Fundamentals of Nursing NCLEX RN Exam Practice Q&A Set 5
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NCLEX RN
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NCLEX RN
Fundamentals of Nursing NCLEX RN Exam Practice Q&A Set 5 | 75 Questions
1. 1. Question
Once a nurse assesses a client’s condition and identifies appropriate nursing diagnoses, a:
o A. Plan is developed for nursing care.
o B. Physical assessment begins.
o C. List of priorities is dete...
fundamentals of nursing nclex rn exam practice qampa set 5 | 75 questions 1 1 question once a nurse assesses a client’s condition and identifies appropriate nursing diagnoses
a o a plan is d
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Fundamentals of Nursing NCLEX RN Exam Practice Q&A Set 5 |
75 Questions
1. 1. Question
Once a nurse assesses a client’s condition and identifies appropriate
nursing diagnoses, a:
o A. Plan is developed for nursing care.
o B. Physical assessment begins.
o C. List of priorities is determined.
o D. Review of the assessment is conducted with other team
members.
Incorrect
Correct Answer: A. Plan is developed for nursing care.
The planning stage is where goals and outcomes are formulated that
directly impact patient care based on EDP guidelines. These patient-
specific goals and the attainment of such assist in ensuring a positive
outcome. Nursing care plans are essential in this phase of goal setting.
Option B: Assessment is the first step and involves critical
thinking skills and data collection; subjective and objective.
Subjective data involves verbal statements from the patient or
caregiver. Objective data is measurable, tangible data such as
vital signs, intake and output, and height and weight.
Option C: A nursing diagnosis encompasses Maslow’s Hierarchy
of Needs and helps to prioritize and plan care based on patient-
centered outcomes. In 1943, Abraham Maslow developed a
hierarchy based on basic fundamental needs innate for all
individuals.
Option D: Data may come from the patient directly or from
primary caregivers who may or may not be direct relation family
members. Friends can play a role in data collection. Electronic
health records may populate data and assist in assessment.
2. 2. Question
, Planning is a category of nursing behaviors in which:
A. The nurse determines the health care needed for the client.
B. The physician determines the plan of care for the client.
C. Client-centered goals and expected outcomes are
established.
D. The client determines the care needed.
Incorrect
Correct Answer: C. Client-centered goals and expected
outcomes are established.
The planning stage is where goals and outcomes are formulated that
directly impact patient care based on EDP guidelines. These patient-
specific goals and the attainment of such assist in ensuring a positive
outcome.
Option A: Nursing care plans are essential in this phase of goal
setting. Care plans provide a course of direction for personalized
care tailored to an individual’s unique needs. Overall condition
and comorbid conditions play a role in the construction of a care
plan.
Option B: As explored by Salmond and Echevarria, healthcare is
changing, and the traditional roles of nurses are transforming to
meet the demands of this new healthcare environment. Nurses
are in a position to promote change and impact patient delivery
care models in the future.
Option D: Care plans enhance communication, documentation,
reimbursement, and continuity of care across the healthcare
continuum. Critical thinking skills will play a vital role as nurses
develop plans of care for these patient populations with multiple
comorbidities and embrace this challenging healthcare arena.
3. 3. Question
Priorities are established to help the nurse anticipate and sequence
nursing interventions when a client has multiple problems or
alterations. Priorities are determined by the client’s:
A. Physician
, B. Non-Emergent, non-life-threatening needs
C. Future well-being.
D. Urgency of problems
Incorrect
Correct Answer: D. Urgency of problems
Triage of patients involves looking for signs of serious illness or injury.
These emergency signs are connected to the Airway – Breathing –
Circulation/Consciousness – Dehydration and are easily remembered
as ABCD. If the client does not have any emergency signs, the health
worker proceeds to assess the client for priority conditions. This should
not take more than a few seconds. Some of these signs will have been
noticed during the ABCD triage and others need to be rechecked.
Option A: All clinical staff involved in the care of the sick should
be prepared to carry out a rapid assessment to identify the few
clients who are severely ill and require emergency treatment.
Option B: Triage is the process of rapidly examining sick
children when they first arrive in order to place them in one of
the following categories: those with EMERGENCY SIGNS who
require immediate emergency treatment; those with PRIORITY
SIGNS who should be given priority in the queue so they can be
rapidly assessed and treated without delay; and those who have
no emergency or priority signs and are NON-URGENT cases.
These clients can wait their turn in the queue for assessment and
treatment. The majority of sick clients will be non-urgent and will
not require emergency treatment.
Option C: Ideally, all clients should be checked on their arrival
by a person who is trained to assess how ill they are. This person
decides whether the client will be seen immediately and receive
life-saving treatment, or will be seen soon, or can safely wait for
his or her turn to be examined.
4. 4. Question
A client-centered goal is a specific and measurable behavior or
response that reflects a client’s:
A. Desire for specific health care interventions.
, B. Highest possible level of wellness and independence in
function.
C. Physician’s goal for the specific client.
D. Response when compared to another client with a similar
problem.
Incorrect
Correct Answer: B. Highest possible level of wellness and
independence in function.
Client-centered practices facilitate the development of strong
therapeutic relationships and enable care providers to understand how
to maximize clients’ strengths and minimize challenges in achieving
treatment and recovery goals.
Option A: Care providers negotiate between clients’ decisions
and ongoing risk assessments. The care plan reflects safe
practices and promotes interventions that minimize or reduce
potential harms to the client.
Option C: Client-centred care empowers clients, promoting
autonomy, rights, voice, and self-determination in the treatment
planning and recovery process and supports care plans that are
developed in collaboration with clients, and allows clients to
express their self-identified needs and choices.
Option D: Client-centred care is about treating clients as they
want to be treated, with knowledge about and respect for their
values and personal priorities. Health care providers who take the
time to get to know their clients can provide care that better
addresses the needs of clients and improves their quality of care.
5. 5. Question
For clients to participate in goal setting, they should be:
A. Alert and have some degree of independence.
B. Ambulatory and mobile.
C. Able to speak and write.
D. Able to read and write.
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