NCLEX-PN clinical judgment practice questions, set 15
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 15
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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 patient has been diagnosed with fibromyalgia and COPD. Which of the following tasks should the nurse delegate to a nursing assistant?
A. Transferring the patient to the shower.
B. Ambulating the patient for the first time.
C. Taking the patient's breath sounds.
D. Educating the patient on monitoring fatigue.
Show answer and rationale
Correct answer: A — Transferring the patient to the shower.
The correct answer is to delegate the task of transferring the patient to the shower to a nursing assistant. Nursing assistants are trained to assist with transfers safely, making this task appropriate for delegation. Ambulating the patient for the first time involves assessing the patient's mobility and tolerance, which requires more assessment and monitoring by a nurse, especially in a patient with fibromyalgia and COPD. Taking the patient's breath sounds involves assessing the patient's respiratory status, which is a nursing responsibility due to the need for clinical judgment. Educating the patient on monitoring fatigue involves providing vital information and should be done by the nurse to ensure comprehensive understanding and tailored recommendations.
Question 2
When obtaining a health history on a menopausal woman, which information should a nurse recognize as a contraindication for hormone replacement therapy?
A. family history of stroke
B. ovaries removed before age 45
C. frequent hot flashes and/or night sweats
D. unexplained vaginal bleeding
Show answer and rationale
Correct answer: D — unexplained vaginal bleeding
When considering hormone replacement therapy for a menopausal woman, unexplained vaginal bleeding should be recognized as a contraindication. This is because it could be indicative of a serious underlying condition that needs investigation before initiating hormone therapy. A family history of stroke, by itself, is not a contraindication for hormone replacement therapy, unless the woman herself has a history of stroke or blood-clotting events. Ovaries removed before age 45 may actually increase the likelihood of needing hormone replacement therapy due to early menopause. Frequent hot flashes and night sweats, on the other hand, are symptoms that can be relieved by hormone replacement therapy, making them a potential indication rather than a contraindication.
Question 3
The LPN on shift notices a client coming into the clinic with bruises on his arm. The client seems very afraid and doesn't speak much, which concerns the nurse because these are signs of physical abuse. The nurse should ____.
A. use therapeutic communication to talk to the client and offer support while reporting the findings to the appropriate authorities based on the state requirements and protocols
B. report the findings to the appropriate authorities based on the state requirements and protocols
C. ignore the bruises, as this is not why the client is being treated and is not appropriate for the nurse to address
D. report the suspected abuse to another nurse and collaborate on how to handle it
Show answer and rationale
Correct answer: B — report the findings to the appropriate authorities based on the state requirements and protocols
In cases of suspected abuse, healthcare providers have a legal and ethical obligation to report such incidents to the relevant authorities. This not only ensures the safety and well-being of the client but also helps in preventing further harm. Option A is incorrect as attempting to gather evidence of abuse may interfere with the official investigation and is not the nurse's role. Offering support is crucial, but the priority is to report the findings to the appropriate authorities. Option C is incorrect as ignoring signs of abuse goes against the duty of a healthcare provider to protect their clients. Option D is incorrect as reporting suspected abuse to other nurses without involving the appropriate authorities may delay necessary actions and intervention.
Question 4
When a client informs the nurse that he is experiencing hypoglycemia, the nurse provides immediate intervention by providing:
A. one commercially prepared glucose tablet
B. two hard candies
C. 4-6 ounces of fruit juice
D. 2-3 teaspoons of honey
Show answer and rationale
Correct answer: D — 2-3 teaspoons of honey
The correct immediate intervention for hypoglycemia is to provide 10-15 grams of fast-acting simple carbohydrates orally if the client is conscious and able to swallow. This can be achieved by giving 2-3 teaspoons of honey. Honey is a quick source of simple sugars that can rapidly raise blood glucose levels. Commercially prepared glucose tablets or 4-6 ounces of fruit juice are also appropriate options. However, adding sugar to fruit juice is unnecessary as the natural fruit sugar in juice already provides enough simple carbohydrates to raise blood glucose levels. Hard candies are not the best choice for immediate intervention in hypoglycemia as they may not provide a sufficient amount of fast-acting carbohydrates needed to raise blood sugar levels quickly.
Question 5
When a client informs the nurse that he is experiencing hypoglycemia, the nurse provides immediate intervention by offering:
A. one commercially prepared glucose tablet.
B. two hard candies.
C. 4-6 ounces of fruit juice.
D. 2-3 teaspoons of honey.
Show answer and rationale
Correct answer: D — 2-3 teaspoons of honey.
The correct answer is 2-3 teaspoons of honey. In the case of hypoglycemia, the usual recommendation for treatment is 10-15 grams of fast-acting simple carbohydrate orally if the client is conscious and able to swallow. This can be achieved by providing 2-3 teaspoons of honey. While commercially prepared glucose tablets or 4-6 ounces of fruit juice are also suitable choices, adding sugar to unsweetened juice is unnecessary as the fruit sugar in juice contains enough simple carbohydrate to raise blood glucose levels. Adding sugar could lead to a sharp and prolonged increase in blood sugar levels. Two hard candies may not provide the recommended 10-15 grams of fast-acting carbohydrate needed for quick elevation of blood glucose levels in cases of hypoglycemia.
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Question 6
Once the nurse has made initial rounds and checked all of the assigned clients, which client should be cared for first?
A. A client who is scheduled for surgery at 1 p.m.
B. A client in skeletal traction who has just received pain medication
C. A client scheduled for physical therapy at 11 a.m.
D. A client who is able to perform activities of daily living independently
Correct answer:
The priority should be given to the client who is scheduled for surgery at 1 p.m. Preparing a client for surgery involves various tasks such as physical and emotional preparation, following healthcare provider instructions, and potential last-minute changes in the surgical schedule. It is crucial to ensure the client is adequately prepared. Providing care to a client who just received pain medication can wait until the medication takes effect. Clients who are independent in performing daily activities and those scheduled for physical therapy later in the morning are not as high a priority as preparing a client for an upcoming surgery. Therefore, the client scheduled for surgery should be cared for first to ensure all necessary preparations are completed.
The nurse is making assignments for the day. Which client should be assigned to the pregnant nurse?
A. The client receiving linear accelerator radiation therapy for lung cancer
B. The client with a radium implant for cervical cancer
C. The client who has just been administered soluble brachytherapy for thyroid cancer
D. The client who returned from placement of iridium seeds for prostate cancer
Correct answer:
The pregnant nurse should not be assigned to any client with radioactivity present. The client receiving linear accelerator therapy is the correct choice because the radiation stays in the department, and the client is not radioactive. Choices B, C, and D involve clients who are radioactive or pose a risk due to radioactivity. The client with a radium implant for cervical cancer (choice B) is radioactive, the client who has just been administered soluble brachytherapy for thyroid cancer (choice C) is radioactive for approximately 72 hours, and the client who returned from placement of iridium seeds for prostate cancer (choice D) is also radioactive, especially right after the procedure. These options are not suitable for assignment to the pregnant nurse.
A client has experienced a CVA with right hemiparesis and is ready for discharge from the hospital to a long-term care facility for rehab. To provide optimal continuity of care, the nurse should do all of the following except:
A. document the current functional status
B. have the physician fax a report to the receiving facility
C. copy appropriate parts of the medical record for transport to the receiving facility
D. phone a report to the facility
Correct answer:
To ensure optimal continuity of care for a client transitioning to a long-term care facility for rehab after a CVA, the nurse plays a crucial role in communication. Documenting the current functional status is essential for the receiving facility to plan appropriate care. Copying relevant parts of the medical record for transport provides important background information. Phoning a report directly to the facility is a direct and effective way to communicate the client's condition and care plan. However, having the physician fax a report to the receiving facility introduces an extra step that may delay essential information transfer and increase the risk of miscommunication. Therefore, it is not the optimal choice for ensuring seamless continuity of care.
Mrs. Peterson complains of difficulty falling asleep, awakening earlier than desired, and not feeling rested. She attributes these problems to leg pain that is secondary to her arthritis. What is the most appropriate nursing diagnosis for her?
A. Sleep Pattern Disturbances (related to chronic leg pain)
B. Fatigue (related to leg pain)
C. Knowledge Deficit (regarding sleep hygiene measures)
D. Sleep Pattern Disturbances (related to chronic leg pain)
Correct answer:
The most appropriate nursing diagnosis for Mrs. Peterson is 'Sleep Pattern Disturbances (related to chronic leg pain).' Mrs. Peterson's sleep issues are directly linked to her chronic leg pain, which is a result of her arthritis. This nursing diagnosis addresses the primary cause of her sleep disturbances and allows for interventions that focus on managing the pain to improve her sleep. Choices A, B, and C are incorrect. Choice A correctly identifies the relationship between sleep disturbances and chronic leg pain, addressing the root cause. Choice B is incorrect as it only focuses on fatigue and does not encompass the broader sleep issues. Choice C is not relevant as there is no indication that Mrs. Peterson lacks knowledge about sleep hygiene measures.
The client is being assessed for possible pernicious anemia. Which finding would support this diagnosis?
A. A weight loss of 10 pounds in 2 weeks
B. Complaints of numbness and tingling in the extremities
C. A red, beefy tongue
D. A hemoglobin level of 12.0 g/dL
Correct answer:
The correct answer is a red, beefy tongue, which is characteristic of pernicious anemia due to the atrophy of the papillae on the tongue. This finding is known as glossitis. A red, beefy tongue is a classic sign of pernicious anemia. Choice A, weight loss of 10 pounds in 2 weeks, is non-specific and not a typical finding in pernicious anemia. Choice B, complaints of numbness and tingling in the extremities, are more indicative of peripheral neuropathy, a common symptom of vitamin B12 deficiency, which can be seen in pernicious anemia. Choice D, a hemoglobin level of 12.0 g/dL, falls within the normal range and does not specifically point towards pernicious anemia, which is characterized by low hemoglobin levels due to impaired absorption of vitamin B12.
A nurse provides instructions to an older adult about measures to prevent heatstroke. Which statement by the client indicates a need for further instruction?
A. ''I should wear cool, light clothing in warm weather.''
B. ''I need to wear a hat with a wide brim when I go outdoors.''
C. ''I need to wear additional antiperspirant and deodorant in warm weather.''
D. ''I should drink extra fluids during the summer.''
Correct answer:
As an individual ages, the number of sweat glands decreases, resulting in reduced body odor and decreased evaporative heat loss due to less sweating. The need for antiperspirants and deodorants is reduced in older adults. Therefore, the statement 'I need to wear additional antiperspirant and deodorant in warm weather' indicates a need for further instruction. Older adults should focus on wearing cool, light clothing in warm weather to prevent overheating, wearing a hat with a wide brim when outdoors to protect from the sun's rays, and staying hydrated by drinking extra fluids during the summer. These measures are more effective in preventing heatstroke in older adults compared to using additional antiperspirants and deodorants, which are not necessary.
A nurse manager asks a nurse to work overtime because of a short-staffing problem. The nurse has made plans to do Christmas shopping after work and does not want to work overtime. What is the most assertive response by the nurse to her nurse manager?
A. "I'm not working overtime today."
B. "I have plans after work and will not be able to work overtime."
C. "You know how I hate to work overtime."
D. "I will if you need me, but I am not happy about this."
Correct answer:
The most assertive response in dealing with this conflict is the one that is direct and conveys a clear message in a positive manner. The nurse should assertively communicate her unavailability for overtime without being confrontational. Option A, "I'm not working overtime today," is too blunt and may come across as rude. Option C, "You know how I hate to work overtime," is not assertive but rather passive-aggressive. Option D, "I will if you need me, but I am not happy about this," is a passive-aggressive response as it implies compliance while expressing discontent. Option B, "I have plans after work and will not be able to work overtime," is the most appropriate response as it clearly states the nurse's unavailability without unnecessary aggression.
A nurse is watching as a new nurse employee administers an intramuscular (IM) injection in a client's deltoid muscle. The nurse determines that the new employee is performing the procedure correctly if the new employee uses which technique?
A. Administers the injection 2 inches below the acromion process
B. Positions the client with the deltoid muscle exposed
C. Administers the injection in the thigh
D. Places the client in the Sims position
Correct answer:
When administering an intramuscular injection in the deltoid muscle, the correct technique involves administering the injection 2 inches below the acromion process, which is the bony structure on top of the shoulder blade. This location ensures safe and effective administration. Administering the injection in the thigh (vastus lateralis or rectus femoris muscle) is not appropriate for a deltoid injection as the deltoid muscle is located in the upper arm. The Sims position is not the correct position for a deltoid muscle injection. While positioning the client with the deltoid muscle exposed allows for proper access and visualization, the critical aspect for a correct deltoid injection is the accurate injection site, 2 inches below the acromion process.
When caring for African-American clients, what is an important consideration regarding their needs?
A. Families may have specific needs.
B. Special hair, skin, and nail care might be required.
C. Cultural diets should be respected.
D. Clients are generally future-oriented.
Correct answer:
Correct answer: Special hair, skin, and nail care might be required. African-American clients may have specific hair, skin, and nail care needs due to their unique characteristics such as curly hair and melanin-rich skin. It is important for healthcare providers to be knowledgeable about these needs to provide appropriate care. Option A is incorrect as it does not address the specific care aspect related to the clients themselves. Option C is incorrect as assuming all African-American clients follow cultural diets is a stereotype and may not apply to every individual. Option D is incorrect as being future-oriented is not a characteristic that is universally applicable to African-American clients and does not directly impact nursing care considerations.
A client delivered a term male infant four hours ago. The infant was stillborn. Which room assignment would be most appropriate for this client?
A. Request a private room on the GYN floor
B. Assign her to a private room on the postpartum unit
C. Discharge her home as soon as her condition is stable
D. Room her with another client who experienced a pregnancy loss
Correct answer:
In this situation, the most appropriate room assignment for the client who delivered a stillborn infant would be to request a private room on the GYN floor. This client needs privacy to grieve, and having a private space allows for family members to offer support. Placing her in a GYN unit ensures that she is away from the maternity unit's sights and sounds, which could be painful reminders for her. Assigning her to a postpartum unit may cause distress due to the presence of other mothers and newborns. Discharging her home too early may not allow her sufficient time for emotional and physical recovery. Rooming her with another client who experienced a pregnancy loss may not provide the necessary privacy and space she needs for her emotional well-being.
NCLEX-PN clinical judgment practice questions, set 15 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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