NCLEX-PN clinical judgment practice questions, set 16
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 16
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 nurse is teaching the mother of an 11-month-old infant how to clean the infant's teeth. The nurse tells the mother to take which action?
A. Use a small amount of toothpaste and a soft-bristle toothbrush
B. Use water and a cotton swab and rub the teeth
C. Use diluted fluoride and rub the teeth with a soft washcloth
D. Dip the infant's pacifier in maple syrup so that the infant will suck
Show answer and rationale
Correct answer: C — Use diluted fluoride and rub the teeth with a soft washcloth
The correct action when cleaning an infant's teeth is to use water and a cotton swab to gently rub the teeth. This method helps in removing any food particles or plaque buildup without the risks associated with toothpaste ingestion. Using a small amount of toothpaste and a soft-bristle toothbrush is not recommended for infants as they may swallow the toothpaste, leading to potential fluoride ingestion issues. Using diluted fluoride and rubbing the teeth with a soft washcloth is unnecessary at this age since infants typically receive fluoride through other sources like formula. Dipping the infant's pacifier in maple syrup is highly inappropriate and poses a significant risk of tooth decay due to the high sugar content, which can harm the infant's teeth.
Question 2
A safety measure to implement when transferring a client with hemiparesis from a bed to a wheelchair is:
A. standing the client and walking him or her to the wheelchair.
B. moving the wheelchair close to the client's bed and standing and pivoting the client on his unaffected extremity to the wheelchair.
C. moving the wheelchair close to the client's bed and standing and pivoting the client on his affected extremity to the wheelchair.
D. having the client stand and push his body to the wheelchair.
Show answer and rationale
Correct answer: B — moving the wheelchair close to the client's bed and standing and pivoting the client on his unaffected extremity to the wheelchair.
When transferring a client with hemiparesis from a bed to a wheelchair, it is crucial to ensure their safety. The correct safety measure involves moving the wheelchair close to the client's bed and having the client stand and pivot on his unaffected extremity to the wheelchair. This method provides support with the unaffected limb, reducing the risk of falls and promoting a safer transfer. Choice A is incorrect because walking the client is unsafe and not recommended. Choice C is incorrect as pivoting the client on his affected extremity can lead to injury or falls due to weakness or lack of control. Choice D is incorrect as it puts the client at risk by requiring them to push their body, which may not be feasible or safe for someone with hemiparesis.
Question 3
The nurse who was not promoted then went to the utility room and slammed several cupboard doors while looking for Kleenex. This behavior exemplifies:
A. displacement.
B. sublimation
C. conversion.
D. reaction formation.
Show answer and rationale
Correct answer: A — displacement.
Displacement unconsciously transfers emotions associated with a person, object, or situation to another less threatening person, object, or situation. In this scenario, the nurse slammed doors instead of expressing anger towards the promoted nurse or the administrator who made the promotion decision. Sublimation is the unconscious process of substituting constructive activity for unacceptable impulses. Since slamming cupboard doors is not a constructive activity, this choice is incorrect. Conversion involves transforming anxiety into physical symptoms, which is not demonstrated in the given behavior. Reaction formation keeps unacceptable feelings or behaviors out of awareness by displaying the opposite feeling or behavior, which is not the case here.
Question 4
A client needs to rapidly achieve a therapeutic plasma drug concentration of a medication. Rather than wait for steady state to be achieved, the physician might order:
A. a maintenance dose.
B. a loading dose.
C. a medication with no first-pass effect.
D. the medication to be given intravenously.
Show answer and rationale
Correct answer: B — a loading dose.
To rapidly achieve a therapeutic plasma drug concentration, a loading or priming dose is ordered. This dose quickly establishes the desired drug level. It is calculated by multiplying the volume of distribution by the desired plasma drug concentration. A maintenance dose, like choice A, is used to maintain the therapeutic level after the loading dose. Waiting for steady state without a loading dose would take five drug half-lives. Choice C, a medication with no first-pass effect, does not directly address the need for rapid attainment of therapeutic levels. While intravenous administration (choice D) offers excellent bioavailability, a single dose by this route may not achieve the desired therapeutic plasma concentration as rapidly as a loading dose.
Question 5
A nursing care plan for a client with sleep problems has been implemented. All of the following should be expected outcomes except:
A. the client reports no episodes of awakening during the night.
B. the client falls asleep within 1 hour of going to bed.
C. the client reports satisfaction with their amount of sleep.
D. the client rates sleep as an 8 or more on the visual analog scale.
Show answer and rationale
Correct answer: B — the client falls asleep within 1 hour of going to bed.
An expected outcome for a nursing care plan targeting sleep problems is that the client reports no episodes of awakening during the night, the client reports satisfaction with their amount of sleep, and the client rates sleep as an 8 or more on the visual analog scale. Falling asleep within 1 hour of going to bed is not necessarily an expected outcome. While it is generally desirable for individuals to fall asleep within a reasonable time frame, this specific timeframe may vary among individuals, and it is not a strict criterion for successful sleep outcomes. Therefore, the correct answer is that the client falls asleep within 1 hour of going to bed, as this is not a definitive measure of the effectiveness of the nursing care plan for sleep problems.
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Question 6
Which of the following observations is most important when assessing a client's breathing?
A. presence of breathing and pulse rate
B. breathing pattern and adequacy of breathing
C. presence of breathing and adequacy of breathing
D. patient position and adequacy of breathing
Correct answer:
The correct answer is the presence of breathing and adequacy of breathing. It is crucial to ensure that the client is not only breathing but also breathing adequately. Choices A and D are incorrect as pulse rate and patient position are not the most critical observations when assessing a client's breathing. Pulse rate is more related to assessing circulation, and patient position is important but not as crucial as ensuring the client is breathing and breathing adequately. Choice B is partially correct as breathing pattern is important, but the most critical observation is the adequacy of breathing. Adequacy of breathing ensures that the client is receiving enough oxygen to support proper body function and is the key focus during breathing assessment.
A 4-year-old client is unable to go to sleep at night in the hospital. Which nursing intervention best promotes sleep for the child?
A. turning off the room light and closing the door
B. engaging the child in calming activities before bedtime
C. identifying the child's home bedtime rituals and following them
D. encouraging relaxation techniques like deep breathing exercises
Correct answer:
For a 4-year-old client struggling to sleep in the hospital, the best nursing intervention is to identify the child's home bedtime rituals and follow them. Preschool-age children often have specific bedtime routines that provide comfort and promote sleep. This familiarity can help create a sense of security in an unfamiliar hospital environment. Choice A, turning off the room light and closing the door, may increase the child's fear of the dark and being alone. Choice B, engaging the child in calming activities before bedtime, is a better choice than tiring them with play exercises. Choice D, encouraging relaxation techniques like deep breathing exercises, although helpful, may not be as effective as following the child's familiar bedtime routines.
A client is taking hydrocodone (Vicodin) for chronic back pain. The client has required an increase in the dose and asks whether this means he is addicted to Vicodin. The nurse should base her reply on the knowledge that:
A. the client's body has developed tolerance, requiring more drug to produce the same effect.
B. the client is preoccupied with getting the drug and is experiencing loss of control, indicating drug dependence.
C. addiction is the term used to describe physical dependence with withdrawal symptoms and tolerance.
D. the client has a dual diagnosis of substance abuse and chronic back pain
Correct answer:
Drug tolerance is characterized by the ability to ingest a larger dose without adverse effects and decreased sensitivity to the substance. In this scenario, the client needing an increased dose of hydrocodone to achieve the same pain relief indicates tolerance developing, not addiction. Choice B is incorrect as it describes drug dependence, where the individual is preoccupied with the drug and has a loss of control. Choice C is incorrect because addiction involves psychological behaviors related to substance use, not just physical dependence with withdrawal symptoms and tolerance. Choice D is incorrect as it refers to a dual diagnosis, which is the coexistence of substance abuse and psychiatric disorders, not the development of tolerance to a drug.
What are the side effects of first-generation over-the-counter (OTC) antihistamines like diphenhydramine (Benadryl) and hydroxyzine (Atarax) in infants and children?
A. Reye's syndrome.
B. cholinergic effects.
C. paradoxical CNS stimulation.
D. nausea and diarrhea.
Correct answer:
The correct answer is paradoxical CNS stimulation. First-generation OTC antihistamines, such as diphenhydramine and hydroxyzine, can lead to paradoxical CNS stimulation in infants and children. This phenomenon is characterized by symptoms like excitement, euphoria, restlessness, and confusion, rather than the expected sedative effect. Due to this unexpected response, these antihistamines are used less frequently in pediatric populations. Reye's syndrome is a rare systemic response to a virus and is not a side effect of antihistamines. First-generation OTC antihistamines do not typically exhibit cholinergic effects. Nausea and diarrhea are uncommon side effects of these antihistamines and are less commonly observed than paradoxical CNS stimulation.
When planning care of a client who has been diagnosed with Amphetamine Abuse, the nurse should use the knowledge that:
A. Amphetamines increase energy by increasing dopamine levels at neural synapses.
B. Amphetamines have a low risk of tolerance or addiction.
C. Amphetamines produce a 10-20-second rush followed by a 2-4-hour high.
D. Addiction to barbiturates and amphetamines is rare because they have opposite effects.
Correct answer:
The correct answer is that amphetamines increase energy by increasing dopamine levels at neural synapses. Amphetamines cause the release of norepinephrine and dopamine from storage vesicles into the synapse, leading to increased stimulation. It is important to note that clear patterns of tolerance and withdrawal have not been described with amphetamines. Choice B is incorrect as prolonged or excessive use of amphetamines can lead to psychosis, indicating a potential for addiction. Choice C is incorrect as the duration of the effects of amphetamines is typically longer than 2-4 hours. Choice D is incorrect as addiction to amphetamines is not rare; in fact, drug cravings are common and can lead to relapse, indicating a significant risk of addiction.
When teaching a woman about possible side effects of hormone replacement therapy, the nurse should include information about all of the following except:
A. Hypoglycemia in diabetic women.
B. The possible return of monthly menses when taking combination hormones.
C. Increased risk of gallbladder disease.
D. Increased risk of breast, cervical, and ovarian cancer with long-term use.
Correct answer:
The correct answer is 'Hypoglycemia in diabetic women.' When educating a woman about hormone replacement therapy, it is important to discuss the possible side effects. It is true that monthly menses might return when taking combination hormones, as the progestin can cause this. Additionally, there is an increased risk of gallbladder disease associated with hormone replacement therapy. Furthermore, long-term use of hormone replacement therapy is linked to an increased risk of breast, cervical, and ovarian cancer. However, hypoglycemia is not a common side effect of hormone replacement therapy, especially in diabetic women. In fact, estrogen can have a positive impact on glucose control in some cases, so hypoglycemia would not be a typical concern.
Which of the following post-operative diets is most appropriate for the client who has had a hemorrhoidectomy?
A. High-fiber
B. Low-residue
C. Bland
D. Clear-liquid
Correct answer:
The correct answer is 'Clear-liquid.' After a hemorrhoidectomy, the client is usually started on a clear-liquid diet to allow the intestines to rest and promote healing. This diet helps prevent straining during bowel movements, which is crucial for recovery. Stool softeners are often included in the plan to avoid constipation. Once the client tolerates the clear liquids well, they can progress to a regular diet. High-fiber diet (choice A) is beneficial in the later stages of recovery to prevent constipation but is not typically the initial post-operative diet. Low-residue diet (choice B) and bland diet (choice C) are not appropriate for this type of surgery as they may not provide the necessary post-operative care and support needed for healing.
A healthcare professional is assessing a patient's right lower extremity. The extremity is warm to touch, red, and swollen. The patient is also running a low fever. Which of the following conditions would be the most likely cause of the patient's condition?
A. Herpes
B. Scleroderma
C. Dermatitis
D. Cellulitis
Correct answer:
The patient's presentation of a warm, red, swollen extremity with a low fever is indicative of cellulitis, which is inflammation of cellular tissue. Cellulitis is commonly associated with these symptoms due to a bacterial infection in the skin and underlying tissues. Herpes (Choice A) is a viral infection that typically presents with grouped vesicles, not the warm, red, swollen presentation seen in cellulitis. Scleroderma (Choice B) is a chronic autoimmune condition affecting the skin and connective tissue, presenting differently from the acute symptoms of cellulitis. Dermatitis (Choice C) refers to skin inflammation, which does not typically present with the described symptoms of warmth, redness, swelling, and low fever observed in cellulitis.
Which task would be appropriate for the LPN to perform?
A. Changing a colostomy bag.
B. Hanging a new bag of TPN.
C. Drawing a peak antibiotic blood level from a central line.
D. Administering IV pain medication to a two-day post-op client.
Correct answer:
The correct answer is changing a colostomy bag. This task falls within the LPN's scope of practice. LPNs are trained to provide basic nursing care, including assisting with activities of daily living and certain medical procedures like changing ostomy bags. Hanging a new bag of TPN and drawing a peak antibiotic blood level from a central line are tasks that require a higher level of training and are typically performed by RNs due to their complexity and potential risks. Administering IV pain medication to a two-day post-op client is usually the responsibility of an RN as it involves close monitoring, assessment of the client's condition, and the administration of potent medications that require a higher level of clinical judgment and expertise.
Major competencies for the nurse giving end-of-life care include:
A. demonstrating respect and compassion, and applying knowledge and skills in care of the family and the client.
B. assessing and intervening to support total management of the family and client.
C. setting goals, expectations, and dynamic changes to care for the client.
D. keeping all sad news away from the family and client.
Correct answer:
In providing end-of-life care, nurses must possess essential competencies. Demonstrating respect and compassion, along with applying knowledge and skills in caring for both the family and the client, are crucial competencies. These skills help create a supportive and empathetic environment for individuals facing end-of-life situations. Choice B is incorrect because while assessing and intervening are important, they do not encompass the core competencies required for end-of-life care. Choice C is also incorrect; although setting goals and expectations is valuable, the primary focus should be on providing compassionate care. Choice D is incorrect as withholding sad news goes against the principles of honesty and transparency in end-of-life care.
NCLEX-PN clinical judgment practice questions, set 16 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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