NCLEX-PN clinical judgment practice questions, set 24
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 24
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
The home health nurse has made a visit to an 85-year-old female client's home who has recently had surgery to replace her left knee. The client has been discharged from a rehab facility and has been able to walk on her own. The nurse assesses the need for teaching related to fall prevention. What should the nurse include in this teaching plan?
A. The client should remove all scatter rugs from the floor and minimize clutter.
B. The client should not limit her movement within the home unless advised by the physician.
C. The client should have a raised toilet seat and grab bars available in the bathroom.
D. The client should not wear a robe and socks while walking in the house.
Show answer and rationale
Correct answer: A — The client should remove all scatter rugs from the floor and minimize clutter.
The correct answer is to instruct the client to remove all scatter rugs from the floor and minimize clutter. Rugs and clutter are common causes of falls in the home, especially for the elderly or those with gait issues. Removing them can significantly reduce the risk of falls. While having a raised toilet seat and grab bars in the bathroom is important for safety, it is not the priority in this scenario. The client should not limit her movement within the home unless specifically advised by the physician, as maintaining mobility is essential for recovery. Lastly, the client should avoid wearing robes and socks while walking in the house to prevent tripping, slipping, or falling on slippery floors.
Question 2
Ms. Petty is having difficulty falling asleep. Which of the following measures promote sleep?
A. exercising vigorously for 20 minutes each night starting at 9:30 p.m.
B. taking a cool shower and drinking a hot cup of tea
C. watching TV nightly until midnight
D. getting a back rub and drinking a glass of warm milk
Show answer and rationale
Correct answer: D — getting a back rub and drinking a glass of warm milk
Getting a back rub and drinking a glass of warm milk are appropriate measures to promote sleep as they can help relax the body and induce sleepiness. Exercising vigorously, as suggested in choice A, can be counterproductive as it stimulates the body rather than relaxing it, making it harder to fall asleep. Choice B, taking a cool shower and drinking a hot cup of tea, may also increase alertness due to the temperature changes and the caffeine in tea, which can interfere with falling asleep. Watching TV until midnight, as in choice C, exposes the individual to blue light and mental stimulation, making it harder to fall asleep. Therefore, choice D is the best option to promote sleep in this scenario.
Question 3
If your patient is acutely psychotic, which of the following independent nursing interventions would not be appropriate?
A. Conveying calmness through one-on-one interaction
B. Recognizing and managing your own feelings to prevent escalation of the patient's anxiety level
C. Encouraging client participation in group therapy
D. Listening and identifying causes of their behavior
Show answer and rationale
Correct answer: C — Encouraging client participation in group therapy
When a patient is acutely psychotic, they may not be able to effectively participate in group therapy due to their altered mental state. Group settings can be overwhelming and may exacerbate the patient's symptoms. Choices A, B, and D are appropriate interventions. Choice A is correct as providing calmness through one-on-one interaction can be beneficial in establishing trust and reducing anxiety. Choice B is also important as recognizing and managing the nurse's feelings can prevent further escalation of the patient's symptoms. Choice D is relevant as listening and identifying causes of the patient's behavior can aid in understanding and providing appropriate care tailored to the patient's needs.
Question 4
A patient has recently been prescribed Lidocaine Hydrochloride. Which of the following symptoms may occur with an overdose?
A. Memory loss and lack of appetite
B. Confusion and fatigue
C. Heightened reflexes
D. Tinnitus and spasticity
Show answer and rationale
Correct answer: B — Confusion and fatigue
The correct answer is 'Confusion and fatigue.' Lidocaine Hydrochloride, when taken in excess, can lead to symptoms such as confusion and fatigue. It affects the central nervous system, leading to these cognitive and physical impairments. Choice A ('Memory loss and lack of appetite') is incorrect because memory loss is not a common symptom of Lidocaine Hydrochloride overdose, and lack of appetite is not a typical effect. Choice C ('Heightened reflexes') is incorrect as Lidocaine Hydrochloride overdose usually depresses reflexes rather than heightening them. Choice D ('Tinnitus and spasticity') is incorrect as tinnitus and spasticity are not commonly associated with Lidocaine Hydrochloride overdose.
Question 5
What should the nurse do while caring for a client with an eating disorder?
A. Encourage the client to cook for others
B. Weigh the client daily and keep a journal
C. Restrict access to mirrors
D. Monitor food intake and behavior for one hour after meals
Show answer and rationale
Correct answer: D — Monitor food intake and behavior for one hour after meals
The correct answer is to monitor food intake and behavior for one hour after meals. This is crucial in caring for a client with an eating disorder as it helps in assessing any immediate risks related to the disorder. Option A is incorrect as it may trigger additional stress for the client and distract from the main focus of managing the disorder. Option B, weighing the client daily, could lead to an unhealthy focus on weight and potentially worsen the client's mental health. Option C, restricting access to mirrors, although it may be beneficial for body image concerns, does not directly address the core issue of monitoring food intake and behavior, which is essential in managing eating disorders.
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Question 6
The nurse receives an order to administer phenytoin through the client's J-tube. The order instructs that tube feedings are stopped at least an hour prior to administering the medication and an hour after the medication is administered. Which of the following considerations may be a reason to discuss this order with the physician?
A. The client has a history of Type II diabetes.
B. The client is on a continuous tube-feeding regimen.
C. The client is on fluid restriction.
D. The pharmacy has provided phenytoin in tablet form.
Correct answer:
For a client on a continuous tube-feeding regimen, stopping tube feedings for two hours to administer this medication may compromise the client's nutritional status. This interruption can lead to inadequate nutrient intake, affecting the client's overall nutritional well-being. The other choices are less relevant in this situation. Type II diabetes does not directly impact the administration of phenytoin through a J-tube. Fluid restriction would not prevent the temporary interruption of tube feedings for medication administration. The form of phenytoin provided by the pharmacy does not impact the need to discuss the order with the physician regarding the client's continuous tube-feeding regimen.
A 12-year-old male is brought to his primary care provider to determine whether sexual abuse has occurred. The mother states, 'Because there is no permanent physical damage, he does not need any more treatment.' The nurse's response should be based on which of the following pieces of information?
A. Male victims of sexual abuse can have long-term psychological problems.
B. Survivors of male sexual abuse might become confused about their sexual identity.
C. Not all male sex abuse survivors grow up to abuse other children.
D. The needs of sexually abused children can vary based on gender and individual circumstances.
Correct answer:
Male children are sexually abused nearly as often as female children. Perpetrators are usually men but can be women. Needs of male children who have been sexually abused might be different from the needs of female survivors. Male survivors might respond in anger, question their sexuality, use alcohol and other drugs, and might try to prove their masculinity by performing daring acts. Choice A is incorrect because male victims of sexual abuse can indeed have long-term psychological problems. Choice C is incorrect as not all male sex abuse survivors grow up to abuse other children. Choice D is incorrect as the needs of sexually abused children can vary based on gender and individual circumstances.
Which of the following statements is correct regarding rape?
A. Most rapes go unreported.
B. Legally, a woman can be raped by her spouse.
C. Prosecuting and convicting for rape can be challenging.
D. Rape can occur in different locations.
Correct answer:
The correct statement is that legally, a woman can be raped by her spouse. Rape is defined as sexual intercourse against someone's will, and it can occur between any two persons regardless of their relationship, including spouses. Choice A is incorrect as most rapes are not reported due to various reasons like fear, shame, or distrust in the legal system. Choice C is incorrect as prosecuting and convicting for rape can be challenging due to factors like lack of evidence, societal biases, and victim blaming. Choice D is incorrect as the most common location of rape is not necessarily the victim's own home; it can happen in various settings such as public places, workplaces, or social gatherings.
The healthcare provider recognizes that which of the following would be most appropriate to wear when providing direct care to a client with a cough?
A. Mask
B. Gown
C. Gloves
D. Shoe covers
Correct answer:
When providing care to a client with a cough, it is crucial to wear a mask to protect oneself from inhaling respiratory droplets containing infectious agents. The primary mode of transmission for coughs is through airborne droplets, making a mask the most appropriate choice to prevent the spread of respiratory infections. Gloves and gowns are more relevant when there is a risk of contact with bodily fluids, which is not the main concern with a cough. Shoe covers are not necessary in this scenario as the transmission of respiratory infections is not linked to footwear. Therefore, wearing a mask is the best choice to prevent airborne transmission and ensure the safety of the healthcare provider.
Which intervention should the nurse take first to assist a woman who states that she feels incompetent as the mother of a teenage daughter?
A. Recommend that she discipline her daughter more strictly and consistently.
B. Make a list of things she can do to help improve her husband.
C. Assist the mother to identify what she believes is preventing her success and what she can do to improve.
D. Explore with the mother what the daughter can do to improve her behavior.
Correct answer:
The priority intervention for a mother who feels incompetent in parenting a teenage daughter is to assist her in identifying the factors contributing to her feelings of inadequacy and help her develop better coping and mothering skills. This approach focuses on addressing the mother's emotional needs and empowering her to improve her situation. Option A is incorrect as it focuses on the daughter's discipline, which may not be the root cause of the mother's feelings. Option B is irrelevant as it focuses on improving her husband, not her parenting skills. Option D is incorrect as it shifts the focus solely to the daughter's behavior, neglecting the mother's emotional needs and self-improvement.
An example of a process standard on a med-surg unit is:
A. a procedure for changing IV tubing.
B. a policy for staffing.
C. the job description of the CEO (chief executive officer).
D. a procedure for checking waveforms on a client being treated with an intra-aortic balloon pump.
Correct answer:
Process standards define the actions and behaviors required by staff to provide care on a med-surg unit. A procedure for changing IV tubing is a critical psychomotor skill necessary for safe and effective patient care in this setting. Choice B, a policy for staffing, pertains more to organizational management rather than specific care processes on the unit. Choice C, the job description of the CEO, delineates the responsibilities of the organization's top executive and is not a process standard for frontline staff. Choice D, a procedure for checking waveforms on a client with an intra-aortic balloon pump, is more specific to a cardiac care unit and not typically performed on a med-surg unit.
What is the primary theory that explains a family's concept of health and illness?
A. Health Belief Model
B. Education Factor
C. Family Health Belief Model
D. Family Dynamics Model
Correct answer:
The correct answer is the Health Belief Model. The Health Belief Model is a widely recognized theory that explains individuals' perceptions and behaviors related to health and illness. It considers factors such as perceived susceptibility, severity of health issues, benefits of action, and barriers to taking action. Choices B, C, and D are incorrect. Choice B, 'Education Factor,' is too general and does not specifically address a family's concept of health and illness. Choice C, 'Family Health Belief Model,' is a combination of terms and not a recognized theory. Choice D, 'Family Dynamics Model,' focuses on family interactions rather than explaining a family's concept of health and illness.
When providing perineal care to a female client, how should the nurse perform the procedure?
A. with gloves, washing the perineal area from front to back
B. without gloves, having the client perform all care
C. with gloves, washing the perineal area from back to front
D. without gloves, pouring water from a sterile bottle
Correct answer:
When providing perineal care to a female client, the nurse should wear gloves and wash the perineal area from front to back. This technique helps prevent the introduction of E. coli and other bacteria into the urethra, reducing the risk of urinary tract infections. Washing from back to front can introduce bacteria from the anal area to the urethra, leading to infections. Performing the procedure without gloves or having the client perform all care does not adhere to infection control practices. Pouring water from a sterile bottle alone may not ensure proper cleansing and infection prevention. Therefore, choices B, C, and D are incorrect as they do not follow proper perineal care guidelines.
A nurse sees another nurse changing an intravenous (IV) solution because the wrong solution is infusing into the client. The nurse who changed the IV solution does not report the error. What should the nurse who observed the error do first?
A. Report the nurse who changed the IV solution
B. Document the error in the client's chart
C. Call the client's health care provider
D. Ask the nurse whether she intends to report the error
Correct answer:
The first thing the nurse who observed the error should do is ask the nurse whether she intends to report the error. Ensuring client safety is paramount, and all errors must be reported to the health care provider, but this is not the initial action. The client should also be assessed immediately. The nurse who discovered the error should complete an incident report and make appropriate documentation in the client's record. If the nurse who observed the error finds out that it will not be reported, it may be necessary to involve the supervisor. Therefore, the best course of action initially is to communicate with the nurse who made the error to understand her intentions regarding reporting.
If Ms. Barrett's distance vision is 20/30, which of the following statements is true?
A. The client can read from 20' what a person with normal vision can read at 30'.
B. The client can read from 30' what a person with normal vision can read at 20'.
C. The client can read the entire chart from 30'.
D. The client can read the chart from 20' with the left eye and from 30' with the right eye.
Correct answer:
When Ms. Barrett's distance vision is measured as 20/30, it means that she can read from 20 feet away what a person with normal vision can read at 30 feet. The numerator (20) represents the distance in feet between the chart and the client, while the denominator (30) indicates the distance at which a normal eye can read the chart. In this case, Ms. Barrett's vision is slightly worse than normal, as she needs to be closer to the chart to read it clearly. Therefore, choice A is correct. Choices B, C, and D are incorrect: Choice B reverses the distances, Choice C assumes the client can read the entire chart from 30 feet, and Choice D introduces information not related to the 20/30 measurement.
NCLEX-PN clinical judgment practice questions, set 24 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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