1. Nurs 230/CRITICAL THINKING/NURSING PROCESS
NCLEX-QUESTIONS
Nurs 230/CRITICAL THINKING/NURSING PROCESS

2. NCLEX QUESTIONS
During the change-of-shift report the night nurse states that a client mentioned having a bad experience with surgery in the past. The nurse was called away and was unable to continue the conversation with the client. The nurse tells the day shift nurse about the comment and notes that the client appears anxious. When the day shift nurse visits the client to clarify the client's bad experience with surgery, the nurse is exhibiting which aspect of critical thinking?
A) Integrity B) Discipline C) Confidence D) Perseverance
Workbook page

3. Answer: B
Discipline includes completing the task at hand, including assessments (which were not completed on the previous shift). Integrity includes recognizing when one's opinions conflict with those of others and finding a mutually satisfying solution. Confidence is demonstrated in one's presentation and belief in one's knowledge and abilities. Perseverance helps the critical thinker to find effective solutions to client care problems, especially when they have been previously unresolved.

4. A client newly admitted to the hospital begins to have chest pain
A client newly admitted to the hospital begins to have chest pain. Before calling the physician, the nurse should gather what additional data? (Select all that apply.) A) Pain intensity B) Location of pain C) Character of pain D) Radiation of pain E) Meaning of pain to the client F) Family history of myocardial infarctions

5. Answer: A,B, C, D, E
The nurse should gather the data the physician will need to determine whether the chest pain represents a myocardial infarction. Family history is important in comprehensive pain assessment; however, taking time to obtain this information is inappropriate in this critical situation.

6. The nurse is assessing the urinary history of a middle-aged married woman. The nurse asks her if she gets up at night. She replies, "Yes." What other question should the nurse ask?
A) "How many times do you get up at night?" B) "How long have you been getting up at night?" C) "Why do you get up at night?" D) "How easily do you go back to sleep after you get up?"

7. Answer: C
Perhaps it is the client's husband who is getting up in the middle of the night because of a prostate problem, and this is why she is awakened. The nurse should not assume nocturia without further assessment questions.

8. A nurse refers to a client's postsurgical written plan of care, noting that the client has a drainage device collecting wound drainage. The surgeon is to be notified when drainage in the device exceeds 100 ml for the day. The nurse carefully notes the amount of drainage currently in the device. This is an example of:
A) Planning B) Evaluation C) Assessment D) Intervention

9. Answer: C
Assessment is the process of observing and collecting data. Planning is the step in which the diagnosis is analyzed for problem resolution. Intervention consists of the steps actually taken after planning. Evaluation measures the effectiveness of the plan.

10. A nurse uses an institution's procedure manual to confirm how to insert a Foley catheter. The level of critical thinking the nurse is using is:
A)Commitment B) Scientific method C) Basic critical thinking D) Complex critical thinking

11. Answer: C
At the basic level of critical thinking, a learner trusts the experts and follows a procedure step by step. Complex critical thinkers separate themselves from authorities and analyze and examine choices more independently. Commitment is the third level of critical thinking in which the person anticipates the need to make choices without assistance from others. The scientific method is a process of problem solving.

12. The purpose of an assessment is to:
A) Make a diagnostic conclusion. B) Delegate nursing responsibility. C) Teach the client about his or her health. D) Establish a database concerning the client.

13. Answer: D
The purpose of assessment is to establish a database about the client's perceived needs, health problems, and responses to these problems. The data also reveal related experiences, health practices, goals, values, and expectations. The other options are not purposes of assessment.

14. Assessment data must be descriptive, concise, and complete
Assessment data must be descriptive, concise, and complete. In performing an assessment the nurse should not:
A)Include subjective data from the client. B) Perform a thorough physical examination. C) Use interpersonal and cognitive skills. D) Include inferences or interpretative statements not supported with data.

15. Answer: D
The nurse should not generalize or form judgments not supported by the collected data. Inferences and interpretive statements must be supported by data. Assessments do include conducting a thorough physical examination, using interpersonal and cognitive skills, and obtaining subjective data from the client.

16. During data clustering, a nurse:
A)Provides documentation of nursing care B) Reviews data with other health care providers C) Makes inferences about patterns of information D) Organizes cues into patterns that lead to identification of nursing diagnosis

17. Answer: D
During data clustering, the nurse organizes cues into patterns that indicate individualized nursing diagnoses and identify collaborative problems. The other options are incorrect.

18. The nurse gathered the following assessment data
The nurse gathered the following assessment data. Which of these cues form a pattern? (Select all that apply.)
A) Client is restless. B) Respirations are 24/min and irregular. C) Client states feeling short of breath. D) Fluid intake for 8 hours is 800 ml. E) Client has drainage from surgical wound. F) Client reports loss of appetite for over 2 weeks.

19. Answer: A,B, C
The data in items 1, 2, and 3—rapid irregular breathing, complaints of shortness of breath, and restlessness—form a pattern indicating that the client may be experiencing hypoxia, because all are signs and symptoms characteristic of this condition. The other information, although important, is not related to hypoxia.

20. The nursing assessment is which phase of the nursing process?
A) First B) Second C) Third D) Fourth

21. Answer: A
The nursing process cannot proceed unless the nurse first conducts a client assessment. The other phases of the nursing process occur after assessment.

22. A nursing diagnosis is:
A) The diagnosis and treatment of human responses to health and illness B) The advancement of the development, testing, and refinement of a common nursing language C) A clinical judgment about individual, family, or community responses to actual and potential health problems or life processes D) The identification of a disease condition based on a specific evaluation of physical signs, symptoms, the client's medical history, and the results of diagnostic tests

23. Answer: C
A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes. It is not a disease condition or medical diagnosis, or the diagnosis and treatment of human responses to health and illness. Nursing diagnoses are not a development or refinement in nursing language

24. nursing diagnosis Readiness for enhanced communication is an example of which of the following?
A) Risk nursing diagnosis B) Actual nursing diagnosis C) Potential nursing diagnosis D) Wellness nursing diagnosis

25. Answer: D
The term readiness indicates a wellness nursing diagnosis. An actual nursing diagnosis describes a human response to health conditions or life processes in an individual, family, or community. A potential nursing diagnosis is a risk for diagnosis.

26. The nursing diagnosis Hypothermia is an example of which of the following?
A) Risk nursing diagnosis B) Actual nursing diagnosis C) Potential nursing diagnosis D) Wellness nursing diagnosis

27. Answer: B
An actual nursing diagnosis describes a human response to health conditions or life processes in an individual, family, or community. The term readiness is present in a wellness nursing diagnosis. A potential nursing diagnosis is a risk for diagnosis.

28. Which of the following nursing interventions is written correctly?
A) Change dressing once a shift. B) Perform neurovascular checks. C) Elevate head of bed 30 degrees before meals. D) Apply continuous passive motion machine during day.

29. Answer: C
Option 3 is specific—it indicates what to do and when.

30. Which of the following are defining characteristics for the nursing diagnosis of Impaired urinary elimination? (Select all that apply.)
A) Nocturia B) Frequency C) Urinary retention D) Inadequate urinary output E) Receipt of intravenous fluids F) Sensation of bladder fullness

31. Answer: A, B, C
The defining characteristics for Impaired urinary elimination according to NANDA include nocturia, frequency, and urinary retention. The other options are not defining characteristics from NANDA.