NCLEX-PN clinical judgment practice questions, set 11
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 11
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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
The nurse is caring for a client scheduled for a surgical repair of a sacular abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period?
A. Assessment of the client's level of anxiety
B. Evaluation of the client's exercise tolerance
C. Identification of peripheral pulses
D. Assessment of bowel sounds and activity
Show answer and rationale
Correct answer: C — Identification of peripheral pulses
The most crucial assessment during the preoperative period for a client with a sacular abdominal aortic aneurysm scheduled for surgical repair is the identification of peripheral pulses. During surgery, the aorta will be clamped, potentially affecting blood circulation to the kidneys and lower extremities. Therefore, it is essential for the nurse to assess peripheral pulses and monitor the return of circulation to the lower extremities postoperatively. Assessing the client's level of anxiety (Choice A) is important but not as crucial as ensuring adequate circulation. Evaluating exercise tolerance (Choice B) is not recommended preoperatively for this situation. Assessing bowel sounds and activity (Choice D) is of lesser concern compared to the critical need to monitor peripheral circulation.
Question 2
The nurse is caring for a dying client who has persistently requested that the nurse 'help her to die and be in peace.' According to the Code of Ethics for Nurses, the nurse should:
A. Ask the client whether she has signed the advance directives document.
B. Tell the client that he or she will ask another nurse to care for her.
C. Instruct the client that only a physician can legally assist in suicide.
D. Try to make the client as comfortable as possible, but refuse to assist in death.
Show answer and rationale
Correct answer: D — Try to make the client as comfortable as possible, but refuse to assist in death.
The correct answer is to try to make the client as comfortable as possible but refuse to assist in death. According to the Code of Ethics for Nurses, nurses are committed to providing compassionate care, respecting the dignity and rights of the dying person. In this situation, it is important for the nurse to focus on providing comfort and support to the client while upholding ethical standards. Choice A is incorrect because discussing advance directives does not address the immediate request for assistance in dying. Choice B is incorrect as it does not address the ethical dilemma presented. Choice C is incorrect because instructing the client that only a physician can assist in suicide does not fully address the complexity of the situation or the nurse's role in providing end-of-life care.
Question 3
A licensed practical nurse (LPN) in the long-term care unit who has another LPN and a nursing assistant on the nursing team is planning task assignments for the day. Which task should the nurse assign to the LPN?
A. Monitoring a client receiving oxygen who requires frequent pulse oximetry monitoring and respiratory treatments
B. Assisting a client who is wearing eye patches and requires assistance with hygiene measures
C. Feeding a client on bedrest who needs assistance with feeding
D. Turning a client who must be turned and repositioned every 2 hours
Show answer and rationale
Correct answer: A — Monitoring a client receiving oxygen who requires frequent pulse oximetry monitoring and respiratory treatments
When a nurse assigns tasks for a client's care to another staff member, the nurse is responsible for appropriately assigning tasks based on the educational level and competency of the staff member. In this scenario, the LPN should be assigned the task of monitoring a client receiving oxygen who requires frequent pulse oximetry monitoring and respiratory treatments. This is because the LPN is competent to perform these tasks and can accurately note changes in the client's condition. Tasks such as feeding a client, turning and repositioning a client, and assisting with hygiene measures, which are noninvasive interventions, can be assigned to a nursing assistant. These tasks do not require the same level of assessment and monitoring as the respiratory treatments and pulse oximetry monitoring.
Question 4
Which of the following diseases or conditions is least likely to be associated with an increased potential for bleeding?
A. metastatic liver cancer
B. gram-negative septicemia
C. pernicious anemia
D. iron-deficiency anemia
Show answer and rationale
Correct answer: C — pernicious anemia
Pernicious anemia is least likely to be associated with an increased potential for bleeding compared to the other conditions listed. Pernicious anemia is a condition resulting from vitamin B12 deficiency due to the absence of intrinsic factor, necessary for B12 absorption. While pernicious anemia can lead to neurological issues, it is not directly linked to an increased risk of bleeding. Metastatic liver cancer can cause liver dysfunction leading to coagulopathy, gram-negative septicemia can result in disseminated intravascular coagulation (DIC), and iron-deficiency anemia can lead to microcytic hypochromic red blood cells, increasing the risk of bleeding. Therefore, pernicious anemia is the least likely to be associated with an increased potential for bleeding out of the options provided.
Question 5
A nurse enters a client's room to administer a medication that has been prescribed by the health care provider. The client asks the nurse about the medication. Which response by the nurse is appropriate?
A. 'I know that it's for fluid buildup, and I think you've taken it before.''
B. 'It's called furosemide (Lasix), and it will promote urination and rid your body of the excess fluid. It can cause an alteration in electrolyte levels, so we'll need to increase the potassium in your diet.''
C. 'It's to help get rid of the swelling in your feet.''
D. ''You need to discuss this medication with your health care provider.''
Show answer and rationale
Correct answer: B — 'It's called furosemide (Lasix), and it will promote urination and rid your body of the excess fluid. It can cause an alteration in electrolyte levels, so we'll need to increase the potassium in your diet.''
A client has the right to be informed of the medication name, purpose, action, and potential undesirable effects of a prescribed medication. The nurse should provide adequate information to the client. Choice B is the correct answer as it includes the medication name, its purpose (promoting urination and eliminating excess fluid), and a potential side effect (alteration in electrolyte levels) with a plan for managing it (increasing potassium in the diet). This response demonstrates thorough and complete information. Choice A provides some information but lacks details on potential side effects and dietary adjustments. Choice C is vague and does not provide specific details about the medication. Choice D deflects the client's question and does not fulfill the client's right to information.
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Question 6
While assisting with data collection, the nurse asks the client to close their jaws tightly. Subsequently, the nurse tries to open the closed jaws. In this technique, the nurse is assessing the motor function of which nerve?
A. Trochlear nerve
B. Abducens nerve
C. Trigeminal nerve
D. Oculomotor nerve
Correct answer:
The correct answer is C: Trigeminal nerve. To test the motor function of the trigeminal nerve (cranial nerve V), the nurse assesses the muscles of mastication by asking the client to clench their teeth. By trying to separate the client's jaws, the nurse evaluates the strength of the temporal and masseter muscles innervated by the trigeminal nerve. This technique helps assess if the trigeminal nerve is functioning properly. Choices A, B, and D are incorrect because they relate to other cranial nerves that are not involved in the specific motor function being tested in this scenario. These nerves are usually assessed through different examinations such as assessing the pupils and extraocular movements, which are not part of the jaw clenching and opening technique described in the question.
The schizophrenic client tells you that they are "Jesus"? and "there to save the world"?. They are reading from the Bible and warning others of hell and damnation. The whole unit is getting upset and several are beginning to cry. What should the nurse do at this time?
A. Set limits and send the client to their room.
B. Explain to the client that not all people are Christians.
C. Remove the Bible from the client and explain that they are not "Jesus"?.
D. Ask the client to share with the group how he knows that he is "Jesus"?.
Correct answer:
In this situation, the most appropriate action for the nurse to take is to set limits with the client and redirect them to their room. The client's behavior is disruptive and causing distress among others in the unit. Sending the client to their room allows them to cool down and prevents further agitation among other patients. Removing the client from the current environment can help de-escalate the situation. Asking the client to share how they know they are "Jesus"? (Choice D) may further agitate the situation and is not the immediate priority. Explaining to the client that not all people are Christians (Choice B) may not effectively address the disruptive behavior. Removing the Bible from the client (Choice C) without addressing the underlying issue may escalate the situation further.
A nursing assistant who has been employed in the long-term care center for 8 weeks is consistently taking extended lunch breaks. The nursing assistant's behavior has caused problems with client care during lunch hours. What is the appropriate way for the nurse to deal with this situation?
A. Ignoring the situation
B. Documenting the problem in the nursing assistant's personnel file
C. Asking other staff members to cover for the nursing assistant
D. Meeting with the nursing assistant to discuss the behavior and initiate problem-solving measures
Correct answer:
Taking extended lunch breaks is an unacceptable behavior, especially when it affects client care. The appropriate way for the nurse to deal with this situation is to meet with the nursing assistant to discuss the behavior and initiate problem-solving measures. This direct approach allows for open communication and the opportunity to address the issue effectively. Ignoring the situation (Choice A), asking other staff members to cover (Choice C), or documenting the problem in the nursing assistant's personnel file (Choice B) are not effective solutions. Ignoring the behavior does not address the issue, asking others to cover may not solve the problem at its root, and documenting the problem should come after attempting to resolve the issue through communication and problem-solving first.
The client is scheduled for a Tensilon test to check for Myasthenia Gravis. Which medication should be kept available during the test?
A. Atropine sulfate
B. Furosemide
C. Prostigmin
D. Promethazine
Correct answer:
During a Tensilon test to check for Myasthenia Gravis, Atropine sulfate should be kept available as it is the antidote for Tensilon and is administered to manage cholinergic crises that may occur during the test. Atropine sulfate helps counteract the excessive stimulation of the parasympathetic nervous system caused by Tensilon. Furosemide (choice B) is a diuretic and not related to managing Tensilon-induced crises. Prostigmin (choice C) is used to treat Myasthenia Gravis itself, not for managing the effects of Tensilon. Promethazine (choice D) is an antiemetic and antianxiety agent, which is not necessary for a Tensilon test. Therefore, Atropine sulfate (choice A) is the correct medication to have available during a Tensilon test, making choices B, C, and D incorrect in this context.
According to Erikson, which developmental task is a toddler confronting when they develop 'a will of his own' and 'acts as if he can control others'?
A. Trust versus mistrust
B. Autonomy versus doubt and shame
C. Initiative versus guilt
D. Industry versus inferiority
Correct answer:
According to Erikson, the correct developmental task for a toddler who has developed 'a will of his own' and 'acts as if he can control others' is Autonomy versus doubt and shame. Toddlers at this stage are asserting their wills and realizing they can control others, which is part of developing autonomy. However, they may also experience doubt and shame if their assertiveness is met with disapproval. Trust versus mistrust is the developmental task of the infant, where the main focus is on developing trust in the caregiver. Initiative versus guilt is the developmental task of the preschool-age child, emphasizing the balance between taking initiative and feeling guilty. Industry versus inferiority is the developmental task of the school-age child, focusing on competence and self-esteem.
When assisting with data collection on language development in a toddler from a bilingual family, what characteristic would a nurse expect?
A. Is more advanced than expected
B. Is developing as expected
C. Is slower than expected
D. Will require assistance from a speech therapist
Correct answer:
When assessing language development in a toddler from a bilingual family, a nurse would expect the child's language development to be slower than expected. Various factors, such as physical maturity and reinforcement received, can influence the pace of language development. Children from bilingual families, twins, and non-firstborn children may exhibit slower language development. Therefore, it is common for the language development of a toddler from a bilingual family to be slower than expected. This characteristic does not necessarily imply a need for speech therapy. Choices A, B, and D are incorrect because, in this context, the language development of the child is more likely to be slower than expected rather than more advanced, developing as expected, or requiring speech therapy.
Which of the following are antiviral drug classes used in the treatment of HIV/AIDS?
A. Nucleoside reverse transcriptase inhibitors
B. Protease inhibitors
C. HIV fusion inhibitors
D. All of the above
Correct answer:
The correct answer is 'All of the above.' Nucleoside reverse transcriptase inhibitors inhibit the enzyme reverse transcriptase, protease inhibitors block the activity of the HIV-1 protease enzyme, and HIV fusion inhibitors prevent HIV from entering human cells. Therefore, all the choices provided are valid antiviral drug classes for managing HIV/AIDS. Nucleoside reverse transcriptase inhibitors, protease inhibitors, and HIV fusion inhibitors play crucial roles in combating the virus at different stages. Nucleoside reverse transcriptase inhibitors target an early stage, protease inhibitors act on a later stage, and HIV fusion inhibitors prevent viral entry. Thus, 'All of the above' is the correct and comprehensive answer encompassing different mechanisms of action in managing HIV/AIDS.
When discussing birth control methods with a client, what major factor should a nurse focus on to provide the motivation needed for consistent implementation of a birth control method?
A. Personal preference
B. Work and home schedules
C. Family planning goals
D. Desire to have children in the future
Correct answer:
When discussing birth control methods with a client, a nurse should focus on the client's personal preference as a major factor that will provide the motivation needed for consistent implementation of a birth control method. Personal preference plays a key role in ensuring that the chosen method aligns with the client's lifestyle and values, increasing the likelihood of adherence. While work and home schedules, family planning goals, and the desire to have children in the future can influence the choice of birth control method, they are not the primary motivating factors for consistent implementation. Personal preference is crucial as it empowers the client to select a method that suits their individual needs and preferences, ultimately leading to better compliance and effectiveness.
A mother has come to the pediatric clinic concerned about the recent outbreak of West Nile Virus. The ages of her children are 5, 7, and 10. The mother has asked the nurse what she can do to prevent her children from contracting this illness. Which piece of information is best to provide the mother with?
A. The children should wear long sleeves and long pants while outside.
B. Apply insect repellent containing DEET when the children are outside.
C. Remove standing water from the property.
D. All of the above.
Correct answer:
The best advice to provide to the mother is 'All of the above.' It is recommended that the children wear insect repellent containing DEET and long-sleeved shirts and long pants when they are outside. This helps in preventing mosquito bites, which can transmit the West Nile Virus. Additionally, removing standing water from areas where the children play can help decrease the number of breeding mosquitoes, reducing the risk of contracting the virus. These methods work in combination to provide effective prevention against the West Nile Virus, making 'All of the above' the correct choice. Choices A, B, and C individually address important prevention measures, but a combination of all three strategies is the most comprehensive approach to protect the children from contracting the illness.
Upon arrival at the emergency room, the client presents with severe burns to the left arm, hands, face, and neck. What action should take priority?
A. Starting an IV
B. Applying oxygen
C. Obtaining blood gases
D. Medicating the client for pain
Correct answer:
In a client with severe burns to the face and neck, airway assessment and supplemental oxygen are crucial. Therefore, applying oxygen is the priority to ensure adequate oxygenation for the client. This intervention takes precedence over other actions to stabilize the client's condition. Starting an IV for fluid resuscitation is the next appropriate step following ensuring oxygenation (Choice A). While pain management is important, it is a secondary priority after ensuring oxygenation and fluid resuscitation, making medicating the client for pain a later intervention (Choice D). Obtaining blood gases (Choice C) is not the immediate priority in this scenario and would typically be ordered by the healthcare provider based on the client's condition and response to initial interventions.
NCLEX-PN clinical judgment practice questions, set 11 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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