Nursing Process

Question 1

A nurse is admitting a client with pneumonia. The client has crackles in the right lower lobe, oxygen saturation of 91%, and a respiratory rate of 26 breaths/min. Which nursing diagnosis has the highest priority?

Accepted Answer

Impaired gas exchange related to alveolar inflammation

Answer

Impaired gas exchange addresses an immediate physiological threat to life (SpO2 91%, RR 26). Using Maslow's hierarchy, oxygenation is the most fundamental physiological need. It must be addressed before activity, knowledge, or psychosocial concerns.

Question 2

During the assessment phase of the nursing process, the nurse obtains subjective data. Which is an example of subjective data?

Accepted Answer

The client states, 'My chest feels tight and I am short of breath'

Answer

Subjective data is information reported by the client that cannot be directly observed or measured by others — symptoms such as pain, shortness of breath, and nausea. Objective data includes measurable, observable findings such as vital signs, lab values, and physical exam findings.

Question 3

A nurse has identified the nursing diagnosis 'Risk for infection related to impaired skin integrity.' In the planning phase, which outcome is written correctly using SMART criteria?

Accepted Answer

The client will remain free of signs of wound infection as evidenced by no erythema, edema, or purulent drainage by day 3

Answer

A correctly written SMART nursing outcome is Specific, Measurable, Achievable, Relevant, and Time-bound. 'Free of signs of infection as evidenced by no erythema, edema, or purulent drainage by day 3' includes observable criteria and a timeline. Nurse-focused statements are not appropriate client outcomes.

Question 4

A nurse implements a turning schedule for a client with limited mobility. During evaluation, the nurse notes a new stage 2 pressure ulcer on the client's sacrum. What is the nurse's next action?

Accepted Answer

Revise the care plan to increase repositioning frequency and add a pressure-relief mattress

Answer

Evaluation determines whether the care plan is effective. When a client develops a new complication despite existing interventions, the nurse must revise the plan of care. Increasing repositioning frequency and adding pressure-relief devices are evidence-based modifications.

Question 5

A nurse is collecting data on a newly admitted client. Which action is part of the assessment phase of the nursing process?

Accepted Answer

Auscultating lung sounds and reviewing recent laboratory results

Answer

Assessment is the first step of the nursing process and involves systematic collection of subjective and objective data through physical examination, interview, and review of records. Planning, implementation (medication administration, teaching), and evaluation are subsequent steps.

NCLEX Practice Test

NCLEX Practice Test

Nursing Process