NCLEX-PN clinical judgment practice questions, set 12
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 12
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
People who live in poverty are most likely to obtain health care from:
A. their primary care physician (family doctor)
B. a neighborhood clinic
C. specialists
D. Emergency Departments or urgent care centers
Show answer and rationale
Correct answer: D — Emergency Departments or urgent care centers
Individuals living in poverty often face barriers to accessing regular healthcare services, leading them to utilize Emergency Departments or urgent care centers as their primary source of healthcare. These facilities provide immediate care without the need for appointments or insurance, making them more accessible to those in poverty. While primary care physicians and neighborhood clinics are essential for preventive care, individuals in poverty may have difficulty accessing these services due to financial constraints or lack of insurance. Specialists typically require referrals and may not be easily accessible to individuals without stable healthcare coverage. Therefore, Emergency Departments or urgent care centers are the most likely healthcare option for people living in poverty.
Question 2
Following a thyroidectomy, a client is complaining of shortness of breath (SOB) and neck pressure. Which nursing action is the best response?
A. Stay with the client, remove the dressing, and elevate the head of bed.
B. Call a code, open the trach set, and position the client supine.
C. Have the client say "EEE"? to check for laryngeal integrity.
D. Immediately go to the nurse's station and call the physician
Show answer and rationale
Correct answer: A — Stay with the client, remove the dressing, and elevate the head of bed.
Correct! The client is displaying signs of respiratory distress after a thyroidectomy. By staying with the client, removing the dressing around the neck, and elevating the head of the bed, the nurse can assess the airway and breathing status more effectively. This immediate action can help alleviate any potential airway obstruction. Choice B is incorrect because calling a code and opening the trach set without initial assessment and basic interventions may delay necessary actions. Choice C is incorrect as having the client say "EEE"? is not as immediate or effective in addressing the respiratory distress. Choice D is incorrect as leaving the client alone and calling the physician without providing immediate assistance can be detrimental in a situation of potential airway compromise.
Question 3
The nurse is caring for a client scheduled for removal of a pituitary tumor using the transsphenoidal approach. The nurse should be particularly alert for:
A. Nasal congestion
B. Abdominal tenderness
C. Muscle tetany
D. Oliguria
Show answer and rationale
Correct answer: A — Nasal congestion
During the removal of a pituitary tumor using the transsphenoidal approach, nasal congestion is a significant concern as it can further obstruct the airway. This can be due to mucosal swelling, bleeding, or edema resulting from the surgery. Nasal congestion requires immediate attention to prevent airway compromise. Abdominal tenderness, muscle tetany, and oliguria are not directly associated with the pituitary gland or the transsphenoidal approach, making them incorrect choices. Abdominal tenderness is more common in abdominal or pelvic surgeries due to intra-abdominal issues. Muscle tetany is related to electrolyte imbalances or neuromuscular disorders, not specific to pituitary surgery. Oliguria is a concern in renal-related conditions, not typically in pituitary tumor surgeries.
Question 4
To decrease a client's use of denial and increase the client's expression of feelings, what should the nurse do?
A. Tell the client to stop using the defense mechanism of denial
B. Positively reinforce each expression of feelings
C. Instruct the client to express feelings
D. Challenge the client each time denial is used
Show answer and rationale
Correct answer: B — Positively reinforce each expression of feelings
The most appropriate approach to decrease a client's use of denial and promote the expression of feelings is to positively reinforce each expression of feelings. This method helps the client feel supported and validated, encouraging them to continue expressing their emotions openly. Positively reinforcing the expression of feelings can help reduce the need for denial as the client learns that their emotions are acknowledged and accepted. Choices A, C, and D are incorrect. Choice A of telling the client to stop using denial is too directive and may be ineffective. Instructing the client to express feelings (Choice C) lacks positive reinforcement, and challenging the client each time denial is used (Choice D) can create a confrontational environment that hinders therapeutic progress.
Question 5
In conducting a community health fair for a group of middle-aged citizens, which statement should the nurse emphasize in reducing the risk of coronary heart disease?
A. Participate in at least 30 minutes of moderate physical activity 3 to 5 days per week.
B. Engage in an aerobic exercise class every day.
C. Limit your alcohol intake to a moderate level.
D. The best way to lose weight is to follow a balanced diet.
Show answer and rationale
Correct answer: B — Engage in an aerobic exercise class every day.
Engaging in an aerobic exercise class every day is crucial in reducing the risk of coronary heart disease. Aerobic exercises help keep the heart in shape, lower blood pressure, and improve cholesterol levels. It is recommended to participate in at least 150 minutes of moderate-intensity aerobic exercise per week, which can be achieved by engaging in aerobic exercise daily. Choice A has been corrected to emphasize the frequency required to significantly reduce the risk of coronary heart disease. Choice C has been modified to suggest moderation in alcohol intake, as excessive alcohol consumption is harmful. Choice D is also incorrect as a balanced diet, not specifically high-protein, high-fat, is recommended to reduce the risk of coronary heart disease and maintain a healthy weight.
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Question 6
A nurse is preparing for the admission of a client with pulmonary tuberculosis. Which action reflects the use of evidence-based practice in the care of the client?
A. Keeping the door to the client's room closed
B. Fitting the client for an N95 or HEPA (high-efficiency particulate air) mask to be worn at all times
C. Placing the client in a semiprivate room with a cohort client
D. Using a surgical mask when entering the client's room
Correct answer:
Evidence-based practice is an approach to client care that integrates the client's preferences, clinical expertise, and the best research evidence to deliver quality care. In the case of pulmonary tuberculosis, which is transmitted through the airborne route, keeping the door to the client's room closed is crucial to prevent the spread of infection. Placing the client in a semiprivate room with a cohort client is not recommended for airborne precautions; a private room is required to prevent transmission. Fitting the client for an N95 or HEPA mask is essential for the nurse's protection when entering the room, not for the client to wear at all times. Using a surgical mask when entering the client's room is not sufficient for airborne precautions; an N95 or HEPA mask is necessary.
Which of the following syndromes associated with incomplete lesions of the spinal cord results from damage to one-half of the spinal cord?
A. Brown-Séquard syndrome
B. posterior cord syndrome
C. central cord syndrome
D. cauda equina syndrome
Correct answer:
Brown-Séquard syndrome is indeed associated with incomplete lesions of the spinal cord, and it specifically results from damage to one-half of the spinal cord. This syndrome manifests as ipsilateral motor paralysis, ipsilateral loss of vibration and proprioception, and contralateral loss of pain and temperature sensation. Posterior cord syndrome mainly involves the loss of proprioception and vibratory sense, while sparing motor function and pain sensation. Central cord syndrome typically presents with more weakness in the upper extremities compared to the lower extremities due to central spinal cord damage. Cauda equina syndrome affects the nerve roots at the level of the conus medullaris, leading to symptoms like lower extremity weakness, numbness, and bowel/bladder dysfunction.
A client is refusing to stay in the hospital because he does not agree with his healthcare treatment plan. The nurse stops the client from leaving due to concern for his health. Which of these legal charges could the nurse face?
A. False imprisonment, as the nurse is not allowing the client to leave as he has decided to.
B. Malpractice, as the nurse is intentionally keeping the patient from making his own decisions, thus violating that nursing duty.
C. Invasion of privacy, as the nurse is getting involved in the patient's private decisions regarding healthcare.
D. Negligence, as the nurse ignored the client's right to choose regarding his healthcare.
Correct answer:
Refusing to let a client leave against medical advice (AMA) is a form of false imprisonment. In this scenario, the nurse is restricting the client's freedom of movement by preventing him from leaving the hospital, even though he has expressed his wish to leave. False imprisonment is a legal charge the nurse could face in this situation.
The other options are incorrect:
- Malpractice refers to professional negligence or failure to provide adequate care, not allowing a patient to make their own decisions.
- Invasion of privacy involves disclosing confidential information without consent, not preventing a patient from leaving.
- Negligence is the failure to take reasonable care, but it does not specifically address the act of restricting a patient from leaving against their wishes.
A new nurse employed at a community hospital is reading the organization's mission statement. The new nurse understands that this statement is written for which purpose?
A. To outline what the organization plans to accomplish
B. To identify the policies and procedures of the organization
C. To describe the benefits available to employees
D. To define the rules of the organization that the employees must follow
Correct answer:
The correct answer is 'To outline what the organization plans to accomplish.' A mission statement expresses the purpose or reason for an organization's existence, outlining what it aims to achieve. It often includes statements of philosophy, purpose, and goals. This statement serves as a benchmark for evaluating the organization's performance. The mission statement is not meant to identify policies and procedures (Choice B) or describe employee benefits (Choice C). Choice B specifies the administrative guidelines and protocols of the organization, while Choice C pertains to the perks available to employees. Choice D is incorrect as the rules of the organization that employees must follow are usually detailed in employee handbooks or codes of conduct, not in the mission statement.
To determine the standards of care for the institution, the nurse should consult?
A. Organizational Chart
B. Personnel policies
C. Policies and procedure manual
D. Job descriptions
Correct answer:
The correct answer is the 'Policies and procedure manual.' This manual outlines the policies and procedures that govern patient care within the institution, including the standards of care that healthcare providers are expected to follow. Consulting the policies and procedure manual ensures that the nurse is adhering to the established guidelines and protocols. Choices A, B, and D are incorrect because although they are important documents within an institution, they do not specifically define the standards of care for patient management. The organizational chart illustrates the hierarchy of the institution, personnel policies outline rules related to employees, and job descriptions detail specific roles and responsibilities, none of which directly define patient care standards.
The nurse notes that a client in later adulthood has tremors of the hands. Based on this finding, what action should the nurse take?
A. Ask the healthcare provider about referring the client to a neurological specialist.
B. Obtain a prescription for a muscle relaxant.
C. Notify the healthcare provider immediately.
D. Document the findings.
Correct answer:
When a nurse observes senile tremors, such as intentional tremor of the hands in a client in later adulthood, it is important to document the findings. Senile tremors are benign and a normal age-related occurrence. Referring the client to a neurological specialist (Choice A) is unnecessary as senile tremors do not require specialized neurological intervention. Prescribing a muscle relaxant (Choice B) is not indicated since senile tremors are benign and not typically treated with muscle relaxants. Notifying the healthcare provider immediately (Choice C) is unnecessary as senile tremors do not require urgent intervention. Therefore, the most appropriate action is to document the findings (Choice D) for the client's medical record and to establish a baseline for future assessments.
Under what circumstances is the legal right to confidentiality of client information waived?
A. When a court system subpoenas information.
B. When a family member requests health care information of a client.
C. When a living will takes effect.
D. When the client is declared incompetent by the legal system.
Correct answer:
The legal right to confidentiality of client information is waived when a court system subpoenas information. This occurs when information is required for legal proceedings to occur, such as through summonses, court orders, or litigation information necessary for the court. Subpoenas are legal orders that compel the disclosure of information. The other choices do not inherently waive the legal right to confidentiality. A family member's request for health care information would typically require the client's consent or fall under specific legal exceptions. A living will dictates end-of-life care preferences but does not necessarily waive confidentiality. Lastly, the declaration of incompetence may impact decision-making capacity but does not automatically waive confidentiality.
The healthcare provider is using Cognitive-Behavioral methods of pain control and knows that these methods can be expected to do all the following except:
A. completely relieve all pain.
B. provide benefit by restoring the client's sense of self-control.
C. help the client to control symptoms.
D. help the client actively participate in his or her care.
Correct answer:
Cognitive-Behavioral methods of pain control aim to provide benefit by restoring the client's sense of self-control, helping the client to control symptoms, and encouraging the client to actively participate in their care. However, these methods are not intended to completely relieve all pain. These interventions focus on perception and thought, aiming to influence how one interprets events and bodily sensations. Therefore, the correct answer is that they cannot completely relieve all pain, as pain relief is often a multifaceted approach that may require additional interventions beyond Cognitive-Behavioral methods. Choices B, C, and D are correct as Cognitive-Behavioral methods are designed to empower the individual in managing their pain and improving their overall well-being.
The nurse is developing a care plan for a client with severe anxiety. An appropriate outcome for the client is that within 4 days the client should:
A. Have decreased anxiety.
B. Talk to the nurse for 10 minutes.
C. Sit quietly for 30 minutes.
D. Develop an adaptive coping mechanism.
Correct answer:
When developing outcome criteria for a client with severe anxiety, it is crucial for the goals to be specific, measurable, and realistic. In this scenario, the most appropriate outcome is for the client to talk to the nurse for 10 minutes within 4 days. This goal is specific (talking for a defined duration), measurable (10 minutes), and realistic given the client's condition. Expecting a severely anxious client to sit quietly for 30 minutes is not realistic and may even exacerbate their anxiety. While developing an adaptive coping mechanism is important, it is a broader long-term goal and may not be achievable within the specified timeframe. Having decreased anxiety is a desirable outcome, but it lacks specificity and measurability, making it less suitable as an immediate goal.
When removing hard contact lenses from an unresponsive client, what should the nurse do?
A. Gently irrigate the eye with an irrigating solution from the inner canthus outward.
B. Grasp the lens with a gentle pinching motion.
C. Don sterile gloves before attempting the procedure.
D. Ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens.
Correct answer:
When removing hard contact lenses, it is crucial to ensure that the lens is correctly positioned on the cornea before removal. Directly grasping the lens can potentially scratch the cornea, so it is essential to gently manipulate the lids to release the lens safely. Gently irrigating the eye is unnecessary and could be harmful, especially without the client's cooperation. Wearing sterile gloves is also unnecessary for this specific procedure. Therefore, the correct approach is to ensure the proper positioning of the lens and then gently manipulate the lids to release it. Options A and C are incorrect because irrigating the eye and wearing sterile gloves are not necessary for contact lens removal. Option B is incorrect as directly grasping the lens can be harmful to the cornea.
NCLEX-PN clinical judgment practice questions, set 12 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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