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The Nursing Process NCLEX 3000 (73 questions and answers).
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The Nursing Process NCLEX 3000 (73 questions and answers).
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The NursingProcess NCLEX
3000 (73
questions and
answers)
What is the most appropriate nursing
diagnosis for a client with acute pancreatitis?
- answer 1. Deficient fluid volume
A client is admitted with the following vital
signs: temperature, 102° F (38.9° C); heart
rate, 144 beats/minute and irregular; and
respiratory rate, 22 breaths/minute. Which
nursing diagnosis takes highest priority when
planning this client's care? - answer 1.
Decreased cardiac output
,The nurse is taking the health history of an
85-year-old client. Which information will be
most useful to the nurse for planning care? -
answer 2. Current health promotion
activities
Which aspect of drug therapy is most
important when planning nursing care for an
elderly client? - answer 3. Noncompliance
A client with acquired immunodeficiency
syndrome (AIDS) develops Pneumocystis
carinii pneumonia. Which nursing diagnosis
has the highest priority? - answer 1.
Impaired gas exchange
Which clinical characteristic affects client
compliance? - answer 3. The nurse-client
relationship
Which statement reflects appropriate
documentation in the medical record of a
hospitalized client? - answer 4. "Client's skin
is moist and cool."
, The nurse is changing a client's dressing.
Which observation of the wound warrants
immediate physician notification? - answer
2. Yellow, purulent drainage
A 65-year-old client comes to the physician's
office for a follow-up appointment after
having a basal cell lesion removed from his
face. The nurse teaches the client to inspect
his skin for signs of melanoma. For which
sign should the nurse tell him to look? -
answer 3. Black or purple irregularly shaped
nodules
The nurse assesses capillary refill in a client
admitted with pneumonia and dehydration.
Which capillary refill duration is considered
abnormal and should be reported? - answer
4. 4 seconds
When collecting data, the nurse identifies
these signs and symptoms: impaired
coordination, decreased muscle strength,
limited range of motion, and reluctance to
move. These signs and symptoms indicate
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