NCLEX-PN clinical judgment practice questions, set 20
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 20
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
Which of the following injuries, if demonstrated by a client entering the Emergency Department, is the highest priority?
A. open leg fracture
B. open head injury
C. stab wound to the chest
D. traumatic amputation of a thumb
Show answer and rationale
Correct answer: C — stab wound to the chest
A stab wound to the chest might result in lung collapse and mediastinal shift that, if untreated, could lead to death. Treatment of an obstructed airway or a chest wound is a higher priority than hemorrhage. The principle of ABC (airway, breathing, and circulation) prioritizes care decisions. In this scenario, the stab wound to the chest poses the highest risk to the client's life as it can lead to severe complications such as lung collapse and mediastinal shift. Addressing this injury promptly is crucial to prevent further harm or potential fatality. Open leg fracture, open head injury, and traumatic amputation of a thumb, while serious, do not pose an immediate life-threatening risk compared to a stab wound to the chest.
Question 2
A nurse is returning phone calls in a pediatric clinic. Which of the following reports most requires the nurse's immediate attention and phone call?
A. An 8-year-old boy has been vomiting, appears to have slower movements, and has a history of an atrioventricular shunt placement.
B. A 10-year-old girl feels a dull pain in her abdomen after doing sit-ups in gym class.
C. A 7-year-old boy has been having a low fever and headache for the past 3 days and has a history of an anterior knee wound.
D. A 7-year-old girl who had a cast on her right ankle is complaining of itching.
Show answer and rationale
Correct answer: A — An 8-year-old boy has been vomiting, appears to have slower movements, and has a history of an atrioventricular shunt placement.
The correct answer is the 8-year-old boy with vomiting, slower movements, and a history of an atrioventricular shunt placement. This report requires immediate attention because the symptoms could indicate a blocked shunt, which is a serious medical condition needing urgent evaluation and intervention. Slower movements in the context of an atrioventricular shunt history could suggest increased intracranial pressure. The other choices involve less urgent issues: choice B describes post-exercise pain, choice C presents with a low-grade fever and headache that could be due to a mild infection, and choice D reports itching associated with a cast, which is a common issue and less critical compared to a potentially blocked shunt.
Question 3
A pregnant Asian client who is experiencing morning sickness wants to take ginger to relieve the nausea. Which of the following responses by the nurse is appropriate?
A. "I will call your physician to see if we can start some ginger."?
B. "We don't use home remedies in this clinic."?
C. "Herbs are not as effective as regular medicines."?
D. "Just eat some dry crackers instead."?
Show answer and rationale
Correct answer: A — "I will call your physician to see if we can start some ginger."?
The correct response is to offer to consult with the physician regarding the use of ginger, showing cultural sensitivity. Ginger is known to help relieve nausea, especially in pregnancy. Choice A is the correct answer as it respects the client's preference for a home remedy and involves the physician in the decision-making process. Choice B dismisses the client's preference for a home remedy without exploring its potential benefits. Choice C makes a generalized statement discrediting the effectiveness of herbs, which is not evidence-based and disregards the client's beliefs. Choice D offers an alternative without addressing the client's specific request, failing to acknowledge the client's autonomy and cultural background.
Question 4
The anemias most often associated with pregnancy are:
A. folic acid and iron deficiency.
B. folic acid deficiency and thalassemia.
C. iron deficiency and thalassemia.
D. thalassemia and B12 deficiency.
Show answer and rationale
Correct answer: B — folic acid deficiency and thalassemia.
Folic acid and iron deficiency anemia are the most common types of anemia associated with pregnancy. Approximately 50% of pregnant women experience this type of anemia. Iron deficiency anemia during pregnancy typically results from the increased plasma volume, rather than a decrease in iron levels. Moreover, if a woman has iron deficiency anemia before pregnancy, it often worsens during pregnancy. Folic acid deficiency is also prevalent during pregnancy due to the increased demand for this nutrient to support fetal development. Thalassemia and B12 deficiency, while types of anemia, are not as commonly associated with pregnancy compared to folic acid and iron deficiency anemia, making them incorrect choices in this context.
Question 5
When auscultating breath sounds, the nurse auscultates over the following locations:
A. Trachea and lateral areas of thoracic cage
B. Anterior and posterior aspects of all lung fields
C. The mid section as well as the lateral section of the lungs
D. The mid-clavicular to mid-axillary lines comparing side to side
Show answer and rationale
Correct answer: B — Anterior and posterior aspects of all lung fields
The correct answer is B: Anterior and posterior aspects of all lung fields. When auscultating breath sounds, it is essential to listen to the front (anterior) and back (posterior) aspects of all lung fields. This comprehensive approach allows for a thorough assessment of breath sounds throughout the lungs. Choices A, C, and D are incorrect. Choice A is too limited as it only focuses on the trachea and lateral areas, not covering all lung fields. Choice C is also too limited, referring to specific sections of the lungs (mid section and lateral section). Choice D is incorrect as it suggests comparing specific lines on the chest (mid-clavicular to mid-axillary), which is not a standard practice for auscultating breath sounds.
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Question 6
After a client with an Automated Internal Cardiac Defibrillator (AICD) is successfully defibrillated for Ventricular Fibrillation (VF), what should the nurse do next?
A. Go to the client to assess for signs and symptoms of decreased cardiac output.
B. Call the physician to inform them of the VF episode for medication adjustments.
C. Call the 'on-call' person in the cath lab to re-charge the ICD in case of a recurrence.
D. Document the incident on the code report form and follow up regularly.
Correct answer:
After a client is successfully defibrillated, the immediate priority is to assess the client for signs and symptoms of decreased cardiac output, such as altered level of consciousness, chest pain, shortness of breath, or hypotension. This assessment is crucial to determine the effectiveness of the defibrillation and the client's current hemodynamic status. Calling the physician for medication adjustments without assessing the client first could delay essential interventions. Contacting the 'on-call' person in the cath lab to re-charge the ICD is not the initial action needed after successful defibrillation. Documenting the incident is important but should not take precedence over assessing the client's immediate condition.
The physician's role in case management includes all of the following except:
A. participating in interdisciplinary planning for clients.
B. serving as the expert for resource utilization.
C. consulting with the case management team to facilitate timely orders as needed.
D. contributing to the documentation of a client's needs for services.
Correct answer:
The correct answer is 'serving as the expert for resource utilization.' While physicians play a crucial role in case management, their primary focus is on medical diagnosis and treatment rather than resource utilization. Choices A, C, and D are all roles that physicians typically fulfill in case management. A physician participating in interdisciplinary planning for clients ensures comprehensive care, consulting with the case management team helps in coordinating timely orders, and contributing to the documentation of a client's needs for services aids in providing appropriate care. Therefore, serving as the expert for resource utilization does not align with the primary responsibilities of a physician in case management.
A nurse is performing suctioning through an adult client's tracheostomy tube. The nurse notes that the client's oxygen saturation is 89% and terminates the procedure. Which action would the nurse take next?
A. Rechecking the pulse oximetry reading
B. Calling the respiratory therapist
C. Calling the healthcare provider
D. Oxygenating the client with 100% oxygen
Correct answer:
The nurse should monitor the client's heart rate and pulse oximetry during suctioning to assess the client's tolerance of the procedure. Oxygen desaturation to below 90% indicates hypoxemia. If hypoxia occurs during suctioning, the nurse must terminate the procedure and oxygenate the client with 100% oxygen to address the hypoxemia promptly and ensure the client's safety. Rechecking the pulse oximetry reading is important, but the priority is to address the hypoxemia by providing oxygen. Contacting the healthcare provider or respiratory therapist is not necessary at this time as the nurse can manage the hypoxemia with oxygenation. Oxygenating the client with 100% oxygen is the immediate action required in this situation.
While preparing a client for a bronchoscopy, a nurse notes that the client is wearing a gold necklace. What should the nurse do to safeguard the client's necklace?
A. Ask the client for permission to lock the necklace in the hospital safe
B. Ask the client to remove the necklace and place it in the top drawer of the bedside table
C. Ask the client whether the necklace is gold
D. Ask the client to sign a release to free the hospital of responsibility if the necklace is damaged or lost during the procedure
Correct answer:
When a client has valuables such as jewelry, the nurse should ensure their safekeeping. It is appropriate for the nurse to ask the client for permission to lock the necklace in the hospital safe to prevent loss or damage. This option prioritizes the security of the necklace while allowing the client to make an informed decision. Asking the client to sign a release form does not guarantee the necklace's safety; it only releases the hospital from liability. Placing the necklace in a bedside table drawer does not provide adequate security as it is not as secure as a hospital safe. Inquiring whether the necklace is gold is irrelevant to safeguarding the jewelry during the procedure, as the primary concern is its safekeeping.
Why would a nurse employed at a hospital be asked by a nurse manager to review the organizational chart?
A. To be aware of the geographic area that the organization serves
B. To be familiar with the organization's line of authority
C. To understand the organization's reason for existence
D. To be familiar with the beliefs and values of the organization
Correct answer:
The correct answer is 'To be familiar with the organization's line of authority.' Organizational charts provide a visual representation of the chain of command, reporting relationships, and structure within an organization. This helps employees understand who they report to, who reports to them, and the overall hierarchy. Choice A is incorrect because understanding the geographic area served is more about the organization's scope, not depicted in an organizational chart. Choice C is incorrect as it relates to the organization's reason for existence, usually found in its mission statement. Choice D is incorrect as beliefs and values are linked to the organization's culture, not typically shown in an organizational chart.
A client with a closed chest tube drainage system accidentally disconnects the chest tube while being turned by the nurse. What should the nurse do first?
A. Submerge the end of the chest tube in a bottle of sterile water
B. Clamp the chest tube with a Kelly clamp
C. Call the health care provider
D. Instruct the client to inhale and hold his breath
Correct answer:
When a chest tube becomes disconnected, the priority action is to immediately reattach it to the drainage system or submerge the end in a bottle of sterile water or saline solution to reestablish a water seal. This helps prevent air from entering the pleural space and causing complications. Calling the health care provider is important but not the first action in this emergency. Instructing the client to inhale and hold his breath should be avoided as it can introduce atmospheric air into the pleural space, leading to potential issues. Clamping the chest tube is generally contraindicated, especially in cases of residual air leak or pneumothorax, as it may result in a tension pneumothorax by preventing air from escaping.
Which of the following situations requires nurse intervention?
A. A certified nursing assistant states, 'The patient in 307 is not wearing gloves while shaving her legs.'
B. A nursing assistant at the nursing station states, 'The patient in 307 has a respiratory rate of 16.'
C. A nursing student in the cafeteria states, 'Dr. Jones told the patient in room 307 that she was going to die.'
D. A certified nursing assistant states, 'Dr. Jones hasn't made rounds this morning.'
Correct answer:
The correct answer is C. Patient confidentiality must be maintained at all times to respect the patient's privacy and dignity. Disclosing sensitive information like a patient's prognosis in a public setting violates confidentiality and can cause distress. The nurse should intervene in this situation and educate the nursing student about the importance of not discussing confidential patient information in public. Choices A, B, and D do not involve breaching patient confidentiality and do not require immediate nurse intervention. Choice A focuses on infection control measures, choice B relates to clinical assessment, and choice D is about the doctor's rounds, which are not urgent matters requiring immediate intervention.
A patient 3 hours post-op from a hysterectomy is complaining of intense pain at the incision site. When assessing the patient, the nurse notes a BP of 169/93, pulse 145 bpm, and regular. What action should the nurse take?
A. Reassure the patient that pain is normal following surgery.
B. Administer prn Nifedipine and assess the client's response.
C. Administer prn Meperidine HCL and assess the client's response.
D. Recheck BP and pulse rate every 20 minutes for the next hour.
Correct answer:
The correct action for the nurse to take in this situation is to administer prn Meperidine HCL and assess the client's response. A BP of 169/93 and a pulse of 145 bpm indicate pain-related hypertension and sinus tachycardia, which are physiological responses to pain. Treating the cause of the increased pulse rate requires pain medication. Reassuring the patient about normal post-surgery pain is important, but addressing the physiological responses to pain is a priority. Administering Nifedipine, a calcium channel blocker, is not indicated for pain management but for hypertension. Rechecking the BP and pulse rate without addressing the pain directly does not address the underlying issue causing the elevated vital signs.
The patient is inquiring about the use of a PCA pump for pain management. Which statement by the patient indicates a need for additional education?
A. "I will continue to report my pain score during assessments."?
B. "I understand that there is a maximum dose per hour that I can receive regardless of how many times I press the button."?
C. "I believe this new PCA pump will finally alleviate my back pain."?
D. "I have more control over when and how much medication I receive."?
Correct answer:
The correct answer is, "I believe this new PCA pump will finally alleviate my back pain."? This statement indicates a need for additional education as it reflects an unrealistic expectation regarding pain management. It is essential for the patient to understand that while a PCA pump can provide effective pain relief, it may not completely eliminate pain. Option A is correct as it demonstrates the patient's understanding of the importance of reporting pain scores for proper pain management. Option B is correct as it shows the patient's awareness of the maximum dose limits to prevent overdose. Option D is correct as it highlights the patient's understanding of the control they have over their medication administration.
Ethical and moral issues concerning restraints include all of the following except:
A. emotional impact on the client and family.
B. dignity of the client.
C. client's quality of life.
D. policies and procedures.
Correct answer:
The correct answer is 'policies and procedures.' While policies and procedures are essential for managing restraints, they are not in themselves ethical or moral issues. The emotional impact on the client and family, the dignity of the client, and the client's quality of life are all ethical and moral concerns related to the use of restraints. These aspects focus on the well-being, respect, and rights of the individual, which are fundamental ethical considerations in healthcare practice. Choices A, B, and C are directly tied to ethical and moral considerations by highlighting the impact on individuals involved and their overall quality of life and dignity, making them key factors to address in ethical decision-making.
NCLEX-PN clinical judgment practice questions, set 20 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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