NCLEX-PN clinical judgment practice questions, set 13
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 13
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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
A Roman Catholic client is preparing to have magnetic resonance imaging. He wants to wear his metal crucifix pendant while he is receiving the test. Which of the following is an appropriate response by the nurse?
A. "Because it gives you comfort, you may wear it."?
B. "It is a violation of religious rights to forbid it."?
C. "I am sorry, but it is not safe for you to wear the crucifix during this test."?
D. "You may wear it because it is important to you."?
Show answer and rationale
Correct answer: C — "I am sorry, but it is not safe for you to wear the crucifix during this test."?
No metal objects may be worn while receiving magnetic resonance imaging due to safety risks involved with the strong magnet. The correct response by the nurse should prioritize the safety of the client. Allowing the client to wear the metal crucifix poses a risk of injury or interference with the imaging process. Option A is not appropriate as safety takes precedence over comfort in this situation. Option B is incorrect as it does not address the safety concerns associated with wearing metal objects during an MRI. Option D is also incorrect as it fails to acknowledge the safety issue involved and instead focuses solely on the importance to the client. It is important for the nurse to offer alternative forms of spiritual support that do not pose a risk during the MRI procedure.
Question 2
A client with cancer is transported to the radiology department for a bone scan to determine whether the cancer has metastasized to bone. While the client is in the radiology department, the client's wife arrives for a visit and asks what test is being performed on the client. What should the nurse tell the wife?
A. A bone scan is being performed.
B. She can read the client's medical record to determine what the health care provider prescribed.
C. The radiology department is not clear as to which test has been prescribed.
D. She will have to discuss the prescribed test with the client.
Show answer and rationale
Correct answer: D — She will have to discuss the prescribed test with the client.
In healthcare, confidentiality is crucial. Without the client's consent, nurses cannot disclose confidential information to anyone else, even to family members. Therefore, the appropriate response is to inform the client's wife that she will have to discuss the test with the client directly. It is not appropriate to disclose sensitive medical information without the client's permission. Offering the wife to read the medical record is a violation of privacy and confidentiality. Indicating that the radiology department is unclear about the prescribed test is inaccurate and does not uphold confidentiality. Moreover, it is not the responsibility of another department to disclose medical information; it is the duty of the healthcare provider and the client to discuss such matters.
Question 3
When teaching bleeding precautions to a client with leukemia, the PN should include which of the following instructions?
A. Use a soft toothbrush.
B. Use dental floss daily.
C. Hold pressure on any scrapes for 1-2 minutes.
D. Use a triple-edged razor.
Show answer and rationale
Correct answer: A — Use a soft toothbrush.
The correct answer is to 'Use a soft toothbrush.' A soft toothbrush is recommended because it is less likely to cause the gums to bleed in clients with leukemia, who are at risk of bleeding due to overcrowding of white cells at the expense of other cell types like platelets. Choice B, 'Use dental floss daily,' is incorrect because dental floss is contraindicated and can make the gums bleed in clients with leukemia. Choice C, 'Hold pressure on any scrapes for 1-2 minutes,' is incorrect because when clotting is impaired, pressure should be held for 5-10 minutes or longer until the bleeding stops. Choice D, 'Use a triple-edged razor,' is incorrect because an electric razor should be used instead of a triple-edged razor to prevent small cuts and bleeding in clients with leukemia.
Question 4
Which of the following coping mechanisms protects an individual from anxiety?
A. denial and fantasy
B. rationalization and suppression
C. regression and displacement
D. reaction formation and projection
Show answer and rationale
Correct answer: A — denial and fantasy
The correct answer is 'denial and fantasy.' Denial involves blocking external events from awareness to avoid anxiety, while fantasy is escaping to a more comfortable, less threatening place. These mechanisms can protect individuals from anxiety by providing temporary relief or distraction. Choices B, C, and D are incorrect. Rationalization and suppression do not directly protect individuals from anxiety. Regression and displacement involve reverting to earlier developmental stages or redirecting emotions to a substitute target, which do not directly shield individuals from anxiety. Reaction formation and projection entail behaving in the opposite way to one's impulses or attributing one's feelings to others respectively, which do not directly protect individuals from anxiety.
Question 5
A client with dumping syndrome should..........................while a client with GERD should..........................
A. Sit up 1 hour after meals; lie flat 30 minutes after meals
B. Lie down 1 hour after eating; sit up at least 30 minutes after eating
C. Sit up after meals; sit up after meals
D. Lie down after meals; lie down after meals
Show answer and rationale
Correct answer: D — Lie down after meals; lie down after meals
For a client with dumping syndrome, lying down 1 hour after eating helps reduce symptoms by slowing down the movement of food through the digestive tract, aiding in symptom management. This position assists in symptom management for dumping syndrome. Conversely, for a client with GERD, sitting up at least 30 minutes after eating can help prevent the backflow of stomach acid into the esophagus, reducing reflux symptoms. This upright position is beneficial for managing GERD. Choice A is incorrect because sitting up is recommended for GERD, not dumping syndrome. Choice C is incorrect as it suggests sitting up for both conditions, which is not appropriate. Choice D is incorrect as lying down after meals is not recommended for GERD; it can worsen symptoms by promoting acid reflux.
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Question 6
A nurse is planning care for a hospitalized toddler. To best maintain the toddler's sense of control and security and ease feelings of helplessness and fear, the nurse should perform which action?
A. Allow the toddler to play with other children in the nursing unit playroom.
B. Spend as much time as possible with the toddler.
C. Allow the toddler to select toys from the nursing unit playroom that can be brought into the toddler's hospital room.
D. Keep hospital routines as similar as possible to those at home.
Correct answer:
The best action for the nurse to take to help a hospitalized toddler maintain a sense of control and security and ease feelings of helplessness and fear is to keep hospital routines as similar as possible to those at home. By incorporating the toddler's usual rituals and routines from home into nursing care activities, the nurse can reduce the stress of hospitalization. This approach gives the toddler a sense of familiarity, control, and security, which can alleviate feelings of helplessness and fear. Allowing the toddler to play with other children in the nursing unit playroom and selecting toys are beneficial activities, but maintaining hospital routines similar to those at home is the most effective way to support the toddler's emotional well-being during hospitalization.
A nurse is planning to administer an oral antibiotic to a client with a communicable disease. The client refuses the medication and tells the nurse that the medication causes abdominal cramping. The nurse responds, 'The medication is needed to prevent the spread of infection, and if you don't take it orally I will have to give it to you in an intramuscular injection.' Which statement accurately describes the nurse's response to the client?
A. The nurse is justified in administering the medication by way of the intramuscular route because the client has a communicable disease.
B. The nurse could be charged with assault.
C. Assault is an intentional threat to bring about harmful or offensive contact. If a nurse threatens to give a client a medication that the client refuses or threatens to give a client an injection without the client's consent, the nurse may be charged with assault. Therefore, the nurse is not justified in administering the medication. Battery is any intentional touching without the client's consent.
D. The nurse will be justified in administering the medication by the intramuscular route once a prescription has been obtained from the health care provider.
Correct answer:
The correct answer explains the concept of assault, which is an intentional threat to bring about harmful or offensive contact. In the scenario provided, the nurse's statement about administering the medication via an intramuscular injection without the client's consent constitutes a threat, potentially falling under the definition of assault. Choice A is incorrect because the nurse's action is not automatically justified solely by the client having a communicable disease. Choice D is also incorrect because even with a prescription, the nurse cannot administer the medication without the client's consent. Choice C provides a detailed explanation distinguishing assault from battery, which helps in understanding the legal implications of the nurse's response in this situation.
A nurse witnesses a client sign the consent form for surgery with the surgeon. As the surgeon leaves, the client starts to speak and then stops. The nurse asks if the client has further questions, and he says, "I don't want to bother the surgeon."? The nurse should ____.
A. acknowledge the client's wish not to bother the surgeon and tell the client to let you know if they change their mind
B. acknowledge the client's wish not to bother the surgeon and answer all of their questions, as appropriate
C. go get the surgeon to answer all of the client's questions
D. answer any questions as appropriate as well as have the surgeon come back to answer any questions if needed
Correct answer:
In this scenario, the nurse should prioritize the client's understanding and comfort. While acknowledging the client's wish not to bother the surgeon is important, it is equally crucial to ensure that the client's questions are answered appropriately and thoroughly. Choice A is correct as it respects the client's initial sentiment and offers the client the opportunity to ask questions later if needed. Choice B is incorrect as it suggests answering all questions immediately, without considering the client's feelings. Choice C is incorrect as it bypasses the nurse's role in addressing the client's concerns. Choice D, the correct answer, balances respecting the client's wish and ensuring that all questions are appropriately addressed, even if it involves the surgeon returning.
A client with massive chest and head injuries is admitted to the ICU from the Emergency Department. All of the following are true except:
A. The physician in charge of the case is the sole person allowed to decide whether organ donation can occur.
B. The client's legally responsible party may make the decision for organ donation for the donor if the client is unable to do so.
C. The organ procurement organization makes the decision regarding which organs to harvest.
D. The donor (or legally responsible party for the donor), the physician, and the organ-procurement organization are all involved in the process.
Correct answer:
While the physician plays a crucial role in the process of organ donation, they are not the sole decision-maker. The client's legally responsible party may make the decision for organ donation if the client is unable to do so. Additionally, the organ procurement organization is responsible for determining which organs are suitable for donation. Therefore, the statement that the physician in charge is the sole person allowed to decide whether organ donation can occur is incorrect. The correct answer is A. Choices B, C, and D are true statements as they highlight the involvement of the legally responsible party, the organ procurement organization, and the donor/legally responsible party, physician, and organ-procurement organization in the organ donation process respectively.
With a breech presentation, the nurse must be particularly alert for which of the following?
A. quickening
B. ophthalmia neonatorum
C. pica
D. prolapsed umbilical cord
Correct answer:
With a breech presentation, the nurse must be particularly alert for a prolapsed umbilical cord. Prolapsed umbilical cord is a critical emergency situation where the umbilical cord descends into the vagina before the fetal presenting part, leading to compression between the presenting part and the maternal pelvis. This compression can compromise or completely cut off fetoplacental perfusion, endangering the fetus. Immediate delivery should be attempted to save the fetus. Quickening refers to fetal movements felt by the mother, ophthalmia neonatorum is an eye infection in newborns, and pica is a condition characterized by cravings for non-nutritive substances, none of which are directly related to the risks associated with a breech presentation and prolapsed umbilical cord.
Mr. H. is upset about being in the hospital for another day due to the high cost. The rights he is likely to demand include all of the following except:
A. the right to examine and question the bill
B. the right to reasonable response to requests
C. the right to refuse treatment
D. the right to confidentiality
Correct answer:
Confidentiality is the maintenance of privacy of information. The question does not suggest that confidentiality has been breached. In this scenario, Mr. H. is concerned about the cost and the length of his stay, which relates to his rights regarding billing, treatment, and response to requests. The right to confidentiality, though important, is not directly related to his current situation of being upset about the high cost and extended stay. Mr. H. is more likely to demand the right to examine and question the bill to understand the charges, the right to reasonable response to requests regarding his care and stay, and the right to refuse treatment if he wishes. Therefore, the correct answer is the right to confidentiality, as it is not a primary concern in this context.
A 64-year-old Alzheimer's patient has exhibited excessive cognitive decline resulting in harmful behaviors. The physician orders restraints to be placed on the patient. Which of the following is the appropriate procedure?
A. Secure the restraints to the bed rails on all extremities.
B. Notify the physician that restraints have been placed properly.
C. Communicate with the patient and family the need for restraints.
D. Position the head of the bed at a 45-degree angle.
Correct answer:
In cases where restraints are considered necessary for a patient, it is crucial to communicate effectively with both the patient and their family about the reasons for this decision. This helps ensure that all parties involved understand the necessity of restraints and are informed about the potential risks and benefits. Option A, securing restraints to the bed rails on all extremities, is not appropriate as it does not involve proper communication or ethical considerations. Option B, notifying the physician that restraints have been placed properly, overlooks the importance of patient and family involvement in decision-making. Option D, positioning the head of the bed at a 45-degree angle, is unrelated to the use of restraints and does not address the situation at hand.
A nurse in a medical-surgical unit overhears the nursing staff openly discussing a client and stating that the client is uncooperative and a real pain to care for. The nurse would most appropriately manage this issue by taking which action?
A. Leaving articles about judgmental opinions in the nurses' report room
B. Reporting the nurses' comments to administration
C. Discouraging the judgmental comments
D. Ignoring the comments made about the client
Correct answer:
Nurses must discuss clients in a professional manner and avoid using judgmental language such as 'uncooperative' or 'difficult.' When such comments and language are discouraged, fewer comments will be made. Ignoring the comments is an inappropriate option because the concern will not be addressed. Leaving articles about judgmental opinions in the nurses' report room indirectly addresses the issue, but there is no guarantee that the staff will read them. Reporting the nurses' comments to administration does not directly address the issue. The best approach for the nurse is to discourage judgmental comments directly with the staff members. Since this action is not provided in the options, discouraging judgmental comments is the most appropriate way to manage this concern.
B. after the client requests rehabilitation services
C. after the client's physical condition stabilizes.
D. when the client is discharged from the hospital.
Correct answer:
Rehabilitation services should begin when the client enters the health care system to ensure early intervention and optimal outcomes. Initiating rehabilitation early can help prevent complications, improve recovery, and enhance overall well-being. Option B is incorrect because waiting for the client to request services may lead to delays in starting treatment, potentially affecting the recovery process. Option C is incorrect as rehabilitation can often commence even when the client's physical condition is not fully stabilized, as early intervention is crucial for progress. Option D is incorrect as beginning rehabilitation only after hospital discharge may not be ideal, as early intervention within the healthcare system is preferred for a more effective recovery journey.
When teaching clients with a diagnosis of Schizophrenia nearing discharge from a residential care facility, what is an essential topic to include?
A. pathophysiology of the disease and expected symptoms.
B. how to recognize and manage symptoms of relapse.
C. the need to take extra medication when feeling stressed.
D. the importance of contact with follow-up care daily.
Correct answer:
When educating clients with Schizophrenia nearing discharge, it is crucial to focus on teaching them how to recognize and manage symptoms of relapse. Clients are usually aware of these symptoms, such as feeling anxious and overwhelmed, before the onset of psychosis. This early stage is vital for intervention, which involves finding a safe environment, seeking help, avoiding stressors, and reducing stimuli. Understanding and managing relapse symptoms empower clients to take proactive steps in their care. Choices A and C are not as immediate and practical as recognizing symptoms of relapse for client safety and well-being. While contact with follow-up care is important, it is not as urgent and specific as knowing how to manage relapse symptoms for immediate intervention.
NCLEX-PN clinical judgment practice questions, set 13 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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