NCLEX-PN clinical judgment practice questions, set 14
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 14
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
A client with suspected renal disease is to undergo a renal biopsy. The nurse plans to include which statement in the teaching session?
A. "You will be positioned lying down during the examination procedure."?
B. "Portions of the procedure will cause pain or discomfort."?
C. "You may be given anesthesia during the procedure."?
D. "You should refrain from eating or drinking before the procedure."?
Show answer and rationale
Correct answer: B — "Portions of the procedure will cause pain or discomfort."?
The correct answer is to inform the client that portions of the renal biopsy procedure can cause pain or discomfort, particularly when the sample is being withdrawn. This prepares the client for any unpleasant sensations during the procedure. Answer A is incorrect because the client will be positioned lying down, not sitting up, during the exam, so this information is not relevant to include in the teaching session. Answer C is incorrect as anesthesia is commonly used to numb the area for a renal biopsy, reducing pain, so the client can expect to receive anesthesia. Answer D is incorrect because clients are usually instructed to refrain from eating or drinking for a period before the procedure to prevent any complications during the biopsy, not simply before the study.
Question 2
How can the nurse best communicate to a client that he or she has been listening?
A. restating the main feeling or thought the client has expressed
B. making a judgment about the client's problem
C. offering a leading question such as, 'And then what happened?'
D. saying, 'I understand what you're saying.'
Show answer and rationale
Correct answer: A — restating the main feeling or thought the client has expressed
The best way for the nurse to communicate to a client that he or she has been listening is by restating the main feeling or thought the client has expressed. Restating helps the client validate the nurse's understanding of the communication, demonstrating active listening skills. Making judgments about the client's problem, as suggested in Choice B, can hinder effective communication by introducing bias and potential misinterpretation. Offering a leading question like in Choice C is not ideal for confirming understanding; it rather seeks more information. Choice D, simply saying 'I understand what you're saying,' may not convey active listening as effectively as restating the client's main feelings or thoughts, as it lacks the validation component present in restating.
Question 3
The nurse is caring for a client following an appendectomy. The client reports nausea and complains of surgical site pain at a 6 on a 0 to 10 scale. The client's employer is present in the room and states he is paying for the insurance and wants to know what pain medication has been prescribed by the physician. Which of the following is the appropriate nurse response?
A. Answer any questions the employer may have as he pays for the insurance.
B. Tell the employer his question is inappropriate and that the information is none of his business.
C. Explain to the employer that you cannot release private information and ask the employer to step out while you conduct your assessment of the client.
D. Ask the employer to leave and wait until the client returns home to visit.
Show answer and rationale
Correct answer: C — Explain to the employer that you cannot release private information and ask the employer to step out while you conduct your assessment of the client.
The appropriate nurse response is to explain to the employer that private information cannot be released and ask the employer to step out while conducting the assessment. This approach respects the client's privacy while still acknowledging the employer. The employer's payment for insurance does not grant rights to confidential information. Sharing information without permission violates the client's right to privacy under HIPAA. Option A is incorrect as it compromises the client's confidentiality by sharing private medical information. Option B is inappropriate and unprofessional as it does not address the situation respectfully. Option D is incorrect as it does not prioritize the client's immediate needs and assumes the client's consent without proper communication.
Question 4
While undergoing hemodialysis, the client becomes restless and tells the nurse he has a headache and feels nauseous. Which of the following complications does the nurse suspect?
A. Infection.
B. Disequilibrium syndrome.
C. Air embolus.
D. Infection.
Show answer and rationale
Correct answer: C — Air embolus.
In this scenario, the client undergoing hemodialysis is experiencing symptoms like restlessness, a headache, and nausea. These symptoms are indicative of an air embolus, a serious complication that can occur during hemodialysis. Air embolus happens when air enters the bloodstream and can lead to symptoms like restlessness, a headache, and nausea. It is crucial for the nurse to suspect and address this complication promptly to prevent further harm to the client. Choices A and D (Infection) are less likely in this case, as the symptoms presented are more suggestive of an air embolus rather than an infection. Choice B (Disequilibrium syndrome) is also less likely as the symptoms described are not typical of this syndrome. Therefore, the correct answer is C: Air embolus.
Question 5
Hormonal agents are used to treat some cancers. An example is:
A. thyroxine to treat thyroid cancer.
B. ACTH to treat adrenal carcinoma.
C. estrogen antagonists to treat breast cancer.
D. glucagon to treat pancreatic carcinoma.
Show answer and rationale
Correct answer: C — estrogen antagonists to treat breast cancer.
Estrogen antagonists are commonly used to treat estrogen hormone-dependent cancers such as breast carcinoma. One well-known estrogen antagonist used in breast cancer therapy is Tamoxifen (Nolvadex). This drug, in combination with surgery and other chemotherapeutic drugs, reduces breast cancer recurrence by 30%. Estrogen antagonists can also be administered to prevent breast cancer in women who have a strong family history. Thyroxine is a thyroid hormone used to treat hypothyroidism, not thyroid cancer. ACTH is an anterior pituitary hormone that stimulates the adrenal glands to release glucocorticoids; it does not treat adrenal cancer. Glucagon is a pancreatic alpha cell hormone that stimulates glycogenolysis and gluconeogenesis; it does not treat pancreatic cancer.
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Question 6
When should rehabilitation services begin?
A. when the client enters the health care system.
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 prevent complications, maximize recovery potential, and improve overall health outcomes. Choice B is incorrect because delaying rehabilitation until the client requests it may result in missed opportunities for timely intervention. Choice C is incorrect as waiting for the client's physical condition to stabilize can lead to unnecessary delays in starting the rehabilitation process, potentially slowing down recovery progress. Choice D is incorrect because starting rehabilitation only after discharge can hinder the recovery process by missing out on crucial early stages of intervention and support.
Which of the following scenarios are considered violations of HIPAA laws?
A. Discussing discharge plans with a client in a multi-bed recovery room with the curtain drawn around the client's bed.
B. Looking up the medical information of a friend without permission.
C. Checking on your spouse's medical record because you are listed as her power of attorney.
D. Avoiding conversations about clients while in line in the cafeteria with a mutual caregiver of that client.
Correct answer:
Scenarios B and C are considered violations of HIPAA laws. Looking up the medical information of a friend who is not in your care, even with permission, is a violation of HIPAA as the friend is not your patient. Checking on your spouse's medical record, even as a power of attorney, is a violation unless it is directly related to caregiving decisions.
Discussing discharge plans with a client in a multi-bed recovery room with the curtain drawn around the client's bed is not a violation of HIPAA. This scenario is considered an 'incidental disclosure' and is not a breach of HIPAA privacy rules. Avoiding conversations about clients while in line in the cafeteria with a mutual caregiver of that client is actually a good practice as it maintains client confidentiality.
The PN is caring for a client with diabetes insipidus. The nurse can expect the lab work to show:
A. elevated urine osmolarity and elevated serum osmolarity.
B. decreased urine osmolarity and decreased serum osmolarity.
C. elevated urine osmolarity and decreased serum osmolarity.
D. decreased urine osmolarity and elevated serum osmolarity.
Correct answer:
In diabetes insipidus, the pituitary releases too much antidiuretic hormone (ADH), causing the client to produce a large amount of dilute urine (decreased osmolarity) and leading to dehydration (elevated serum osmolarity). Therefore, the correct answer is decreased urine osmolarity and elevated serum osmolarity. Choice C, elevated urine osmolarity and decreased serum osmolarity, is incorrect for diabetes insipidus, as it is more characteristic of syndrome of inappropriate ADH (SIADH). Choices A and B, elevated urine osmolarity and elevated serum osmolarity, and decreased urine osmolarity and decreased serum osmolarity, respectively, are generally not seen in diabetes insipidus, as urine and serum osmolarity typically move in opposite directions in this condition.
A nurse and a nursing assistant enter a client's room to provide care and find the client lying on the floor. Which action should the nurse take first?
A. Ask the nursing assistant to complete an incident report
B. Check the client's level of consciousness and vital signs
C. Contact the unit secretary on the intercom and ask that the client's health care provider be called
D. Ask the nursing assistant to assist in getting the client back to bed
Correct answer:
When a client sustains a fall, the nurse must first assess the client. The nurse should check the client's level of consciousness and vital signs to determine the severity of the situation and provide appropriate care promptly. This immediate assessment is crucial in ensuring the client's immediate needs are addressed. Asking the nursing assistant to complete an incident report (choice A) is not the priority as the client's condition needs immediate attention. Contacting the unit secretary to call the client's health care provider (choice C) can be done after the initial assessment has been completed. Asking the nursing assistant to assist in getting the client back to bed (choice D) should only be considered after ensuring the client is stable and safe to move.
A 93-year-old female with a history of Alzheimer's Disease gets admitted to an Alzheimer's unit. The patient has exhibited signs of increased confusion and limited stability with gait. Moreover, the patient is refusing to use a w/c. Which of the following is the most appropriate course of action for the nurse?
A. Recommend the patient remain in her room at all times.
B. Recommend family members bring pictures to the patient's room.
C. Recommend a speech therapy consult to the doctor.
D. Recommend the patient attempt to walk pushing the w/c for safety.
Correct answer:
For a 93-year-old female with Alzheimer's Disease exhibiting signs of increased confusion and limited stability with gait, recommending family members to bring pictures to the patient's room is the most appropriate course of action. Visual stimulation in the form of pictures may help decrease signs of confusion and provide comfort to the patient. Option A is incorrect as isolating the patient in her room at all times may worsen her condition by further limiting stimulation and interaction. Option C is incorrect as speech therapy may not directly address the current issues of confusion and gait instability. Option D is incorrect as pushing a wheelchair may not be safe for the patient if she is refusing to use it, potentially leading to falls or further distress.
Following a classic cholecystectomy resection for multiple stones, the PACU nurse observes serosanguinous drainage on the dressing. The most appropriate intervention is to:
A. notify the physician of the drainage
B. change the dressing
C. reinforce the dressing
D. apply an abdominal binder
Correct answer:
In the context of a classic cholecystectomy resection, serosanguinous drainage is an expected finding postoperatively due to the nature of the surgery. The appropriate intervention in this situation is to reinforce the dressing. Changing the dressing prematurely can increase the risk of introducing infection. Applying an abdominal binder is not recommended as it can obstruct the visualization of the dressing and the underlying wound, making it difficult to monitor for any complications or changes in drainage. Notifying the physician may be necessary if there are significant changes in the drainage characteristics or other concerning signs, but the immediate action should be to reinforce the dressing to maintain a clean and secure environment for wound healing.
A client had a C5 spinal cord contusion that resulted in quadriplegia. Two days after the injury occurred, the nurse sees his mother crying in the waiting room. The mother asks the nurse whether her son will ever play football again. Which of the following is the best initial response?
A. "Given time and motivation, your son may regain some function, but I will seek more information from the physician."?
B. Maintain a calm demeanor and speech pattern while addressing the mother's concerns.
C. "I'm not sure, but I'll call the physician to discuss this with you promptly."?
D. "It's not beneficial for your son if you get upset."?
Correct answer:
The best initial response in this situation is to acknowledge the mother's concern, express uncertainty, and offer to obtain more information from the physician. By saying, "I'm not sure, but I'll call the physician to discuss this with you promptly,"? the nurse demonstrates empathy, honesty, and a commitment to providing accurate information. Offering vague reassurance (Choice A) may raise false hopes as outcomes for spinal cord injuries are unpredictable. While maintaining a calm demeanor (Choice B) is important, it does not directly address the mother's immediate need for information. Discouraging the mother from feeling upset (Choice D) is dismissive of her emotions and does not address her question, which is seeking information about her son's prognosis.
A middle-aged woman tells the nurse that she has been experiencing irregular menses for the past six months. The nurse should assess the woman for other symptoms of:
A. climacteric
B. menopause
C. perimenopause
D. postmenopause
Correct answer:
Perimenopause refers to a period in which hormonal changes occur gradually, ovarian function diminishes, and menses become irregular. It typically lasts around five years. In the case of the middle-aged woman experiencing irregular menses for six months, she aligns with perimenopause as it involves irregular menstrual cycles, one of the common symptoms during this transitional phase. Climacteric is a term describing the period of life with physiologic changes leading to the end of a woman's reproductive ability but not specifically characterized by irregular menses. Menopause marks the permanent cessation of menses and does not involve the transitional irregularities seen in perimenopause. Postmenopause is the phase after the completion of menopausal changes.
The nurse is caring for a client admitted with Class III/IV Pulmonary Hypertension. The nurse explains to the client that Lanoxin is being administered to the client in order to:
A. Manage peripheral edema
B. Improve right ventricular function
C. Increase pulmonary pressure
D. Constrict the pulmonary vessels
Correct answer:
The correct answer is to improve right ventricular function. Lanoxin, also known as digoxin, is a cardiac glycoside that works by slowing the heart rate and increasing myocardial contractility, especially in the ventricles. This action helps improve the efficiency of the heart's pumping function, particularly the right ventricle in conditions like pulmonary hypertension. Choice A, managing peripheral edema, is not directly related to Lanoxin's mechanism of action. Choice C, increasing pulmonary pressure, is incorrect as Lanoxin is not used to increase pressure in the pulmonary circulation. Choice D, constricting the pulmonary vessels, is incorrect as Lanoxin does not cause vasoconstriction in the pulmonary vessels but rather acts on the heart's contractility.
Which of the following home-care strategies is most likely to negatively impact the body image of a client with Cushing's syndrome?
A. providing safety measures to prevent falls
B. taking medications as prescribed
C. wearing a medical ID indicating Cushing's syndrome
D. having regular health assessments
Correct answer:
All of the strategies listed are essential components of home care for a client with Cushing's syndrome. However, wearing a medical ID indicating Cushing's syndrome is the correct answer as it can have a negative impact on body image. This choice may constantly remind the client of their condition, potentially affecting their self-image and confidence. On the contrary, providing safety measures to prevent falls (Choice A) would enhance body image by promoting safety and preventing injuries. Taking medications as prescribed (Choice B) is likely to improve body image by managing symptoms effectively. Having regular health assessments (Choice D) demonstrates good self-care and can positively contribute to body image by showing a commitment to maintaining health.
NCLEX-PN clinical judgment practice questions, set 14 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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