NCLEX-PN clinical judgment practice questions, set 22
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 22
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
When are standard walkers typically used?
A. When clients have poor balance, cannot stand up, have weak arms, and good hand strength.
B. When clients have poor balance, have a broken leg, or have experienced amputation.
C. When clients have poor balance, have cardiac problems, or cannot use crutches or a cane.
D. When clients have poor balance, have an autoimmune disease, or have weak arms.
Show answer and rationale
Correct answer: C — When clients have poor balance, have cardiac problems, or cannot use crutches or a cane.
Standard walkers are typically used for clients who have poor balance, cardiac problems, or those who cannot use crutches or a cane. The rationale is correct in stating that a walker is suitable for individuals needing to bear partial weight and having strength in their wrists and arms to propel the walker forward. Choices A, B, and D are incorrect because they do not accurately reflect the main reasons why standard walkers are used in clinical practice. Using a walker is not solely about having weak arms, good hand strength, a broken leg, experienced amputation, or an autoimmune disease. The primary focus is on addressing balance issues, cardiac problems, or the inability to use crutches or a cane effectively.
Question 2
A child presents to the school nurse with left knee pain after suffering a fall on the playground. Which action should the nurse do first?
A. Instruct the child to extend the affected knee
B. Perform range of motion exercises on both knees
C. Compare the appearance of the left knee to the right knee
D. Have the child soak the affected knee in warm water
Show answer and rationale
Correct answer: C — Compare the appearance of the left knee to the right knee
Comparing the appearance of the left knee to the right knee is the most appropriate initial action as it provides a baseline for assessing any visible differences such as swelling, bruising, or deformities. This comparison helps the nurse identify any acute changes in the affected knee's appearance after the fall. Instructing the child to extend the affected knee (Choice A) may worsen the pain or cause further injury. Performing range of motion exercises on both knees (Choice B) could exacerbate the pain and should be avoided until a proper assessment is done. Having the child soak the affected knee in warm water (Choice D) is not the priority at this stage as assessing for any physical changes is more crucial.
Question 3
The parents of an adolescent tell the school nurse that they are frustrated because their daughter has become self-centered, lazy, and irresponsible. The nurse should provide which response to the parents?
A. That this is normal behavior for an adolescent
B. That their daughter's behavior may be a part of adolescent development
C. That this behavior could be a phase as the adolescent explores identity
D. To restrict any social privileges until the behavior stops
Show answer and rationale
Correct answer: A — That this is normal behavior for an adolescent
During adolescence, identity formation is a significant developmental task. Adolescents may appear self-centered, lazy, or irresponsible as they focus on themselves and explore their identity. Erikson describes this phase as identity formation versus role confusion. It is common for frustrated parents to perceive teenagers this way. The adolescent needs time to introspect and develop a sense of self. Suggesting that the behavior requires a child psychologist is premature and not supported by normal adolescent development. Blaming the behavior on parental spoiling is also inaccurate and unhelpful. Restricting social privileges can lead to resentment and rebellion, rather than addressing the root of the behavior.
Question 4
The client with peripheral vascular disease is reviewing self-care measures. Which of the following statements indicates proper self-care measures?
A. "I like to soak my feet in the hot tub every day."?
B. "I walk to the mailbox in my bare feet."?
C. "I stopped smoking and only use chewing tobacco."?
D. "I have my wife examine the soles of my feet each day."?
Show answer and rationale
Correct answer: D — "I have my wife examine the soles of my feet each day."?
The correct answer is, "I have my wife examine the soles of my feet each day."? Clients with peripheral vascular disease should examine their feet daily for any signs of redness, dryness, or cuts. If the client is unable to do this themselves due to decreased sensation in their feet, a caregiver or family member should assist. Soaking feet in a hot tub should be avoided as the client may not be able to sense if the water is too hot, potentially causing burns. Walking barefoot can lead to injuries, so wearing shoes or slippers is recommended to minimize trauma. While quitting smoking is a positive step, using chewing tobacco can still constrict blood vessels, adversely affecting circulation in the extremities.
Question 5
A client whose right leg is in skeletal traction complains of pain in the leg. Which action should the nurse take first?
A. Asking the client to wiggle their toes
B. Medicating the client with the prescribed analgesic
C. Realigning the client
D. Removing some of the traction weights
Show answer and rationale
Correct answer: C — Realigning the client
When a client in skeletal traction complains of pain, the priority action for the nurse is to realign the client. Severe pain may indicate the need for realignment or that the traction weights are too heavy. Realigning the client should be the initial response as it can help alleviate the pain by ensuring proper alignment. Asking the client to wiggle their toes may not address the underlying issue causing the pain. Removing traction weights should never be done unless specifically ordered by the healthcare provider as it can affect the traction's effectiveness. Medicating the client with analgesics should only be considered after attempting to address the cause of the pain, which in this case, is realignment.
Keep going past these 15 questions
Missed-question review, longer banks, and the rest of 20,000+ nursing practice questions open when you start studying.
Stems and choices stay public so you can still reason. Correct answers and full rationales unlock with the rest of the bank.
Question 6
A client has chronic respiratory acidosis caused by end-stage chronic obstructive pulmonary disease (COPD). Oxygen is delivered at 1 L/min via nasal cannula. The nurse teaches the family that the reason for this is to avoid respiratory depression, based on which of the following explanations?
A. COPD clients are stimulated to breathe by hypoxia.
B. COPD clients depend on a low carbon dioxide level.
C. COPD clients tend to retain hydrogen ions if they are given high doses of oxygen.
D. COPD clients thrive on a high oxygen level.
Correct answer:
In clients with COPD and chronic respiratory acidosis, they are compensating for low oxygen and high carbon dioxide levels. Hypoxia acts as the main stimulus to breathe in individuals with chronic hypercapnia. When oxygen is administered, it can decrease the respiratory drive by eliminating the hypoxic drive and reducing the stimulus to breathe. Therefore, delivering oxygen at 1 L/min via nasal cannula helps prevent respiratory depression by maintaining the hypoxic drive to breathe. The other options are incorrect: COPD clients do not depend on a low carbon dioxide level as they are chronically hypercapnic, they do not retain hydrogen ions with high oxygen doses, and they do not thrive on a high oxygen level.
A client with major head trauma is receiving bolus enteral feeding. The most important nursing order for this client is:
A. measure intake and output.
B. check albumin levels.
C. monitor glucose levels.
D. increase enteral feeding.
Correct answer:
The correct action for a client with major head trauma receiving bolus enteral feeding is to measure intake and output (I&O). Enteral feedings are hyperosmotic agents that can cause fluid shifts. Monitoring I&O is crucial to assess fluid balance, ensuring that input matches output. Checking albumin levels (choice B) is important for assessing nutritional status but is not the immediate priority in this situation. Monitoring glucose levels (choice C) is also important but not as critical as measuring I&O in this context. Increasing enteral feeding (choice D) should only be done based on a healthcare provider's order after assessing the patient's condition, not as the most important nursing order at this time.
What is most important for the healthcare professional to do prior to initiating peritoneal dialysis?
A. Aspirate to check placement
B. Ensure the client voids
C. Irrigate the catheter to maintain patency
D. Warm the fluids
Correct answer:
The correct answer is to warm the fluids. Warming the dialysis fluids is crucial before initiating peritoneal dialysis to prevent abdominal discomfort and promote vasodilation, which helps in achieving good exchange in the peritoneum. Aspirating to check placement (Choice A) is not typically necessary before initiating peritoneal dialysis. Ensuring the client voids (Choice B) is not directly related to the procedure of peritoneal dialysis. Irrigating the catheter to maintain patency (Choice C) is usually done as part of routine care but is not specifically required prior to initiating peritoneal dialysis. Therefore, the most important action to take before starting peritoneal dialysis is to warm the fluids.
The client is scheduled for surgical repair of a detached retina. What is the most likely preoperative nursing diagnosis for this client?
A. Anxiety related to loss of vision and potential failure to regain vision.
B. Deficient knowledge (preoperative and postoperative activities) related to lack of information.
C. Acute pain related to tissue injury and decreased circulation to the eye.
D. Risk for infection related to the eye injury.
Correct answer:
The correct preoperative nursing diagnosis for a client scheduled for surgical repair of a detached retina is 'Anxiety related to loss of vision and potential failure to regain vision.' A client facing the threat of permanent blindness due to a detached retina is likely to experience anxiety. Addressing this anxiety is crucial before providing education, as severe anxiety can hinder the client's ability to absorb new information. The nurse should offer emotional support, encourage the client to express concerns, and clarify any misconceptions. Acute pain is not a typical symptom of a detached retina, and the risk of infection preoperatively is minimal, making choices C and D less relevant in this scenario.
When assessing a client for risk of hyperphosphatemia, which piece of information is most important for the nurse to obtain?
A. A history of radiation treatment in the neck region
B. A history of recent orthopedic surgery
C. A history of minimal physical activity
D. A history of the client's food intake
Correct answer:
The correct answer is a history of radiation treatment in the neck region. Previous radiation to the neck may have damaged the parathyroid glands, which are crucial for calcium and phosphorus regulation. This damage can lead to disruptions in phosphorus levels, increasing the risk of hyperphosphatemia. Choices B, C, and D are not as directly related to phosphorus regulation. Orthopedic surgery, minimal physical activity, and food intake are more closely associated with calcium levels rather than phosphorus regulation. Therefore, it is essential for the nurse to focus on obtaining information about a history of radiation treatment in the neck region when assessing the risk of hyperphosphatemia in a client.
A client has been taking alprazolam (Xanax) for four years to manage anxiety. The client reports taking 0.5 mg four times a day. Which statement indicates that the client understands the nurse's teaching about discontinuing the medication?
A. "I can drink alcohol now that I am decreasing my Xanax."?
B. "I should not take another Xanax pill. Here is what is left of my last prescription."?
C. "I should take three pills per day next week, then two pills for one week, then one pill for one week."?
D. "I can expect to be sleepy for several days after stopping the medicine."?
Correct answer:
The correct answer is that the client should take three pills per day next week, then two pills for one week, and then one pill for one week. This statement indicates a gradual tapering schedule, which is crucial when discontinuing alprazolam (Xanax) to prevent withdrawal symptoms. Choice A is incorrect because alcohol should be avoided while tapering off benzodiazepines due to the increased risk of respiratory depression. Choice B is incorrect because abruptly stopping alprazolam can lead to withdrawal symptoms. Choice D is incorrect because while drowsiness can be a side effect of alprazolam, it is not the primary concern when discontinuing the medication; preventing withdrawal symptoms is the priority.
When administering NSAID adjunctive therapy to an elderly client with cancer, the nurse must monitor:
A. BUN and creatinine.
B. creatinine and calcium.
C. Hgb and Hct.
D. BUN and CFT.
Correct answer:
When an elderly client with cancer is receiving NSAID therapy, monitoring BUN (blood urea nitrogen) and creatinine levels is crucial. NSAIDs can cause renal toxicity, especially in the elderly. BUN and creatinine levels help assess renal function and detect early signs of renal impairment. Monitoring creatinine alone (Choice B) is not sufficient as BUN provides complementary information about renal function. Monitoring hemoglobin (Hgb) and hematocrit (Hct) (Choice C) is important for assessing anemia but not specific to NSAID therapy in the elderly. CFT (Choice D) is not a standard abbreviation in this context, and monitoring coagulation function is not directly related to NSAID therapy in this scenario.
While making rounds at 3 am, the nurse discovers a small fire in a client's room. What should the nurse do first?
A. Remove the client from the room immediately.
B. Leave the client's room to obtain a fire extinguisher.
C. Instruct a nurse tech to pull the fire alarm.
D. Evacuate all clients from the unit.
Correct answer:
During a fire emergency, the priority is the safety of the individual in the room where the fire is located. Removing the client from the room immediately is the first step in the RACE acronym for fire safety: Rescue/Remove, Alarm, Contain, and Extinguish. This action ensures the client's safety before addressing the fire itself. Choice B is incorrect as leaving the client's room to obtain a fire extinguisher can delay the immediate removal of the client from the danger. Choice C is incorrect as pulling the fire alarm should be done after ensuring the client's safety. Choice D is incorrect as evacuating all clients from the unit should come after ensuring the safety of the individual in immediate danger.
The nurse is caring for a non-English speaking client. The surgeon has asked the nurse to hurry up and prepare the client for their scheduled procedure, which is running late. Which of the following is least appropriate?
A. Explain to the client's family member that the procedure may be delayed further.
B. Inform the surgeon that the procedure will be delayed further because getting a staff interpreter will take additional time.
C. Allow the client's family member to serve as the interpreter.
D. Ask if a phone-service interpreting service is available to expedite the client preparation.
Correct answer:
Allowing the client's family member to serve as the interpreter is the least appropriate option. It is not recommended to rely on family members for interpretation as they may not be impartial, accurate, or trained to handle sensitive medical information. This can lead to misunderstandings, breaches in confidentiality, and compromised care. Choice A is a better option as it involves communication with the family member to manage expectations. Choice B is also appropriate as it prioritizes the need for a professional interpreter to ensure accurate communication. Choice D is a valid option as it explores the possibility of using a phone-service interpreting service to facilitate communication efficiently.
Which of the following describes the stages of domestic violence in an intimate relationship?
A. happiness, crisis, angry outburst, intervention
B. honeymoon period, escalation of stress, outburst, reconciliation
C. acting out and making up
D. peace and calm, angry outburst, peace and calm, denial
Correct answer:
The correct answer is B: 'honeymoon period, escalation of stress, outburst, reconciliation.' A pattern of behavior known as the cycle of abuse involves these stages. It starts with a honeymoon phase, followed by a buildup of stress, an outburst which may involve violence, and then reconciliation. This cycle is commonly observed in domestic violence situations. Choices A, C, and D do not accurately represent the stages of domestic violence in intimate relationships. Choice A mixes positive and negative elements, while choice C simplifies the complex dynamics of domestic violence. Choice D repeats 'peace and calm' inappropriately and includes 'denial,' which is not typically a stage in the cycle of abuse.
NCLEX-PN clinical judgment practice questions, set 22 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
No. Nursier is independent practice. Register through the official path named on the NCLEX-PN exam guide.
The first five questions already include the rationale. Start full practice to unlock the remaining keys, missed-question review, and the rest of the bank.
Keep going past these 15 questions
Missed-question review, longer banks, and the rest of 20,000+ nursing practice questions open when you start studying.
