NURSING PROCESS DIAGNOSES PRACTICE TEST
(NCLEX STYLE) 15 QUESTIONS AND ANSWERS
LATEST VERSION VERIFIED RATIONALE GRADED
A+
A female client who received general anesthesia returns from surgery. Postoperatively, which nursing
diagnosis takes highest priority for this client?
A. Acute pain R/T surgery
B. Deficient fluid volume R/T blood and fluid loss from surgery
C. Impaired physical mobility R/T surgery
D. Risk for aspiration R/T anesthesia - ansAnswer: D
Rationale- Risk for aspiration takes priority because general anesthesia may impair gag and swallow
reflexes. The other options, although important, are secondary to this.
A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive the
highest priority at this time?
A. Impaired gas exchange related to increased blood flow
B. Fluid volume excess related to peripheral vascular disease
C. Risk for injury related to edema
D. Altered peripheral tissue perfusion related to venous congestion - ansAnswer: D
Rationale: This answer takes highest priority because venous inflammation and clot formation impede
blood flow in a patient with deep-vein thrombosis.
Option A is incorrect because impaired gas exchange is related to decreased, not increased, blood flow.
Option B is inappropriate because no evidence suggests that this patient has a fluid volume excess.
Option C may be warranted but is secondary to altered tissue perfusion
A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The first
nursing priority for this client would be to:
, NURSING PROCESS DIAGNOSES PRACTICE TEST
(NCLEX STYLE) 15 QUESTIONS AND ANSWERS
LATEST VERSION VERIFIED RATIONALE GRADED
A+
A. Assess the client's airway
B. Provide pain relief
C. Encourage deep breathing and coughing
D. Splint the chest wall with a pillow - ansAnswer: A
Rationale- The first priority is to evaluate airway patency. Pain management and splinting are important
for client comfort, but come after an airway assessment. Coughing and deep breathing may be
contraindicated if the client has internal bleeding and other injuries.
A nurse is assigned to care for a postoperative male client who has diabetes mellitus. During the
assessment interview, the client reports that he's impotent and says he's concerned about the effect on
his marriage. In planning this client's care, the most appropriate intervention would be to:
A. Encourage the client to ask questions about personal sexuality
B. Provide time for privacy
C. Suggest referral to a sex counselor or other appropriate professional
D. Provide support for the spouse - ansAnswer: C
Rationale- Making appropriate referrals is a valid part of planning the client's care. The nurse normally
does not provide sex counseling. While providing time for privacy and providing support for the spouse is
important, it is not as important as referring the client to a sex counselor/appropriate professional.
A nurse is revising a client's care plan. During which step of the nursing process does such a revision take
place?
A. Assessment
B. Planning
(NCLEX STYLE) 15 QUESTIONS AND ANSWERS
LATEST VERSION VERIFIED RATIONALE GRADED
A+
A female client who received general anesthesia returns from surgery. Postoperatively, which nursing
diagnosis takes highest priority for this client?
A. Acute pain R/T surgery
B. Deficient fluid volume R/T blood and fluid loss from surgery
C. Impaired physical mobility R/T surgery
D. Risk for aspiration R/T anesthesia - ansAnswer: D
Rationale- Risk for aspiration takes priority because general anesthesia may impair gag and swallow
reflexes. The other options, although important, are secondary to this.
A female patient is diagnosed with deep-vein thrombosis. Which nursing diagnosis should receive the
highest priority at this time?
A. Impaired gas exchange related to increased blood flow
B. Fluid volume excess related to peripheral vascular disease
C. Risk for injury related to edema
D. Altered peripheral tissue perfusion related to venous congestion - ansAnswer: D
Rationale: This answer takes highest priority because venous inflammation and clot formation impede
blood flow in a patient with deep-vein thrombosis.
Option A is incorrect because impaired gas exchange is related to decreased, not increased, blood flow.
Option B is inappropriate because no evidence suggests that this patient has a fluid volume excess.
Option C may be warranted but is secondary to altered tissue perfusion
A male client is admitted to the hospital with blunt chest trauma after a motor vehicle accident. The first
nursing priority for this client would be to:
, NURSING PROCESS DIAGNOSES PRACTICE TEST
(NCLEX STYLE) 15 QUESTIONS AND ANSWERS
LATEST VERSION VERIFIED RATIONALE GRADED
A+
A. Assess the client's airway
B. Provide pain relief
C. Encourage deep breathing and coughing
D. Splint the chest wall with a pillow - ansAnswer: A
Rationale- The first priority is to evaluate airway patency. Pain management and splinting are important
for client comfort, but come after an airway assessment. Coughing and deep breathing may be
contraindicated if the client has internal bleeding and other injuries.
A nurse is assigned to care for a postoperative male client who has diabetes mellitus. During the
assessment interview, the client reports that he's impotent and says he's concerned about the effect on
his marriage. In planning this client's care, the most appropriate intervention would be to:
A. Encourage the client to ask questions about personal sexuality
B. Provide time for privacy
C. Suggest referral to a sex counselor or other appropriate professional
D. Provide support for the spouse - ansAnswer: C
Rationale- Making appropriate referrals is a valid part of planning the client's care. The nurse normally
does not provide sex counseling. While providing time for privacy and providing support for the spouse is
important, it is not as important as referring the client to a sex counselor/appropriate professional.
A nurse is revising a client's care plan. During which step of the nursing process does such a revision take
place?
A. Assessment
B. Planning
