Nursing Process 2

Question 1

A nurse is performing an initial assessment on a newly admitted client. The client reports chronic back pain and mentions they have been taking ibuprofen daily for 6 months. Which follow-up assessment is most important?

Accepted Answer

Assess the client's stool color and frequency for signs of GI bleeding

Answer

Long-term daily NSAID use (such as ibuprofen) is associated with gastrointestinal irritation, peptic ulcers, and GI bleeding. Assessing stool color and frequency is most important to detect signs of GI complications.

Question 2

A nurse is developing a care plan for a client with diabetes who has a non-healing wound on the left foot. Which nursing diagnosis is most appropriate?

Accepted Answer

Risk for infection related to hyperglycemia and impaired wound healing

Answer

A non-healing wound in a diabetic client poses the highest risk for infection due to hyperglycemia-impaired immune function and poor circulation. Risk for infection is the highest priority nursing diagnosis.

Question 3

A nurse has implemented a plan of care for a client with fluid volume excess. The client's weight has increased by 2 kg over the past 24 hours and breath sounds show new bilateral crackles. In which step of the nursing process is the nurse currently engaged?

Accepted Answer

Evaluation

Answer

Evaluating the outcomes of implemented nursing interventions — in this case, determining that weight has increased and crackles have developed — is the Evaluation step of the nursing process.

Question 4

A nurse is planning care and setting priorities for four clients. Using the nursing process, which client should be seen first?

Accepted Answer

A client with new onset confusion and a blood pressure of 80/50 mmHg

Answer

A client with new onset confusion and a blood pressure of 80/50 mmHg is showing signs of possible shock — this is the highest priority because it represents an immediate threat to life (circulation compromise).

Question 5

A nurse formulates the nursing diagnosis: 'Impaired skin integrity related to immobility as evidenced by a 2 cm x 2 cm Stage 2 pressure injury on the sacrum.' Which part represents the 'etiology' component?

Accepted Answer

Immobility

Answer

In the PES (Problem-Etiology-Signs/Symptoms) nursing diagnosis format, the etiology is the related factor or cause — in this case, 'immobility' is the factor contributing to the skin integrity impairment.

NCLEX Practice Test

NCLEX Practice Test

Nursing Process 2