The nurse uses the nursing process in the care of patients primarily
a. as a scientific-based process of diagnosing the patient’s health care problems.
b. to establish nursing theory that incorporates the biopsychosocial nature of humans.
c. to explain nursing interventions to other health care professionals.
d. as a problem-solving tool to identify and treat patients’ health care needs.
Correct Answer: D
Rationale: The nursing process is a problem-solving approach to the identification and treatment
of patients’ problems. Diagnosis is only one phase of the nursing process. The primary use of the
nursing process is in patient care, not to establish nursing theory or explain nursing interventions
to other health care professionals.
Cognitive Level: Comprehension Text Reference: p. 9
Nursing Process: Implementation
NCLEX: Safe and Effective Care Environment
4. An elderly, emaciated patient is admitted to the intensive care unit (ICU). The nurse plans an
every-2-hours turning schedule to prevent skin breakdown. In this case, the nursing action is
considered to be
a. dependent.
b. cooperative.
c. independent.
d. collaborative.
Correct Answer: D
Rationale: When implementing collaborative nursing actions, the nurse is responsible primarily
for monitoring for complications or providing care to prevent or treat complications. Independent
nursing actions are focused on health promotion, illness prevention, and patient advocacy. A
dependent action would require a physician order to implement. Cooperative nursing functions
are not described as one of the formal nursing functions.
Cognitive Level: Application Text Reference: p. 10
Nursing Process: Implementation
NCLEX: Safe and Effective Care Environment
5. A patient who has been admitted to the hospital for gallbladder surgery tells the nurse on
admission, “I do not feel right about leaving my children with my neighbor.” During
assessment of the patient, an appropriate nursing action by the nurse is to
a. reassure the patient that these feelings are common for parents.
b. call the neighbor to determine whether adequate child care is being provided.
c. have the patient call the children to reassure herself that they are doing well.
d. gather more data about the patient’s feelings about the child care arrangements.
, Rationale: The assessment phase includes gathering multidimensional data about the patient.
The other nursing actions may be appropriate during the implementation phase (after further
assessment of the patient’s concerns is accomplished by the nurse), but they are not part of the
assessment phase.
Cognitive Level: Application Text Reference: p. 10
Nursing Process: Assessment NCLEX: Psychosocial Integrity
6. A patient with a stroke is paralyzed on the left side of the body and is not responsive enough
to turn or move independently in bed. A pressure ulcer has developed on the patient’s left hip.
The best nursing diagnosis for this patient is
a. impaired physical mobility related to paralysis.
b. impaired skin integrity related to altered circulation and pressure.
c. risk for impaired tissue integrity related to impaired physical mobility.
d. ineffective tissue perfusion related to inability to turn and move self in bed.
Correct Answer: B
Rationale: The patient’s major problem is the impaired skin integrity as demonstrated by the
presence of a pressure ulcer. The nurse is able to treat the cause of altered circulation and
pressure by frequently repositioning the patient. Although impaired physical mobility is a
problem for the patient, the nurse cannot treat the paralysis. The “risk for” diagnosis is not
appropriate for this patient, who already has impaired tissue integrity. The patient does have
ineffective tissue perfusion, but the impaired skin integrity diagnosis indicates more clearly what
the health problem is.
Cognitive Level: Application Text Reference: p. 11
Nursing Process: Diagnosis NCLEX: Physiological Integrity
7. A patient with an infection has a nursing diagnosis of fluid volume deficit related to
excessive diaphoresis. An appropriate patient outcome identified by the nurse is that the
a. patient has a balanced intake and output.
b. patient understands the need for increased fluid intake.
c. patient’s bedding is changed when it becomes damp.
d. patient’s skin remains cool and dry throughout hospitalization.
Correct Answer: A
Rationale: This statement gives measurable data showing resolution of the problem of fluid
volume deficit that was identified in the nursing diagnosis statement. The other statements would
not indicate that the problem of fluid-volume deficit was resolved.
Cognitive Level: Application Text Reference: p. 13
Nursing Process: Planning NCLEX: Physiological Integrity
8. A patient has a nursing diagnosis of activity intolerance related to prolonged bed rest as
manifested by the patient’s report of weakness and fatigue. An appropriate NOC outcome and
NIC intervention for this nursing diagnosis would be
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