Nursing Process 3

Question 1

A nurse is caring for a client with a nursing diagnosis of 'Deficient fluid volume related to vomiting as evidenced by dry mucous membranes and decreased skin turgor.' Which goal statement is most appropriate?

Accepted Answer

The client will demonstrate improved fluid balance as evidenced by moist mucous membranes and elastic skin turgor within 24 hours

Answer

A correctly written nursing goal is client-centered (subject is the client), includes a measurable outcome criteria (moist mucous membranes, elastic skin turgor), and includes a time frame (within 24 hours).

Question 2

A nurse completes an assessment and identifies the following: blood pressure 158/94 mmHg, heart rate 88 bpm, respiratory rate 18/min, and the client reports a headache of 7/10. Using the nursing process, which action follows assessment?

Accepted Answer

Analyze and interpret the data to formulate a nursing diagnosis

Answer

The nursing process is Assessment → Diagnosis → Planning → Implementation → Evaluation. After completing the assessment, the next step is to analyze the data and formulate nursing diagnoses, which guide the subsequent plan of care.

Question 3

A nurse is developing a teaching plan for a client newly diagnosed with type 2 diabetes. Which approach best demonstrates application of the nursing process to education?

Accepted Answer

Assessing the client's current knowledge, identifying learning needs, and developing a prioritized individualized teaching plan

Answer

Applying the nursing process to client education means first assessing the client's baseline knowledge and learning needs, then diagnosing learning deficits, planning individualized education, implementing the teaching plan, and evaluating comprehension.

Question 4

A nurse is evaluating the effectiveness of a pain management intervention for a post-operative client. The client reports pain of 3/10 one hour after receiving the analgesic. The pre-intervention pain was 8/10. Which conclusion is most accurate?

Accepted Answer

The intervention was partially effective; the goal of pain ≤4/10 has been achieved

Answer

The goal of pain management is typically to reduce pain to a manageable level (≤4/10), not necessarily to eliminate all pain. A reduction from 8/10 to 3/10 represents significant improvement and meets the commonly used threshold of ≤4/10.

Question 5

A nurse is performing a focused assessment on a client with chest pain. Which question would provide the most clinically significant data?

Accepted Answer

'Can you describe the quality of the pain and whether it radiates anywhere?'

Answer

Asking about the quality of pain (sharp, pressure, tearing, burning) and radiation pattern provides the most clinically significant data for differentiating cardiac from non-cardiac chest pain and directing emergent interventions.

NCLEX Practice Test

NCLEX Practice Test

Nursing Process 3