NCLEX-PN clinical judgment practice questions, set 10
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 10
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
What can the nurse instruct the mother of a teething 9-month-old infant to relieve discomfort?
A. Rub the infant's gums with baby aspirin dissolved in water.
B. Obtain an over-the-counter (OTC) topical medication for gum pain relief.
C. Schedule an appointment with a dentist for a dental evaluation.
D. Give the infant cool liquids or a Popsicle and hard foods such as dry toast.
Show answer and rationale
Correct answer: D — Give the infant cool liquids or a Popsicle and hard foods such as dry toast.
Teething in infants can cause discomfort, but it is a normal process. Symptoms may include nighttime awakening, daytime restlessness, excess drooling, and temporary loss of appetite. The recommended approach to relieve teething discomfort includes providing cool liquids, a Popsicle, or hard foods like dry toast for chewing. These items can help soothe the infant's gums. Rubbing the gums with baby aspirin dissolved in water is not recommended as it can be harmful. OTC topical medications are unnecessary for teething discomfort. Scheduling a dental evaluation is not required solely for teething. It's important to avoid home remedies like baby aspirin and opt for safer options like cool liquids. If necessary, acetaminophen (Tylenol) can be used under healthcare provider guidance to alleviate discomfort.
Question 2
According to Erik Erikson's developmental theory, which choice is a developmental task of the middle adult?
A. Redefining self-perception and capacity for intimacy
B. Making decisions concerning career, marriage, and parenthood
C. Providing guidance during interactions with his children
D. Verbalizing readiness to assume parental responsibilities
Show answer and rationale
Correct answer: C — Providing guidance during interactions with his children
According to Erikson's developmental theory, the primary developmental task of the middle adult is to achieve generativity. Generativity is the willingness to care for and guide others. Middle adults can achieve generativity with their own children or the children of close friends or through guidance in social interactions with the next generation. Providing guidance during interactions with his children aligns with this developmental task. Choices A, B, and D are not specific to the middle adult stage as they are tasks associated with young adults. Redefining self-perception and capacity for intimacy, making decisions concerning career, marriage, and parenthood, and verbalizing readiness to assume parental responsibilities are all developmental tasks of the young adult according to Erikson's theory.
Question 3
A 6-month-old client is admitted with possible intussusception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?
A. "Tell me about his pain."?
B. "What does his vomit look like?"?
C. "Describe his usual diet."?
D. "Have you noticed changes in his abdominal size?"?
Show answer and rationale
Correct answer: C — "Describe his usual diet."?
The least helpful question in obtaining information regarding intussusception is "Describe his usual diet."? This question is least relevant to the specific symptoms and presentation of intussusception. Choices A, B, and D are more directly related to symptoms commonly associated with intussusception and can provide important diagnostic clues. Asking about pain, vomit appearance, and changes in abdominal size can help in assessing the severity and progression of the condition, making them more crucial questions to ask in this scenario. Pain is a cardinal symptom of intussusception, changes in vomit appearance may indicate gastrointestinal issues, and alterations in abdominal size can signify the presence of a mass or obstruction, all of which are pertinent in diagnosing and managing intussusception.
Question 4
Which of the following provides the framework for confidentiality and the client's right to privacy?
A. Health Insurance Portability and Accountability Act
B. CDC Surveillance Programs
C. American Nurses Association Code of Ethics
D. Durable Power of Attorney for Health Care
Show answer and rationale
Correct answer: A — Health Insurance Portability and Accountability Act
The correct answer is the Health Insurance Portability and Accountability Act (HIPAA). HIPAA is the federal statute that outlines client confidentiality and the client's right to privacy. It establishes national standards to protect individuals' medical records and personal health information. The American Nurses Association Code of Ethics emphasizes principles of nursing ethics but does not serve as a legal framework for confidentiality and privacy. CDC Surveillance Programs focus on disease surveillance and control at a public health level and are not directly related to individual client privacy. The durable power of attorney for health care pertains to granting legal decision-making authority to another individual in healthcare matters, rather than addressing confidentiality and privacy rights.
Question 5
Which action exemplifies the use of evidence-based practice in the delivery of client care?
A. Advising a client to agree to the treatment recommended by their healthcare provider
B. Taking a rectal temperature from a client for whom bleeding precautions have been instituted
C. Donning sterile gloves to change an abdominal wound dressing
D. Encouraging a client to take an herbal substance to treat their insomnia
Show answer and rationale
Correct answer: C — Donning sterile gloves to change an abdominal wound dressing
Evidence-based practice is an approach to client care where the nurse integrates the client’s preferences, clinical expertise, and the best research evidence to deliver quality care. Donning sterile gloves to change an abdominal wound dressing exemplifies evidence-based practice as it prevents the entrance of harmful bacteria into the wound, following best practice guidelines. The other options do not align with evidence-based practice. Advising a client to agree to a treatment does not involve integrating research evidence. Taking herbal substances may not be supported by strong research evidence and can pose risks. Additionally, rectal temperature-taking in a client with bleeding precautions can increase the risk of injury to the rectal mucosa, not aligning with best practices in care delivery.
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Question 6
The mother of an adolescent calls the clinic nurse and reports that her daughter wants to have her navel pierced. The mother asks the nurse about the dangers associated with body piercing. The nurse provides which information to the mother?
A. Infection always occurs when body piercing is done
B. Hepatitis B is a concern with body piercing
C. Body piercing is generally harmless as long as it is performed under sterile conditions
D. It is important to discourage body piercing because of the risk of contracting human immunodeficiency virus (HIV)
Correct answer:
Generally, body piercing is harmless if the procedure is performed under sterile conditions by a qualified person. Some complications that may occur include bleeding, infection, keloid formation, and the development of allergies to metal. It is essential to clean the area at least twice a day (more often for a tongue piercing) to prevent infection. HIV and hepatitis B infections are not typically associated with body piercing; however, they are a possibility with tattooing. Choice A is incorrect because infection does not always occur when body piercing is done. Choice B is not the best answer as hepatitis B is not commonly associated with body piercing. Choice D is incorrect because the risk of contracting HIV is not a significant concern with body piercing if performed under sterile conditions.
A 2-year-old child diagnosed with HIV comes to a clinic for immunizations. Which of the following vaccines should the nurse expect to administer in addition to the scheduled vaccines?
A. pneumococcal vaccine
B. hepatitis A vaccine
C. Lyme disease vaccine
D. typhoid vaccine
Correct answer:
For a 2-year-old child diagnosed with HIV, in addition to the scheduled vaccines, the nurse should expect to administer the pneumococcal vaccine. Children with HIV are at an increased risk of infections, including pneumococcal disease. The pneumococcal vaccine helps protect against serious pneumococcal infections like pneumonia, meningitis, and bacteremia. The hepatitis A vaccine is not specifically recommended for all children with HIV unless there are specific risk factors. The Lyme disease vaccine is for individuals at risk for Lyme disease, typically between the ages of 15 and 70, transmitted by ticks. The typhoid vaccine is usually recommended for individuals traveling to endemic areas or working in specific high-risk occupations like microbiology laboratories dealing with Salmonella typhi.
When discussing the child's wishes for future care, it is important for the nurse to first identify what the child knows about the disease and his prognosis. Factors such as the perceived severity of the illness will be significant in planning for end-of-life care. If the child does not understand the disease process or prognosis, the plan of care would not be effective or realistic. In addition, asking a child about desired interventions in the event of cardiac or respiratory arrest would not be an appropriate initial area of questioning. If the child does not understand the disease process, these questions may seem frightening or threatening. While exploring the child's belief about death would be important, it would not be the initial area of discussion and should be guided by the child rather than the nurse.
A. What the child knows about the disease and his prognosis.
B. How the child would like to handle the plan of care.
C. What interventions the child would like in the event of cardiac or respiratory arrest.
D. What the child believes about death.
Correct answer:
When discussing the child's wishes for future care, it is essential to first determine what the child understands about the disease and his prognosis. This information is crucial for planning appropriate end-of-life care. If the child lacks comprehension of the illness and its prognosis, any care plan discussed would be ineffective and unrealistic. Inquiring about desired interventions during cardiac or respiratory arrest is not the initial step, as it may cause distress if the child lacks understanding. While exploring the child's beliefs about death is significant, it should not be the primary focus initially and should be approached based on the child's readiness, not the nurse's agenda. Therefore, the correct first step is to assess what the child knows about the disease and his prognosis.
The nurse is teaching a client about erythema infectiosum. Which of the following factors is not correct?
A. There is no rash.
B. The disorder is uncommon in adults.
C. There is no fever.
D. There is sometimes a 'slapped face' appearance.
Correct answer:
The correct answer is B: 'The disorder is uncommon in adults.' Erythema infectiosum, also known as Fifth's disease, is more common in children than in adults. It typically presents with a rash on the face that gives a 'slapped cheek' or 'slapped face' appearance. Fever may be present, and there is a characteristic rash associated with the condition. Therefore, the statement 'The disorder is uncommon in adults' is incorrect, making it the correct answer. The other statements are true regarding erythema infectiosum, making them incorrect choices. There is indeed a rash associated with erythema infectiosum, which can be a prominent feature. Fever may also be present in individuals with this condition. Additionally, the 'slapped face' appearance is a classic characteristic of erythema infectiosum.
A male client is learning about testicular self-examination (TSE) from a nurse. Which statement should the nurse make to the client?
A. 'A good time to examine the testicles is during or after you take a shower.'
B. 'If you notice an enlarged testicle or a lump, you need to notify the physician.'
C. 'The testicle is round and smooth. It feels firm and without lumps.'
D. 'Perform a testicular exam monthly to detect early signs of testicular cancer.'
Correct answer:
The correct statement for the nurse to make to the client is 'If you notice an enlarged testicle or a lump, you need to notify the physician.' During a shower or bath is the best time to examine the testes because warm temperatures make the testes hang lower in the scrotum. The testes should feel round and smooth, without lumps. Self-examination should be performed monthly to detect any abnormalities early. The physician needs to be notified immediately if any abnormal findings are noticed. Choice A is incorrect because the best time for TSE is during or after a warm shower or bath, not just before. Choice C is incorrect as the testicle should feel round, smooth, and without lumps, not egg-shaped and lumpy. Choice D is incorrect as monthly self-examinations are recommended, not every 2 months.
A 17-year-old female was raped by a young man in her neighborhood. She is in the Emergency Department for evaluation and tests. After the procedure is completed, a rape crisis counselor (nurse specialist) talks to the client in a conference room regarding the rape. Implementing counseling by the nurse specialist for the raped victim represents:
A. assessment.
B. crisis intervention.
C. empathetic concern.
D. unwarranted intrusion
Correct answer:
Crisis intervention is the correct choice. Counseling by a nurse specialist after a traumatic event like rape falls under the Crisis Intervention Model. This approach aims to provide immediate support to individuals facing a crisis to enhance coping mechanisms. In this scenario, the nurse specialist is offering specialized care tailored to rape victims, helping the client navigate through the emotional aftermath of the traumatic experience. Choices A, C, and D are incorrect: A is not the correct answer as the nurse specialist is providing emotional support rather than conducting an assessment; C, while important, does not fully capture the specialized intervention being provided; and D is inaccurate as the nurse specialist's intervention is warranted and essential for the victim's well-being.
Which infection control measure is the priority for the nurse to implement in the care provided for a child admitted to the hospital with bacterial meningitis?
A. Place the child in a private room
B. Gowns and masks must be worn by all personnel in the child's room
C. Visitors are restricted to parents only
D. Hand washing is required by all personnel and visitors having contact with the child
Correct answer:
The priority control measure for the nurse to implement in caring for a child with bacterial meningitis is ensuring that gowns and masks are worn by all personnel in the child's room. This measure is crucial as the child with bacterial meningitis is contagious for at least 24 hours after starting antibiotics, necessitating airborne precautions to prevent the spread of infection to healthcare workers and other patients. Placing the child in a private room (Choice A) is important but secondary to preventing infection transmission. Restricting visitors to parents only (Choice C) is also significant but not as critical as ensuring proper infection control measures. While hand washing (Choice D) is essential, the immediate need to prevent airborne transmission in the child's room takes precedence.
Erythropoietin used to treat anemia in clients with renal failure should be given in conjunction with:
A. iron, folic acid, and B12.
B. an increase in protein in the diet.
C. vitamins A and C.
D. an increase in calcium in the diet.
Correct answer:
Erythropoietin is necessary for red blood cell (RBC) production, and in clients with renal failure who lack endogenous erythropoietin, exogenous erythropoietin is administered. However, for erythropoietin to effectively stimulate RBC production, adequate levels of iron, folic acid, and vitamin B12 are crucial. These nutrients are essential for RBC synthesis and maturation. Therefore, the correct answer is to give iron, folic acid, and B12 with erythropoietin. Choice B, an increase in protein in the diet, is not necessary for RBC production and may exacerbate uremia in clients with renal failure. Choices C and D, vitamins A and C, and an increase in calcium in the diet, respectively, are not directly related to RBC production and are not required to enhance the effectiveness of erythropoietin.
After group therapy, the female victim of intimate partner violence confides to the nurse that she does not feel in any immediate danger. Which of the following statements about victims of domestic violence is true?
A. Victims of domestic violence are often the best predictors of their risk of harm.
B. Victims of domestic violence often overestimate their safety risk.
C. Victims of domestic violence are typically in a state of denial.
D. Victims of domestic violence know that keeping peace with their partner is the best method of preventing another attack.
Correct answer:
Victims of domestic violence are often correct at predicting their risk of harm. It is crucial for the nurse to ensure that the client is expressing herself authentically and not downplaying any potential danger. While victims can be insightful about their risk, it's essential to involve proper authorities, such as the police, in situations of intimate partner violence to ensure safety and provide necessary support. Choice B is incorrect because victims may not necessarily overestimate their safety risk. Choice C is incorrect as not all victims are in a state of denial; some may recognize the dangers they face. Choice D is incorrect because victims may not believe that keeping peace with their partner is the best way to prevent future attacks, as each individual's situation and mindset vary.
In the context of diagnostic genetic counseling, which of the following choices is typically not made by clients?
A. Terminating the pregnancy.
B. Preparing for the birth of a child with special needs.
C. Accessing support services before the birth.
D. Completing the grieving process before the birth.
Correct answer:
In diagnostic genetic counseling, clients may face difficult decisions based on test results. Terminating the pregnancy is a choice some clients may consider if severe abnormalities are detected. Preparing for the birth of a child with special needs involves getting ready to care for a child who may require extra attention and support. Accessing support services before the birth can help clients connect with resources and professionals for assistance during and after the pregnancy. Completing the grieving process before birth is not typically a choice made in the context of genetic counseling. The grieving process often starts or continues after distressing results and can extend beyond the birth of the child. Therefore, the correct answer is completing the grieving process before the birth.
NCLEX-PN clinical judgment practice questions, set 10 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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