You notice cues, form a hypothesis, act, and evaluate — the same loop Next Generation items reward. Five of the 15 questions include the correct answer and rationale. The other ten keep answers in the study hub. Continue with the NCLEX-PN exam guide or more NCLEX-PN practice questions.
Five clinical judgment questions with answers
Cover the key. Write the first action. Then open the rationale and name why the other choices fail.
Question 1
Why must the nurse be careful not to cut through or disrupt any tears, holes, bloodstains, or dirt present on the clothing of a client who has experienced trauma?
A. The clothing is the property of another and must be treated with care.
B. Such care facilitates repair and salvage of the clothing.
C. The clothing of a trauma victim is potential evidence with legal implications.
D. Such care decreases trauma to the family members receiving the clothing.
Show answer and rationale
Correct answer: C — The clothing of a trauma victim is potential evidence with legal implications.
The correct answer is C. Trauma in any client, living or dead, has potential legal and/or forensic implications. Clothing, patterns of stains, and debris are sources of potential evidence and must be preserved. Nurses must be aware of state and local regulations that require mandatory reporting of cases of suspected child and elder abuse, accidental death, and suicide. Each Emergency Department has written policies and procedures to assist nurses and other health care providers in making appropriate reports. Physical evidence is real, tangible, or latent matter that can be visualized, measured, or analyzed. Emergency Department nurses can be called on to collect evidence. Health care facilities have policies governing the collection of forensic evidence. The chain of evidence custody must be followed to ensure the integrity and credibility of the evidence. The chain of evidence custody is the pathway that evidence follows from the time it is collected until it has served its purpose in the legal investigation of an incident. Choices A, B, and D are incorrect because they do not address the crucial aspect of preserving potential evidence with legal implications that may be present on the clothing of a trauma victim.
Question 2
A licensed practical nurse (LPN) works on an adult medical/surgical unit and has been pulled to work on the burn unit, which cares for clients of all ages. What should the LPN do?
A. The LPN should take the assignment, but make it clear they will only care for adult clients.
B. The LPN should take the assignment, but explain the situation to the charge nurse and ask for a quick orientation before starting.
C. The LPN should refuse to take the assignment, as caring for the infant and child population is not within their scope of practice.
D. The LPN should take the assignment, but ask to be paired with a more experienced LPN.
Show answer and rationale
Correct answer: B — The LPN should take the assignment, but explain the situation to the charge nurse and ask for a quick orientation before starting.
In this scenario, it is crucial for the LPN to demonstrate flexibility and a willingness to adapt to the new assignment that involves caring for clients of all ages. While the LPN may have expertise in a specific nursing area, it is essential to be able to provide care to diverse client populations. Accepting the assignment reflects a commitment to teamwork and patient care. However, to ensure safe and competent care, the LPN should communicate with the charge nurse about the situation. Requesting a quick orientation will help the LPN familiarize themselves with the burn unit's specific requirements, equipment, and protocols. This proactive approach allows the LPN to address any concerns, ask questions, and seek necessary support, ultimately ensuring the best care for all clients in the burn unit.
Choice A is incorrect because limiting care to only adult clients may not be feasible in a unit that cares for clients of all ages. Choice C is incorrect as refusing the assignment outright may not be the best approach without considering alternatives. Choice D is not the most effective option as asking to be paired with a more experienced LPN does not address the need for a quick orientation to the new unit.
Question 3
A nurse is determining the fetal heart rate (FHR) and places the fetoscope on the mother's abdomen to count the FHR. The nurse simultaneously palpates the mother's radial pulse and notes that it is synchronized with the sounds heard through the fetoscope. Which action should the nurse take?
A. Count the FHR for 60 seconds, ensuring that it is synchronized consistently with the mother's radial pulse.
B. Move the fetoscope to another area on the mother's abdomen to locate the fetal heart.
C. Ask the mother to lie still while both the FHR and the radial pulse rate are counted.
D. Count the FHR for 30 seconds and then count the radial pulse rate of the mother for 30 seconds.
Show answer and rationale
Correct answer: B — Move the fetoscope to another area on the mother's abdomen to locate the fetal heart.
When auscultating the fetal heart rate, the nurse would place the fetoscope on the maternal abdomen, over the fetal back. The nurse would then palpate the mother's radial pulse. If her pulse is synchronized with the sounds from the fetoscope, the nurse would move the fetoscope to another area on the mother's abdomen to locate the FHR. The nurse needs to be sure that the FHR is what is actually being heard. Other sounds that may be heard are the funic sound (blood flowing through the umbilical cord) and the uterine sound (blood flowing through the uterine vessels). The funic sound is synchronized with the FHR; the uterine sound is synchronized with the mother's pulse. Therefore, moving the fetoscope to a different area will help in accurately locating and counting the fetal heart rate. Choice A is incorrect because counting for 60 seconds without changing the position may not address the issue of accurately locating the FHR. Choice C is incorrect as it does not address the need to reposition the fetoscope to locate the fetal heart. Choice D is incorrect because counting the FHR and the radial pulse rate separately may not help in differentiating the two sounds.
Question 4
Why is starting a low CHO diet a contraindication for a client with renal insufficiency?
A. As long as the client eats a minimum of 30g of CHO/day, there should be no problem.
B. The client's clinical condition is a contraindication to starting a low CHO diet.
C. Calcium supplements should be utilized to prevent the development of osteoporosis while on a low CHO diet.
D. As long as the client eats foods that are high biologic protein sources, a low CHO diet can be followed.
Show answer and rationale
Correct answer: B — The client's clinical condition is a contraindication to starting a low CHO diet.
A client with renal insufficiency should not start a low CHO diet because it could result in an increased renal solute load. Clients with renal or liver disease require protein control in their diet to prevent complications. Proteins used must be of high biologic value, and protein intake is usually weight-based. Protein levels may be adjusted based on the client's clinical condition. A minimum level of carbohydrates is needed in the diet to spare protein. Vitamin and mineral supplements might be needed for clients with liver failure. The dietician plays a crucial role in calculating specific nutrient requirements for these clients and monitoring outcomes in conjunction with the healthcare team. Choice A is incorrect because simply consuming a minimum amount of carbohydrates does not address the issue of increased renal solute load. Choice C is incorrect as calcium supplements are not the primary concern when considering a low CHO diet for a client with renal insufficiency. Choice D is incorrect as the focus should be on the contraindication of a low CHO diet for a client with renal insufficiency rather than just high biologic protein sources.
Question 5
The nurse is teaching parents of a newborn about feeding their infant. Which of the following instructions should the nurse include?
A. Use the defrost setting on microwave ovens to warm bottles.
B. When refrigerating formula, discard partially used bottles after 24 hours.
C. When using formula concentrate, mix one part water and one part concentrate.
D. When using powdered formula, mix two parts water and one part powder.
Show answer and rationale
Correct answer: A — Use the defrost setting on microwave ovens to warm bottles.
The correct answer is to use the defrost setting on microwave ovens to warm bottles. It is essential for parents to be cautious when warming bottles in a microwave oven to prevent superheating of the milk. Choosing the defrost setting and checking the formula temperature before giving it to the baby helps avoid burns. Discarding partially used bottles after 24 hours when refrigerating formula is crucial as it reduces the risk of harmful bacterial growth. Mixing formula concentrate with water in a 1:1 ratio of one part concentrate to one part water ensures proper dilution of the formula. On the other hand, powdered formula should be mixed following the package instructions, typically using two parts water to one part powder. This accurate mixing ratio provides the necessary balance of nutrients for the baby. Adding fresh formula to partially used bottles can introduce pathogens that may harm the infant, underscoring the importance of discarding partially used bottles and preparing formula correctly. Therefore, options B, C, and D are incorrect as they do not address the safe and proper ways to feed a newborn effectively.
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Question 6
In what order should the LPN see the following clients? Use appropriate letters to match the correct order
A. A, D, B, C
B. C, B, D, A
C. D, C, B, A
D. B, C, A, D
Correct answer:
The correct order for the LPN to see the clients is C, B, D, A. It is crucial to prioritize client care based on the urgency of their conditions. The 53-year-old client with lower leg swelling complaining of sudden onset headache and blurry vision (Client C) should be seen first as they are at the highest risk for serious healthcare complications. Next, the LPN should attend to the 23-year-old client with a left arm fracture after an MVA complaining of significant pain in his arm (Client B). Following that, the LPN can address the 47-year-old client requesting more information regarding her surgery scheduled in three hours (Client D). Lastly, the LPN should attend to the 72-year-old client with pneumonia asking to order her dinner (Client A). This order ensures that the most critical needs are met first, followed by the less urgent ones. Choice A is incorrect as it places the 72-year-old client before the 23-year-old client with a painful arm. Choice B is incorrect as it prioritizes the 53-year-old client last. Choice D is incorrect as it does not address the urgency of the clients' conditions appropriately.
A one-month-old infant in the neonatal intensive care unit is dying. The parents request that the nurse administer an opioid analgesic to their infant, who is crying weakly. The infant's heart rate is 68 beats per minute, and the respiratory rate is 18 breaths per minute. The infant is on room air, and the oxygen saturation is 92%. The nurse's response is based on which of the following principles?
A. Providing analgesia during the last days and hours is an ethically appropriate nursing action.
B. Withholding the opioid analgesia during the last days and hours is an ethical duty because administering it would represent assisted suicide.
C. Administering analgesia during the last days and hours is the parents' ethical decision.
D. Withholding the opioid analgesia is clinically appropriate because it will hasten the infant's death.
Correct answer:
All patients, regardless of age, have the right to die with dignity and be free from pain. In this case, the parents' request for an opioid analgesic to relieve the child's distress aligns with the principles of palliative care and ensuring comfort. Assisted suicide involves a conscious decision by the individual, which is not applicable to a 1-month-old infant. Both the nurse and the parents have an ethical duty to ensure the infant's comfort and well-being. Withholding opioid analgesia solely to hasten death is not appropriate, as providing pain relief is a crucial aspect of end-of-life care. Opioids can be administered to dying patients at any age to alleviate suffering without the intention of hastening death. Therefore, providing analgesia during the last days and hours is an ethically appropriate nursing action. Choices B, C, and D are incorrect because the decision to administer analgesia in this scenario is based on the best interest and comfort of the infant, not concerns about assisted suicide or hastening death. The ethical consideration is to provide compassionate care and alleviate suffering.
While taking care of a client, the nurse thinks that physical therapy in the hospital might be beneficial to their condition. The following is the ideal referral process EXCEPT?
A. Transport the client to the physical therapy room for treatment after receiving an official referral.
B. Provide the physical therapist with the client's medical record after the referral.
C. Contact the client's primary care provider to suggest a physical therapy referral.
D. Request the client to self-refer to the physical therapist.
Correct answer:
The ideal referral process for a client to receive physical therapy in the hospital starts with the nurse contacting the client's primary care provider to discuss and suggest a physical therapy referral. The primary care provider should provide an official referral, which is crucial for initiating the treatment process. After obtaining the official referral, the nurse should provide the physical therapist with the client's medical record. This step is essential for the therapist to assess the client's condition and customize the treatment plan accordingly. Once the physical therapist is informed and prepared, the nurse can then transport the client to the physical therapy room for treatment. Therefore, the correct sequence is to first contact the primary care provider (Choice C), then provide the medical record (Choice B), and finally transport the client for treatment (Choice A). Choice D, suggesting the client self-refer to the physical therapist, is incorrect as the referral process should involve healthcare professionals to ensure proper assessment and treatment planning.
A client scheduled for a left mastectomy and axillary lymph node dissection is wearing a wedding band on her left ring finger. The nurse should take which action?
A. Tape the wedding band in place
B. Ask the client to sign a release freeing the hospital of responsibility if the wedding band is lost during surgery
C. Explain to the client why the wedding band must be removed
D. Ask the client whether she would like to remove the wedding band or wear it to surgery
Correct answer:
In most situations, a wedding band may be taped in place and worn during a surgical procedure. However, if there is a possibility that the client will experience swelling of the hand or fingers, the wedding band should be removed. On admission to a healthcare facility, the client is usually asked to sign a form that releases the agency from responsibility if a client's valuables are lost. After a mastectomy with axillary lymph node dissection, the client is at risk for lymphedema, which can result in swelling of the arm and hand on the affected side. Therefore, the appropriate nursing action is to ask the client to remove the wedding band and explain why. This ensures the client's safety and prevents potential complications. Option A is incorrect because taping the wedding band may not be sufficient if swelling occurs. Option B is incorrect as it does not address the immediate need to remove the wedding band. Option D is incorrect because it fails to provide the client with the necessary information about the potential risks of wearing the wedding band during surgery.
Several clients are admitted to the emergency room following a three-car vehicle accident. Which clients can be assigned to share a room in the emergency department during the disaster?
A. The schizophrenic client experiencing visual and auditory hallucinations and the client with ulcerative colitis
B. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm
C. A child with fixed and dilated pupils and his parents, and the client with a frontal head injury
D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain
Correct answer:
The correct answer is to assign the client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm to share a room. The pregnant client needs close monitoring due to the abdominal pain, and the client with facial lacerations and a broken arm requires immediate attention for wound care and possible fracture management. Choice A should not be assigned together as the schizophrenic client experiencing visual and auditory hallucinations needs a separate room for privacy and safety, and the client with ulcerative colitis may require isolation due to the risk of infection. Choice C is incorrect because the child with fixed and dilated pupils is likely in a critical condition and should be in a private room with parents, while the client with a frontal head injury needs a separate room for focused care. Choice D is also incorrect as the client with a large puncture wound to the abdomen needs immediate attention in a separate room, and the client with chest pain requires evaluation and monitoring in a separate setting as well.
A client goes to the mental health center for difficulty concentrating, insomnia, and nightmares. The client reports being raped as a child. The nurse should assess the client for further signs of:
A. generalized anxiety disorder.
B. schizophrenia.
C. post-traumatic stress disorder.
D. bipolar disorder.
Correct answer:
Given the history of childhood sexual abuse and the presenting symptoms of difficulty concentrating, insomnia, and nightmares, the nurse should assess the client for post-traumatic stress disorder (PTSD). Childhood sexual abuse is strongly associated with adult-onset depression and an increased risk for PTSD. Individuals with PTSD may exhibit re-experiencing symptoms such as flashbacks, nightmares, and heightened reactions to trauma triggers. They may also display emotional numbing, avoidance behaviors, and increased arousal symptoms like difficulty sleeping and hypervigilance. Generalized anxiety disorder (Choice A) is characterized by excessive worry and anxiety about various events or activities, not necessarily tied to a specific trauma. Schizophrenia (Choice B) is a severe mental disorder characterized by distortions in thinking, perception, emotions, and behavior, unrelated to the traumatic event described. Bipolar disorder (Choice D) involves mood swings between depressive and manic episodes, and its symptoms differ from those typically seen in PTSD.
A health care provider repeatedly asks a nurse to write his verbal prescriptions in his clients' charts after he makes his rounds. The nurse is uncomfortable with writing the prescriptions and explains this to the health care provider, but the health care provider tells the nurse that she will be reported if she does not write the prescriptions. How should the nurse manage this conflict?
A. Stating to the health care provider, 'I don't really care whether you report me. I am not writing your prescriptions.'
B. Fulfilling the health care provider's request
C. Discussing the situation with the nurse manager
D. Reporting the health care provider to the chief of medicine at the hospital
Correct answer:
When a conflict arises, it is most appropriate to try resolving the conflict directly. In this situation, the nurse has tried to explain why she is uncomfortable with the health care provider's request but has been unable to resolve the conflict. The nurse would then most appropriately use organizational channels of communication and discuss the issue with the nurse manager, who would then proceed to resolve the conflict. The nurse manager may attempt to discuss the situation with the health care provider or seek assistance from the nursing supervisor. Fulfilling the health care provider's request and writing the prescriptions in the clients' charts ignores the issue. Reporting the health care provider to the chief of medicine is inappropriate because the nurse should use the appropriate organizational channels of communication to resolve the conflict. Stating 'I don't really care whether you report me. I am not writing your prescriptions.' is an inappropriate statement and will result in further conflict between the nurse and health care provider.
A nurse is caring for an older client who has a bronchopulmonary infection. The nurse monitors the client's ability to maintain a patent airway because of which factor involved in the normal aging process?
A. Increased respiratory system compliance
B. Decreased number of alveoli and increased function of those remaining
C. Decreased older client's ability to clear secretions
D. Increased production of surfactant
Correct answer:
The correct answer is 'Decreased older client's ability to clear secretions.' Respiratory changes related to the normal aging process decrease an older adult's ability to clear secretions and protect the airway. In healthy older adults, the number of alveoli does not change significantly; their structure, however, is altered. Respiratory system compliance decreases with advancing age because of a progressive loss of elastic recoil of the lung parenchyma and conducting airways, and reduced elastic recoil of the lung and opposing forces of the chest wall. Production of surfactant in the lung does not usually decrease with aging, nor does it increase. However, the production of alveolar cells responsible for surfactant production is diminished. Choices A, B, and D are incorrect. Choice A is incorrect because respiratory system compliance decreases with aging. Choice B is incorrect as the number of alveoli does not significantly decrease in healthy older adults. Choice D is incorrect as the production of surfactant does not usually decrease with aging.
When a person using over-the-counter nasal decongestant drops experiences unrelieved and worsening nasal congestion, what should be instructed?
A. switch to a stronger dose of the same medication.
B. discontinue the medication for a few weeks.
C. continue taking the same medication, but use it more frequently.
D. use a combination of medications for better relief.
Correct answer:
When a person using over-the-counter nasal decongestant drops experiences unrelieved and worsening nasal congestion, it is crucial to discontinue the medication for a few weeks. Prolonged use of decongestant drops can lead to rebound congestion, which is relieved by stopping the medication for a period of time. Nasal congestion occurs due to various factors like infection, inflammation, or allergy, leading to swelling of the nasal cavity. Nasal decongestants work by stimulating alpha-adrenergic receptors, causing vasoconstriction and shrinking of nasal mucous membranes. However, prolonged use can result in vasodilation, worsening nasal congestion. Switching to a stronger dose of the same medication is not recommended as it can exacerbate the issue. Continuing the same medication more frequently or using a combination of medications are also not advised and may lead to side effects. Educating individuals on proper decongestant use and potential risks of prolonged usage is essential, especially for those with specific health conditions.
A health care provider writes a medication prescription in a client's record. While transcribing the prescription, the nurse notes that the prescribed dose is three times higher than the recommended dose. The nurse calls the health care provider, who states that this is the dose that the client takes at home and that it is acceptable for this client's condition. What is the appropriate action for the nurse to take?
A. Verifying the prescribed dose with the client before administering the medication
B. Contacting the nursing supervisor
C. Asking the nurse assigned to care for the client to administer the medication
D. Continuing to transcribe the prescription
Correct answer:
In this scenario, the nurse has identified a significant discrepancy between the prescribed dose and the recommended dose. While the health care provider has justified the higher dose based on the client's home regimen, the nurse's primary responsibility is to ensure patient safety. If a nurse has concerns about a prescription being incorrect or potentially harmful, they should seek further clarification from the health care provider. Since the nurse still believes the dose is inappropriate after discussing with the health care provider, the next appropriate action is to contact the nursing supervisor. Continuing to transcribe the prescription without addressing the concern could jeopardize the client's safety. Asking another nurse to administer the medication without proper resolution of the dosage concern would also pose a risk to the client. While verifying the prescribed dose with the client is important, in this situation, the nurse should first escalate the issue to the nursing supervisor to ensure appropriate actions are taken.
NCLEX-PN clinical judgment practice questions for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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