The following questions are similar to those that may appear on the NCLEX-RN® exam. Some questions may have more
than one correct response. During this
... [Show More] review, you should select the one best response.
CHAPTER 1
1.1 A client is being discharged and
needs instructions on wound care.When
planning to teach the client, the nurse
should:
a. identify the client’s learning needs
and learning ability.
b. identify the client’s learning needs
and advise him what to do.
c. identify the client’s problems and
make the appropriate referral.
d. provide pamphlets or videotapes for
ongoing learning.
Answer: a
Rationale: To provide the most appropriate teaching, the nurse first needs to
identify what the client needs to know and determine the client’s educational
level and learning ability.
Comprehension
Implementation
Health Promotion: Prevention and/or Early Detection of Health Problems
1.2 A client is requesting a second
opinion. The nurse who supports and
promotes the client’s rights is acting as
the client’s:
a. teacher.
b. adviser.
c. supporter.
d. advocate.
Answer: d
Rationale: The nurse’s role as client advocate involves actively promoting clients’
rights to make decisions and choices.
Comprehension
Assessment
Safe, Effective Care Environment: Coordinated Care
Health Promotion: Prevention and/or Early Detection of Health Problems
1.3 The client tells the nurse she has
been smoking one pack of cigarettes a
day for the past 20 years. The nurse
recognizes this is what part of the
nursing process?
a. assessment
b. planning
c. implementation
d. evaluation
Answer: a
Rationale: Data collection occurs during the assessment phase; the information
can be obtained during the initial assessment as well as during ongoing
assessment.
Knowledge
Assessment
Health Promotion: Prevention and/or Early Detection of Health Problems
1.4 During the assessment step of the
nursing process, the nurse collects
subjective and objective data. The nurse
uses the information to identify:
a. medical diagnoses.
b. actual or potential problems.
c. client’s response to illness.
d. need for community support groups.
Answer: b
Rationale: Information obtained during the assessment step is used in planning
and implementing nursing care, based on the problems identified from the
assessment data.
Analysis
Planning
Health Promotion: Prevention and/or Early Detection of Health Problem
Answer: b
Rationale: Quality of care is evaluated through documentation reviews,
interviews and surveys, observation and equipment checks.
Application
Implementation
Health Promotion: Prevention and/or Early Detection of Health Problems
1.5 The nurse performs daily, routine
equipment checks to detect possible
malfunction. This is part of the nurse’s
role in the:
a. nursing process.
b. quality assurance plan.
c. care management.
d. assessment plan.
1.6 The nurse is developing a
nursing diagnosis for a client who
has pneumonia. The nurse recognizes
the diagnosis describes an actual or
potential problem that:
a. the nurse can treat independently.
Answer: a
Rationale: Nursing diagnoses reflect client problems that the nurse can treat
independently.
Application
Planning
Safe, Effective Care Environment: Coordinated Care
© 2007 Pearson Education, Inc. NCLEX-PN® Test Bank Questions 399
b. the nurse can treat with a physician’s
order.
c. requires physician’s intervention.
d. relates to the clients’ primary
diagnosis.
1.7 After administering pain
medication, the nurse returns to check
the client’s level of comfort. This stage
of the nursing process is known as:
a. assessment.
b. planning.
c. implementation.
d. evaluation.
Answer: d
Rationale: In the evaluation step the nurse determines if the interventions were
effective.
Analysis/Diagnosis
Evaluation
Safe, Effective Care Environment: Coordinated Care
1.8 A client has lost 10 pounds related
to nausea and vomiting. The nurse
identifies an appropriate expected
outcome: The client will:
a. gain weight.
b. gain 2 pounds within 1 week.
c. not lose weight.
d. gain 10 pounds in 2 days.
Answer: b
Rationale: Expected outcomes should reflect a goal that is client centered,
realistic, and measurable. Answers a and c are not measurable; d is not realistic.
Analysis/Diagnosis
Planning
Physiological Integrity: Physiological Adaptation
1.9 A problem-solving process that
requires empathy, knowledge, divergent
thinking, discipline, and creativity is
known as:
a. critical thinking.
b. nursing process.
c. framework for nurses.
d. care management.
Answer: a
Rationale: Critical thinking involves self-directed thinking, combining the nurse’s
cognitive skills as well as attitude, experience, empathy, and discipline.
Comprehension
Analysis/Diagnosis
Safe, Effective Care Environment: Coordinated Care
1.10 At the end of the shift, the nurse is
ready to leave but has not been relieved
by the oncoming shift nurse. The nurse’s
responsibility to provide care for clients
is part of the nurse’s:
a. Code of Ethics.
b. nursing process.
c. critical thinking.
d. quality assurance.
Answer: a
Rationale: The Code of Ethics guides the behavior of nurses. The nurse’s primary
commitment is to the client, ensuring he or she receives safe, competent, and
continual care.
Comprehension
Implementation
Safe, Effective Care Environment: Coordinated Care [Show Less]