NCLEX-PN clinical judgment practice questions, set 18
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 18
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
After the client discusses her relationship with her father, the nurse says, "Tell me whether I am understanding your relationship with your father. You feel dominated and controlled by him?"? This is an example of:
A. verbalizing the implied.
B. seeking consensual validation.
C. encouraging evaluation.
D. suggesting collaboration.
Show answer and rationale
Correct answer: B — seeking consensual validation.
Seeking consensual validation is the correct answer. Consensual validation is a technique used to check one's understanding of what the client has said. It involves confirming with the client whether the nurse's interpretation aligns with the client's feelings or thoughts. This process helps build rapport, trust, and a shared understanding between the nurse and the client. Verbalizing the implied (choice A) refers to expressing the underlying or implicit meaning of a client's statement. Encouraging evaluation (choice C) involves prompting the client to assess or judge a situation. Suggesting collaboration (choice D) entails proposing working together with the client on a shared goal, which is not the primary focus in the scenario provided.
Question 2
The nurse in the emergency room is admitting a client who has sustained a gunshot wound and will require immediate surgery. The client is unconscious and by themselves. Which of the following actions is most appropriate?
A. Call the charge nurse and request that the facility's legal counsel provide a waiver for informed consent.
B. Attempt to stabilize the client in the emergency room until they are conscious enough to provide informed consent.
C. Try to locate the client's family to obtain informed consent before transporting the client to the operating room.
D. Proceed with transporting the client to the operating room without obtaining informed consent.
Show answer and rationale
Correct answer: D — Proceed with transporting the client to the operating room without obtaining informed consent.
In emergency situations where a client is unconscious and requires immediate surgery to save their life, the priority is to proceed with necessary interventions without delay to ensure the best possible outcome. Obtaining informed consent is essential in healthcare, but in situations where a delay in treatment can be life-threatening, healthcare providers are ethically and legally permitted to proceed with treatment without consent. Attempting to stabilize the client until conscious enough to provide consent or trying to locate family members for consent would cause a dangerous delay in critical care. Therefore, the most appropriate action in this scenario is to transport the unconscious client to the operating room for immediate surgery.
Question 3
Elderly persons with pernicious anemia should be instructed:
A. to increase their dietary intake of foods high in B12.
B. that they do not need to return for follow-up for at least a month after initiation of treatment.
C. that oral B12 is safer and less expensive than parenteral replacement.
D. that diarrhea can be a transient side effect of B12 injections.
Show answer and rationale
Correct answer: D — that diarrhea can be a transient side effect of B12 injections.
Elderly persons with pernicious anemia, a condition characterized by vitamin B12 deficiency due to lack of intrinsic factor, should be informed about the potential side effects of B12 injections. Diarrhea is a known transient side effect of B12 injections, along with pain and burning at the injection site, and peripheral vascular thrombosis. Increasing dietary intake of B12-rich foods would not be sufficient due to the malabsorption issue in pernicious anemia. Follow-up is essential in managing pernicious anemia, so instructing patients they do not need to return for follow-up is incorrect. While oral B12 may be a suitable option for some cases, it is not the preferred choice for pernicious anemia where malabsorption is the primary issue.
Question 4
When supporting a family who has just experienced a sudden and unexpected death, the nurse needs to know:
A. that survivors have greater emotional turmoil and shock than when death is expected.
B. that survivors have less emotional turmoil and shock than when death is expected.
C. that survivors have the same emotional turmoil and shock as when death is expected.
D. that survivors have little emotional turmoil and shock because they were not there.
Show answer and rationale
Correct answer: A — that survivors have greater emotional turmoil and shock than when death is expected.
The correct answer is that survivors have greater emotional turmoil and shock than when death is expected. Sudden death produces more emotional turmoil and shock in survivors compared to gradual, expected death. Survivors of sudden death do not have the opportunity to engage in anticipatory grief. The unexpectedness of sudden death is the most disturbing and unbalancing factor, leading to heightened emotional turmoil and shock. Choice B is incorrect as survivors of sudden death experience more emotional turmoil and shock. Choice C is incorrect because sudden death brings about a different level of emotional turmoil and shock. Choice D is incorrect as survivors of sudden and unexpected death still go through significant emotional distress.
Question 5
The client has just returned from electroconvulsive therapy (ECT) and is very drowsy. What is the position of choice until the client regains full consciousness?
A. Supine
B. Fowlers
C. Lateral
D. High Fowlers
Show answer and rationale
Correct answer: C — Lateral
The correct answer is 'Lateral.' When a client is very drowsy or sedated, placing them in the lateral position is important to maintain an open airway and allow for drainage of secretions. This position helps prevent airway obstruction and aspiration.
Choice A, 'Supine,' is lying flat on the back and may not be ideal for a drowsy client due to the risk of airway compromise.
Choice B, 'Fowlers,' is a semi-sitting position that is beneficial for clients with respiratory distress, but it may not be the best choice for a very drowsy individual.
Choice D, 'High Fowlers,' is a more upright sitting position, which again may not be suitable for a drowsy client as it does not facilitate airway patency as effectively as the lateral position.
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Question 6
When preparing a client for platelet pheresis in the blood bank, which information is most significant to obtain during the history assessment?
A. Allergies to shellfish
B. Date of last platelet donation
C. Time of last oral intake
D. Blood type
Correct answer:
The most significant information to gather when a client is scheduled for platelet pheresis is the date of their last platelet donation. Platelet donors can typically have their platelets apheresed as frequently as every 14 days. Knowing the date of the last donation helps ensure the client is eligible for the procedure without risking any adverse effects from frequent donations. Allergies to shellfish may be important for other procedures where anticoagulants containing heparin are used, but it is not directly related to platelet pheresis. The time of the last oral intake is more crucial for procedures requiring sedation or anesthesia. Blood type is significant for blood transfusions but is not the primary concern for platelet pheresis.
The LPN notices a client with poor gait and balance. She is currently being treated for hypertension, but the nurse is concerned. What should the nurse do?
A. Add this issue to the nursing care plan and include daily gait/balance training as an intervention.
B. Do nothing as this is unrelated to the client's hospitalization.
C. Speak with the attending physician about the concerns and request a referral for the client to go to physical therapy.
D. Speak with the attending physician about the concerns and request a referral to physical therapy.
Correct answer:
Nurses should address any concerns regarding a client's health, even if they are not directly related to the reason for hospitalization. In this case, the nurse noticing the client's poor gait and balance should communicate these concerns to the attending physician. The correct course of action is to request a referral to physical therapy, as this specialized intervention can help address the client's issues effectively. Adding gait/balance training to the care plan without professional assessment and intervention may not be appropriate. Doing nothing is not in line with providing comprehensive care, and referring the client to the hospital gym is not as effective as a referral to physical therapy for addressing gait and balance issues.
A director of nursing at a long-term care center has announced a change to computerized documentation of nursing care. A certified nursing assistant (CNA) on the team, resistant to the change, is not taking an active part in facilitating the implementation of the new procedure. Which strategy would be the best approach to dealing with the conflict?
A. Meeting with the CNA and encouraging him to express his feelings regarding the change
B. Ignoring the resistance
C. Telling the CNA that a licensed practical nurse (LPN) will perform all computer documentation while he documents intake and output and vital signs
D. Telling the CNA that noncompliance will be documented in the personnel record
Correct answer:
The best approach to dealing with resistance to change is through open communication and understanding. Meeting with the CNA and encouraging him to express his feelings regarding the change allows for a constructive dialogue where issues can be addressed, and alternative solutions can be explored. Ignoring the resistance does not help in resolving the conflict and may lead to further issues. Telling the CNA that a licensed practical nurse (LPN) will perform all computer documentation while he documents intake and output and vital signs does not address the underlying concerns of the CNA and may create more resistance. Threatening the CNA with noncompliance consequences may escalate the resistance and create a negative work environment.
A nurse reviews the health history of a client who will be seeing the health care provider to obtain a prescription for a combination oral contraceptive (estrogen and progestin). Which finding in the health history would cause the nurse to determine that the use of a combination oral contraceptive is contraindicated?
A. The client has type 2 diabetes mellitus.
B. The client is being treated for hypertension.
C. The client has been treated for breast cancer.
D. The client has hyperlipidemia.
Correct answer:
The correct answer is that the client has been treated for breast cancer. Combination oral contraceptives containing estrogen and progestin are contraindicated for women with a history of certain conditions, such as thrombophlebitis, thromboembolic disorders, cerebrovascular disease, coronary artery disease, myocardial infarction, known or suspected breast cancer, known or suspected estrogen-dependent neoplasm, benign or malignant liver tumors, and undiagnosed abnormal genital bleeding. Although having type 2 diabetes mellitus, being treated for hypertension, or having hyperlipidemia are risk factors that require caution when using combination oral contraceptives, they are not absolute contraindications like a history of breast cancer.
What is one of the main goals of Healthy People 2010?
A. reduction of health care costs
B. elimination of health disparities
C. investigation of substance abuse
D. determination of an acceptable morbidity rate
Correct answer:
The main goal of Healthy People 2010 is the elimination of health disparities among the U.S. population. This initiative outlines specific objectives to improve the overall health of Americans by addressing disparities in health outcomes. Choice A, reduction of health care costs, is not the primary goal of Healthy People 2010, although it may be a beneficial outcome. Choice C, investigation of substance abuse, is not a main goal of Healthy People 2010; while substance abuse may be a factor in health disparities, the primary focus is on broader disparities. Choice D, determination of an acceptable morbidity rate, is not the main focus of Healthy People 2010; instead, it aims to address health disparities in different population groups.
A home health care nurse is visiting a male African American client who was recently discharged from the hospital. Which family member does the nurse ensure is present when teaching the client about his prescribed medications?
A. The client's grandson
B. The client's mother
C. The client's father
D. The client's son
Correct answer:
In the African American family structure, the woman, especially the mother, often plays a central role in healthcare decisions and maintaining family health. It is essential for the nurse to involve the client's mother in teaching him about his prescribed medications as she may be responsible for his care and treatment decisions. While other family members may also be involved, the African American family is often matrifocal, emphasizing the importance of the mother's role. Therefore, it is crucial for the nurse to ensure the client's mother is present during medication teaching. Choices A, C, and D are incorrect as they do not align with the traditional African American family structure and the role of women in healthcare decisions.
The nurse is caring for a client and wants to assess the neurologic function. Which of the following will give the most information?
A. Level of consciousness
B. Doll's eye reflex
C. Babinski reflex
D. Reaction to painful stimuli
Correct answer:
The correct answer is 'Level of consciousness.' Assessing the client's level of consciousness provides crucial information about their neurologic function, including subtle changes in verbal ability, orientation, and responsiveness to commands. Doll's eye reflex is a specific eye movement test used in neurologic assessments but may not provide as much comprehensive information as the client's overall consciousness level. The Babinski reflex is a test used to assess specific spinal cord function rather than overall neurologic function. Reaction to painful stimuli provides information about sensory function and pain response but may not offer as much insight into the client's neurologic status as assessing their level of consciousness.
Which of the following is not an advanced directive?
A. informed consent
B. living will
C. durable power of attorney for health care
D. health care proxy
Correct answer:
Informed consent is the process of obtaining permission from a patient before conducting a healthcare intervention. It is not considered an advanced directive. A living will is a legal document that outlines a person's preferences for medical treatment if they are unable to communicate. A durable power of attorney for health care designates a person to make medical decisions on behalf of the patient. A health care proxy, which is another term for a durable power of attorney for health care, also involves appointing someone to make healthcare decisions for an individual if they become unable to do so. Therefore, the correct answer is 'informed consent,' as it is not an advanced directive but rather a different aspect of patient care.
When educating an obese client about nutritional needs and weight loss, which of the following should not be included?
A. knowledge of food and food products
B. development of a positive mental attitude
C. adequate exercise
D. starting a fast weight-loss diet
Correct answer:
When educating an obese client about nutritional needs and weight loss, it is important to cover factors such as knowledge of food and food products, the development of a positive mental attitude, and the importance of adequate exercise. These aspects contribute to a holistic approach to weight management. However, recommending the client to start a fast weight-loss diet should not be included. Fast weight-loss diets can be harmful, leading to health risks, nutrient deficiencies, and unsustainable outcomes. It is crucial to advocate for gradual, sustainable weight loss strategies to ensure long-term success and overall well-being. Therefore, starting a fast weight-loss diet is the least appropriate option among the choices provided.
When providing culturally competent care to a couple from the Philippines living in the United States who are expecting their first child, what should the nurse do first?
A. review their own cultural beliefs and biases
B. respectfully request that the couple only use medically approved health care providers
C. understand the clients' need to learn the accepted medical practices of their new country
D. study family dynamics to comprehend the male and female gender roles in the clients' culture
Correct answer:
When providing culturally competent care, the nurse's initial step is to reflect on and understand their own cultural beliefs and biases. By doing so, the nurse can approach the care of the couple from the Philippines with sensitivity and respect. This self-awareness helps the nurse recognize potential differences in beliefs and values, fostering effective communication and care. Option B is incorrect because it does not address the nurse's need for self-reflection. Option C is incorrect as it focuses on the clients adapting to the new country's practices rather than the nurse understanding the clients' existing beliefs. Option D is incorrect as it pertains to family dynamics and gender roles rather than the nurse's self-awareness.
NCLEX-PN clinical judgment practice questions, set 18 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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