NCLEX-PN clinical judgment practice questions, set 17
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 17
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 schizophrenia and his parents are meeting with the nurse. One of the young man's parents says to the nurse, 'We were stunned when we learned that our son had schizophrenia. He was no different from his older brother when they were growing up. Now he's had another relapse, and we can't understand why he stopped his medication.' Which response by the nurse is appropriate?
A. Telling the parents, 'Medication noncompliance is the most frequent reason that people with this diagnosis relapse.'
B. Telling the parents, 'Well, it's his decision to take his medicine, but it's yours to have him live with you if he stops the medication.'
C. Asking the client, 'How can we help you to take your medicine or to tell us when you're having problems so that your medication can be adjusted?'
D. 'Your concerns are appropriate, but I wonder whether your son was having trouble telling someone that he had concerns about his medication.'
Show answer and rationale
Correct answer: C — Asking the client, 'How can we help you to take your medicine or to tell us when you're having problems so that your medication can be adjusted?'
The appropriate response is to ask the client how they can be helped in taking their medication or sharing problems to adjust the medication. This approach promotes direct communication with the client, allowing for better assessment of the situation and understanding the client's motivations and behaviors. It also encourages openness and mutual communication between the client and their family. Choice A provides important information about noncompliance as a common reason for relapse but lacks a therapeutic approach by not facilitating emotional expression. Choice B uses a threatening message and is nontherapeutic. Choice D prematurely analyzes the client's motivations without sufficient assessment and lacks a therapeutic communication style.
Question 2
During shift change, a nurse is giving report to the oncoming LPN. Which of these is an inappropriate way to give shift report?
A. The nurse gives report to the oncoming LPN, checking a wound vac and dressing together.
B. The nurse reports in SBAR format, noting that the client was noncompliant with their diet during the shift.
C. The nurse reports in the hallway, in SBAR format, and alerts the oncoming LPN about how rude the client was throughout the shift.
D. The nurse reports at bedside with the oncoming LPN and discusses the client's concerns after the chart has been reviewed.
Show answer and rationale
Correct answer: C — The nurse reports in the hallway, in SBAR format, and alerts the oncoming LPN about how rude the client was throughout the shift.
The correct answer is 'The nurse reports in the hallway, in SBAR format, and alerts the oncoming LPN about how rude the client was throughout the shift.' This choice is inappropriate because shift report should be given at the bedside, in SBAR format, and in an objective way. It is important to maintain professionalism and focus on the client's condition and care needs, rather than personal opinions or subjective comments. Reporting in the hallway may compromise patient privacy and confidentiality. Choices A, B, and D demonstrate appropriate ways of giving shift report by focusing on relevant information, using SBAR format, and discussing client concerns after reviewing the chart, which promotes effective communication and continuity of care.
Question 3
A client with diabetes mellitus who takes a daily dose of NPH insulin has a hard time drawing the insulin into a syringe because he has difficulty seeing the markings on the syringe. To which services does the nurse suggest a referral?
A. Home care
B. Occupational therapy
C. Social services
D. Physical therapy
Show answer and rationale
Correct answer: B — Occupational therapy
For a client with diabetes mellitus who struggles to draw insulin due to poor vision, the nurse should suggest a referral to home care services. Home care provides various support services, including assistance with insulin administration. In this scenario, a home care nurse can prefill a week's supply of syringes with the correct insulin dose for the client. These syringes can be stored in the client's refrigerator for self-administration. Occupational therapy focuses on helping individuals with activities of daily living, such as using adaptive devices. Social services typically address counseling and financial aspects of care. Physical therapy is geared towards treating physical disabilities or impairments through exercises and techniques.
Question 4
Which of the following activities is not part of client advocacy?
A. involving the client in treatment and decision-making
B. standing up for what is right for the client
C. sharing your personal opinions to help provide additional information
D. encouraging the client to advocate for themselves
Show answer and rationale
Correct answer: C — sharing your personal opinions to help provide additional information
The correct answer is 'sharing your personal opinions to help provide additional information.' Client advocacy involves supporting the client's autonomy and choices. It is essential for the nurse to involve the client in treatment and decision-making (Choice A) to ensure their preferences are considered. Standing up for what is right for the client (Choice B) is also a crucial aspect of advocacy, ensuring their rights and well-being are protected. Encouraging the client to advocate for themselves (Choice D) empowers the client to express their needs. However, sharing personal opinions (Choice C) may influence the client's decision-making process and is not a recommended practice in client advocacy, as it can compromise the client's autonomy.
Question 5
A client returns to the nursing unit post-thoracotomy with two chest tubes in place connected to a drainage device. The client's spouse asks the nurse about the reason for having two chest tubes. The nurse's response is based on the knowledge that the upper chest tube is placed to:
A. Remove air from the pleural space
B. Create access for irrigating the chest cavity
C. Evacuate secretions from the bronchioles and alveoli
D. Drain blood and fluid from the pleural space
Show answer and rationale
Correct answer: A — Remove air from the pleural space
The correct answer is 'Remove air from the pleural space.' When a client has two chest tubes in place post-thoracotomy, the upper chest tube is typically positioned to remove air from the pleural space. Air rises, so placing the tube at the top allows for efficient removal of air that has accumulated in the pleural cavity. Choice B, creating access for irrigating the chest cavity, is incorrect as chest tubes are not primarily used for irrigation. Choice C, evacuating secretions from the bronchioles and alveoli, is incorrect as chest tubes are not designed for this purpose. Choice D, draining blood and fluid from the pleural space, is also incorrect as the upper chest tube in this scenario is specifically for removing air, not blood or fluid.
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Question 6
The nurse notes that a healthcare provider has documented the following prescription in a client's record: Furosemide (Lasix) 40 mg stat once. What action should the nurse take?
A. Administering the medication
B. Drawing up the medication in a syringe
C. Planning to have the nurse on the next shift administer the medication
D. Contacting the healthcare provider
Correct answer:
The correct action for the nurse to take in this situation is to contact the healthcare provider. The prescription provided lacks crucial information such as the route of administration. Before administering any medication, the nurse must clarify any missing details with the provider, especially for a stat prescription that requires immediate administration. Drawing up or administering the medication without verifying the route of administration is unsafe and can lead to errors. Planning for the next shift nurse to administer the medication is not appropriate in this scenario as the stat order necessitates immediate action. Therefore, the best course of action is to contact the healthcare provider to obtain clarification on the prescription.
While assisting a healthcare provider in assessing a hospitalized client, the healthcare provider is paged to report to the recovery room. The healthcare provider instructs the nurse verbally to change the solution and rate of the intravenous (IV) fluid being administered. What is the most appropriate nursing action in this situation?
A. Calling the nursing supervisor to obtain permission to accept the verbal prescription
B. Asking the healthcare provider to write the prescription in the client's record before leaving the nursing unit
C. Telling the healthcare provider that the prescription will not be implemented until it is documented in the client's record
D. Changing the solution and rate of the IV fluid per the healthcare provider's verbal prescription
Correct answer:
Verbal prescriptions should be avoided due to the risk of errors. If a verbal prescription is necessary, it should be promptly written and signed by the healthcare provider, typically within 24 hours. Following agency policies and procedures regarding verbal prescriptions is crucial. In this scenario, the most appropriate nursing action is to request the healthcare provider to document the prescription in the client's record before leaving the unit. Calling the nursing supervisor to accept the verbal prescription without documentation, telling the healthcare provider to delay treatment until documented, and directly changing the IV fluid based on verbal orders all pose risks and do not align with best practices in medication administration.
A client with stress incontinence should be advised:
A. to avoid relying solely on absorbent undergarments.
B. that Kegel exercises might help.
C. that effective surgical treatments are available.
D. that behavioral therapy can be beneficial.
Correct answer:
Kegel exercises, which involve tightening and releasing the pelvic floor muscles, can be beneficial for stress incontinence by strengthening the muscles that control urination. Choice A is incorrect as it is important for the client to know that absorbent undergarments can be used as a temporary solution but do not address the underlying issue. Choice C is incorrect as while surgical treatments are available, they are usually considered when conservative treatments like exercises and behavioral therapy have not been successful. Choice D is incorrect as behavioral therapy can be beneficial in managing stress incontinence through lifestyle and dietary modifications, bladder training, and more, contrary to the statement that it is ineffective.
What is the primary force in sex education in a child's life?
A. school nurse
B. peers
C. parents
D. media
Correct answer:
Parents are the primary force in sex education in a child's life. Parents play a central role in shaping a child's understanding of sex from an early age. They provide continuous guidance, values, and information about sex and relationships. While the school nurse is involved in formal sex education and counseling within the school setting, parents have the most direct and significant impact on a child's sex education. Peers become more influential during adolescence, but their information may not always be accurate or appropriate. The media also exert significant influence on children's perceptions of sex through various forms of entertainment like movies, TV shows, and video games, but parents remain the primary educators on this subject.
A case manager is reviewing the records of the clients in the nursing unit. Which note(s) in a client's record indicate an unexpected outcome and the need for follow-up?
A. A client is performing their own colostomy irrigations.
B. A client with a central venous catheter has a temperature of 100.6°F.
C. A client who has just undergone surgery has a urine output of more than 30 mL/hr.
D. A client with a new diagnosis of diabetes mellitus is self-administering insulin.
Correct answer:
A case manager is a healthcare professional responsible for coordinating a client's care from admission through and after discharge. They evaluate and update the plan of care as needed, monitoring for unexpected outcomes and providing follow-up. A temperature of 100.6°F in a client with a central venous catheter is an unexpected outcome that requires follow-up due to the potential indication of an infection. Choices A, C, and D describe expected outcomes and appropriate self-care management. The client self-irrigating their colostomy, a post-surgical client having adequate urine output, and a newly diagnosed diabetic self-administering insulin are all positive indicators of self-care and expected outcomes, not requiring immediate follow-up.
A case manager is serving on a community task force on violence in schools. The members of the task force are planning to develop interventions to help prevent violence. According to the nursing process, which is the first activity that the case manager would suggest to the task force?
A. Teaching schoolchildren about the dangers of school violence
B. Conducting a community survey to assess community perceptions regarding school violence
C. Looking at what other communities are doing about school violence
D. Distributing flyers that identify the causes of school violence to families in the community
Correct answer:
The correct answer is to conduct a community survey to assess community perceptions regarding school violence. In the nursing process, assessment is always the first step. By conducting a survey, the task force can gather important data about how the community perceives school violence, which is essential for developing effective interventions. Choices A, C, and D involve actions that come after the assessment phase. Teaching schoolchildren about the dangers of violence and distributing flyers are important activities but should come after understanding the community's perceptions and needs. Looking at what other communities are doing is valuable but should also follow a thorough assessment of the specific community's needs and perceptions.
The client asked about the role of leptin in the body. Which response should the nurse provide?
A. It increases food intake in clients, thereby promoting obesity.
B. It assists in the regulation of steroids.
C. It increases the total fat mass of people who are obese.
D. It might decrease the total fat mass in the bodies of people who are obese.
Correct answer:
Leptin is a protein hormone expressed in fat cells that regulates fat cell percentage in the body. It is associated with increased energy expenditure and decreased food intake through hypothalamic control. In obese individuals, there may be insensitivity or resistance to leptin's effects. Leptin influences other hormones like insulin and genetic factors related to fat regulation. Therefore, the correct response is that leptin might decrease total fat mass in obese individuals as it is involved in energy balance and fat regulation. Choices A, B, and C are incorrect because leptin does not increase food intake or promote obesity; it does not assist in the regulation of steroids, and it does not increase total fat mass in people who are obese.
During a home health visit, a nurse consults with a male patient diagnosed with CAD and COPD who is taking Ventolin, Azmacort, Aspirin, and Theophylline and complains of upset stomach, nausea, and discomfort. What should the nurse do?
A. Contact the patient's physician immediately
B. Recommend the patient lie on his right side
C. Advise the patient to schedule a doctor's visit the next day
D. Suggest holding the drug Azmacort
Correct answer:
The correct answer is to contact the patient's physician immediately. The patient's symptoms of upset stomach, nausea, and discomfort could indicate theophylline toxicity, a potentially serious condition. It is crucial to consult the physician promptly to address this issue. Option B, recommending the patient lie on his right side, is incorrect as it does not address the potential theophylline toxicity and is not a priority. Option C, advising the patient to schedule a doctor's visit the next day, is inappropriate as the symptoms may indicate an urgent concern. Option D, suggesting holding the drug Azmacort, is incorrect as it does not address the potential theophylline toxicity and should not be done without consulting the physician first.
After applying oxygen using bi-nasal prongs to a client who is having chest pain, the nurse should implement which intervention?
A. Have the client take slow deep breaths in through their mouth and out through their nose.
B. Post signs indicating that oxygen is in use on the client's door and in their room
C. Apply Vaseline petroleum to both nares and 2 by 2 gauze around the oxygen tubing at the client's ears
D. Encourage the client to hyperextend the neck, take a few deep breaths and cough.
Correct answer:
After applying oxygen using bi-nasal prongs to a client with chest pain, it is essential for the nurse to post signs indicating that oxygen is in use on the client's door and in their room. This safety precaution alerts healthcare providers and visitors that the client is receiving oxygen therapy, reducing the risk of accidents or misunderstandings. Choice A is incorrect because instructing the client to take slow deep breaths is not the appropriate intervention after applying oxygen. Choice C suggests applying Vaseline and gauze, which is unnecessary and not a standard practice. Choice D advising the client to hyperextend the neck, take deep breaths, and cough is not indicated after applying oxygen therapy and could potentially be harmful.
A 65-year-old female client is experiencing postmenopausal bleeding. Which type of physician should this client be encouraged to see?
A. a radiologist
B. a gynecologist
C. a physiatrist
D. an oncologist
Correct answer:
A 65-year-old female experiencing postmenopausal bleeding should be encouraged to see a gynecologist. Gynecologists specialize in treating and managing diseases of the female reproductive organs, making them the most appropriate physician for this issue. Postmenopausal bleeding can indicate various gynecological conditions such as endometrial atrophy, endometrial hyperplasia, or endometrial cancer, highlighting the importance of consulting a gynecologist for proper diagnosis and management. Radiologists evaluate X-rays, physiatrists manage rehabilitation teams, and oncologists treat clients with cancer. Therefore, in this case, the symptoms point towards a gynecological problem, emphasizing the necessity of seeking care from a gynecologist.
NCLEX-PN clinical judgment practice questions, set 17 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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