NCLEX-PN clinical judgment practice questions, set 21
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 21
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
What is the most effective strategy to assist a client in recognizing and using personal strength?
A. Encouraging the client's self-identification of strengths.
B. Promoting the client's active external thinking.
C. Listening to the client and providing advice as needed.
D. Assisting the client in maintaining an external locus of control.
Show answer and rationale
Correct answer: A — Encouraging the client's self-identification of strengths.
Encouraging the client to identify their own strengths is empowering and helps build self-awareness and self-confidence. This strategy promotes autonomy and self-efficacy, enabling the client to recognize and utilize their personal strengths effectively. Option B, promoting the client's active external thinking, is vague and not directly related to recognizing personal strengths. Option C, listening to the client and providing advice as needed, focuses more on the nurse's role rather than empowering the client to recognize their strengths independently. Option D, assisting the client in maintaining an external locus of control, goes against the goal of helping the client recognize and utilize their internal strengths.
Question 2
Nurses should understand the chain of infection because it refers to:
A. the linkages involved in disease transmission.
B. the sequence required for transmission of disease.
C. the clustering of bacteria in a specific pattern.
D. increasing virulence patterns among microorganisms.
Show answer and rationale
Correct answer: B — the sequence required for transmission of disease.
The chain of infection refers to the sequence required for the transmission of disease, involving steps like the pathogen's presence, movement from a reservoir, and entry into a susceptible host. Understanding this sequence helps healthcare professionals, including nurses, in implementing effective infection control measures. Choices A, C, and D are incorrect because they do not accurately describe the concept of the chain of infection. Choice A is too broad and does not specifically address the sequential nature of disease transmission. Choice C focuses on bacterial clustering rather than the transmission process. Choice D mentions virulence patterns, which are not the primary focus of the chain of infection concept.
Question 3
A nurse suspects a patient is developing Bell's Palsy. The nurse wants to test the function of cranial nerve VII. Which of the following would be the most appropriate testing procedures?
A. Test the taste sensation over the back of the tongue and activation of the facial muscles.
B. Test the taste sensation over the front of the tongue and activation of the facial muscles.
C. Test the sensation of the facial muscles and sensation of the back of the tongue.
D. Test the sensation of the facial muscles and sensation of the front of the tongue.
Show answer and rationale
Correct answer: B — Test the taste sensation over the front of the tongue and activation of the facial muscles.
The facial nerve (VII) is responsible for motor function to the face and sensory function to the anterior two-thirds of the tongue. Therefore, to appropriately test the function of cranial nerve VII, the most appropriate testing procedures involve assessing the taste sensation over the front of the tongue (sensory) and activation of the facial muscles (motor). Option B, 'Test the taste sensation over the front of the tongue and activation of the facial muscles,' is the correct answer. Choices A, C, and D are incorrect because they do not involve the correct combination of sensory testing over the front of the tongue and motor activation of the facial muscles, which are key functions associated with cranial nerve VII.
Question 4
During a health assessment, a nurse is assisting with gathering subjective data from a client and plans to ask the client about the medical history of the client's extended family. About which family members would the nurse ask the client?
A. Aunts, uncles, grandparents, and cousins
B. Foster children and their parents
C. Wife's children from a previous marriage
D. Wife and wife's parents
Show answer and rationale
Correct answer: B — Foster children and their parents
The correct answer is 'Aunts, uncles, grandparents, and cousins.' When gathering medical history from the client's extended family, it is essential to inquire about relatives beyond the nuclear family, such as aunts, uncles, grandparents, and cousins, as they share genetic and environmental influences. Choice C, 'Wife's children from a previous marriage,' pertains to stepchildren, not extended family members. Choice B, 'Foster children and their parents,' involves individuals who are not biologically related to the client's family. Choice D, 'Wife and wife's parents,' focuses solely on immediate family members and excludes the client's extended family members, which are crucial for a comprehensive health assessment.
Question 5
When transferring a client with hemiparesis from a bed to a wheelchair, which safety measure should be implemented?
A. Standing the client and walking them to the wheelchair
B. Moving the wheelchair close to the client's bed and standing and pivoting the client on their unaffected extremity to the wheelchair
C. Moving the wheelchair close to the client's bed and standing and pivoting the client on their affected extremity to the wheelchair
D. Having the client stand and push their body to the wheelchair
Show answer and rationale
Correct answer: C — Moving the wheelchair close to the client's bed and standing and pivoting the client on their affected 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 is to move the wheelchair close to the client's bed and have the client stand and pivot on their unaffected extremity to the wheelchair. This method provides support with the unaffected limb, reducing the risk of falls or injuries. Choice A is incorrect as it suggests walking the client, which may not be safe or feasible. Choice C is incorrect because pivoting on the affected extremity can increase the risk of injury. Choice D is incorrect as it does not consider the client's limitations and safety needs, as it involves pushing their body which may not be possible with hemiparesis.
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Question 6
The physician orders the antibiotics ampicillin (Omnipen) and gentamicin (Garamycin) for a newly admitted client with an infection. The nurse should:
A. administer both medications simultaneously
B. give the medications sequentially, and flush well between them
C. ask the physician or pharmacy which medication to give first and how long to wait before giving the other drug
D. start one medication now and begin the other medication in 2-4 hours
Correct answer:
The correct answer is to give the medications sequentially and flush well between them. Ampicillin has a pH of 8-10, while gentamicin has a pH of 3-5.5, making them incompatible when given together. Flushing well between drugs is necessary to prevent any potential interactions. Option A is incorrect because administering both medications simultaneously can lead to incompatibility issues. Option C is incorrect because the nurse should already be aware of the correct administration sequence and not need to consult the physician or pharmacy each time. Option D is incorrect because delaying the second medication by several hours can slow down the treatment of the client's infection, which is not ideal in this scenario.
A nurse is assisting with data collection regarding the motor development of a 24-month-old child. Which activities would the nurse expect the mother to report that the child can perform?
A. Go to the bathroom without help
B. Dress himself appropriately
C. Put on and tie his shoes
D. Align two or more blocks
Correct answer:
By 24 months of age, a child can perform various activities. While the child may be able to put on simple items of clothing, distinguishing front from back might still be a challenge. They may also be able to zip large zippers, put on shoes, wash and dry their hands, align two or more blocks, and turn book pages one at a time. However, the fine motor skill required to tie shoes is usually not developed at this age. Full independence in dressing, using the bathroom, and eating typically occurs around 4 to 5 years of age. Therefore, the correct expectation for a 24-month-old child would be aligning two or more blocks. Choices A, B, and C are incorrect as they represent skills that are usually achieved at a later age.
One of the major functions of the kidneys in maintaining normal fluid balance is:
A. the manufacture of antidiuretic hormone.
B. the regulation of calcium and phosphate balance.
C. the regulation of the pH of the extracellular fluid.
D. the control of aldosterone levels.
Correct answer:
The correct answer is 'the regulation of the pH of the extracellular fluid.' The kidneys play a crucial role in maintaining normal fluid balance by regulating extracellular fluid and osmolarity through selective retention and excretion of fluids. Additionally, they regulate the pH of the extracellular fluid by retaining hydrogen ions and excreting metabolic wastes and toxic substances. Choice A is incorrect because antidiuretic hormone (ADH) is manufactured by the pituitary gland, not the kidneys. Choice B is incorrect as the regulation of calcium and phosphate balance is primarily controlled by the parathyroid gland. Choice D is incorrect as aldosterone levels are controlled by the adrenal glands, not the kidneys.
A client with dumping syndrome should ___________ while a client with GERD should ___________.
A. lie down 1 hour after meals; sit up at least 30 minutes after meals
B. sit up 1 hour after meals; lie flat 30 minutes after meals
C. sit up after meals; sit up after meals
D. lie down after meals; lie down after meals
Correct answer:
Clients with dumping syndrome should lie down after eating to decrease the symptoms of dumping syndrome, which include rapid gastric emptying leading to various gastrointestinal symptoms. On the other hand, clients with GERD should sit up at least 30 minutes after meals to prevent the backflow of stomach acid into the esophagus. This position helps reduce symptoms by allowing gravity to keep the stomach contents in place, minimizing the chances of reflux. Therefore, the correct answer is to lie down 1 hour after eating for dumping syndrome and to sit up at least 30 minutes after eating for GERD. Choices B, C, and D are incorrect because they do not accurately reflect the appropriate positioning for each condition.
The nurse is caring for a client who is 28 weeks pregnant and complains of swollen hands and feet. Which symptom below would cause the greatest concern?
A. Nasal congestion
B. Hiccups
C. Blood glucose of 150
D. Muscle spasms
Correct answer:
The correct answer is muscle spasms because they can be indicative of a severe condition like preeclampsia, which is a serious complication during pregnancy characterized by high blood pressure and signs of damage to another organ system, most often the liver and kidneys. Nasal congestion and hiccups are common discomforts during pregnancy and do not pose a severe risk to the client or fetus. A blood glucose level of 150, while slightly elevated, may not be alarming in a pregnant individual and can be managed through dietary modifications or medication adjustments. Muscle spasms, especially in the context of pregnancy, should be taken seriously and thoroughly assessed to rule out any underlying serious conditions.
How can a diet high in fiber content benefit an individual?
A. aid in weight loss.
B. reduce diabetic ketoacidosis.
C. lower cholesterol.
D. reduce the need for folate.
Correct answer:
A diet high in fiber content can help lower cholesterol levels by reducing the absorption of cholesterol in the bloodstream. Fiber-rich foods, like grains, apples, potatoes, and beans, can aid in this process. While fiber can aid in weight loss by promoting a feeling of fullness and aiding digestion, it is not primarily for fast weight loss. Fiber does not directly reduce the risk of diabetic ketoacidosis, which is more related to managing blood sugar levels through insulin therapy and dietary control. Folate is a B vitamin that is essential for various bodily functions and is not influenced by fiber intake. Therefore, the correct answer is to lower cholesterol, as fiber plays a significant role in this benefit.
Clomiphene is prescribed for a female client to treat infertility. The nurse is providing information to the client and her spouse about the medication and provides the couple with which information?
A. If the oral tablets are not successful, the medication will be administered intravenously.
B. The couple should engage in coitus at least every other day during treatment.
C. The physician should be notified immediately if breast engorgement occurs.
D. Multiple births occur in a small percentage of clomiphene-facilitated pregnancies.
Correct answer:
The correct answer is that multiple births (usually twins) occur in a small percentage (8% - 10%) of clomiphene-facilitated pregnancies. The couple should be informed about this potential outcome. Clomiphene is available in 50-mg tablets for oral use; there is no intravenous form of the medication. Breast engorgement is a common side effect of clomiphene that typically resolves after discontinuation of the medication. Ovulation usually happens 5 to 10 days after the last dose of clomiphene, and the couple is advised to engage in coitus at least every other day during this time. Therefore, choices A, B, and C are incorrect as they do not provide accurate information regarding clomiphene treatment for infertility.
When evaluating a kinetic family drawing, which of the following nursing actions is most effective?
A. instructing the child to draw their family doing something
B. suggesting specific elements to include in the drawing
C. discouraging the child from discussing the drawing
D. noting the omission of any family members
Correct answer:
When evaluating a kinetic family drawing, the most effective nursing action is noting the omission of any family members. This approach helps healthcare providers gather crucial information about family dynamics. It is important to pay attention to what the child includes and omits in the drawing, as it can provide insights into underlying emotions and concerns. Choices A, B, and C are not recommended actions for evaluating the drawing. Instructing the child to draw their family doing something or suggesting specific elements to include may bias the drawing, leading to misinterpretations. Discouraging the child from discussing the drawing can impede communication and the understanding of the child's perspective.
After a left heart catheterization (LHC), a client complains of severe foot pain on the side of the femoral stick. The nurse notes pulselessness, pallor, and a cold extremity. What should the nurse's next action be?
A. Administer an anticoagulant.
B. Warm the room and re-assess.
C. Increase IV fluids.
D. Notify the physician stat.
Correct answer:
The correct action for the nurse to take next is to notify the physician immediately (stat). The client's symptoms of foot pain, pulselessness, pallor, and cold extremity suggest a potential vascular complication, such as arterial occlusion. Prompt notification of the physician is crucial as this condition requires urgent intervention to restore blood flow and prevent tissue damage. Administering an anticoagulant (Choice A) without physician evaluation could be harmful as the underlying cause needs to be determined first. Warming the room and re-assessing (Choice B) may delay necessary treatment. Increasing IV fluids (Choice C) is unlikely to address the urgent vascular issue indicated by the symptoms described.
Which of the following blood pressure parameters indicates PIH? Elevation over a baseline of:
A. 30 mmHg systolic and/or 15 mmHg diastolic.
B. 40 mmHg systolic and/or 20 mmHg diastolic.
C. 10 mmHg systolic and/or 5 mmHg diastolic.
D. 20 mmHg systolic and/or 20 mmHg diastolic.
Correct answer:
The correct answer is A: 30 mmHg systolic and/or 15 mmHg diastolic. These parameters indicate mild PIH (pregnancy-induced hypertension). Mild preeclampsia is characterized by an increase in systolic blood pressure greater than 30 mmHg or an increase in diastolic blood pressure greater than 15 mmHg, observed on two readings taken 6 hours apart (or reaching 140/90). Choice B (40 mmHg systolic and/or 20 mmHg diastolic) represents a more significant elevation and would indicate a more severe condition than mild PIH. Choices C (10 mmHg systolic and/or 5 mmHg diastolic) and D (20 mmHg systolic and/or 20 mmHg diastolic) do not meet the criteria for indicating PIH as they are below the accepted parameters for mild PIH.
NCLEX-PN clinical judgment practice questions, set 21 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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