NCLEX-PN clinical judgment practice questions, set 26
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 26
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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 nursing diagnoses is most appropriate for a client with a new colostomy?
A. Excess Fluid Volume
B. Risk for Aspiration
C. Disturbed Body Image
D. Urinary Retention
Show answer and rationale
Correct answer: C — Disturbed Body Image
Disturbed Body Image is the most appropriate nursing diagnosis for a client with a new colostomy. A new colostomy can significantly impact a person's body image and self-esteem due to the physical changes it brings. This can lead to emotional distress, adjustment issues, and concerns about body image. Excess Fluid Volume, Risk for Aspiration, and Urinary Retention are not directly related to the psychosocial impact of a new colostomy and are therefore not as relevant in this context. While Excess Fluid Volume, Risk for Aspiration, and Urinary Retention are important nursing diagnoses, they are not the priority when considering the psychological and emotional effects of a new colostomy.
Question 2
The difference between spirituality and religion is that spirituality is:
A. a belief about a higher power.
B. an individual's relationship with a higher power.
C. organized worship.
D. a belief in an invisible energy or ideal.
Show answer and rationale
Correct answer: B — an individual's relationship with a higher power.
The correct answer is 'an individual's relationship with a higher power.' Spirituality is more about personal connection, beliefs, and experiences related to a higher power or force, whereas religion is often associated with organized practices, rituals, and doctrines within a specific faith community. Choice A is incorrect as spirituality goes beyond just believing in a higher power; it encompasses a personal connection. Choice C, 'organized worship,' is incorrect because spirituality can exist outside formal religious settings. Choice D is incorrect as it oversimplifies spirituality as merely a belief in an invisible energy or ideal, missing the relational aspect with a higher power.
Question 3
Which direction given to the nursing assistant is most likely to accomplish the task of getting a urine specimen delivered to the lab immediately after collection?
A. "Make it a stat delivery."?
B. "Please do it as soon as you can after break."?
C. "This client is delirious, and we're worried about urinary sepsis."?
D. "Take this client to the bathroom now and collect a urine specimen from this voiding. Take the specimen to the lab immediately."?
Show answer and rationale
Correct answer: D — "Take this client to the bathroom now and collect a urine specimen from this voiding. Take the specimen to the lab immediately."?
Effective delegation depends on clear, concise direction that leaves no room for question or interpretation on the part of the one being delegated to. In this scenario, the most appropriate direction is to ensure the urine specimen is collected promptly and delivered to the lab immediately. Choice A is too vague and does not specify the urgency required. Choice B does not emphasize the immediate need for the specimen to be delivered. Choice C introduces unnecessary medical information that is beyond the scope of a nursing assistant and may cause confusion. Therefore, choice D is the correct answer as it provides clear instructions for immediate action without room for misunderstanding.
Question 4
Two staff nurses were considered for promotion to head nurse. The promotion is announced via a memo on the unit bulletin board. The nurse who was not promoted tells a friend, "Oh, well, I really didn't want the job anyway."? This is an example of:
A. rationalization.
B. denial.
C. projection.
D. compensation.
Show answer and rationale
Correct answer: A — rationalization.
This is an example of rationalization, specifically the sour grapes form, where the individual convinces themselves that they didn't want something after realizing they couldn't have it. Rationalization is an unconscious form of self-deception involving making excuses. In this scenario, the nurse is rationalizing her disappointment by downplaying her desire for the promotion. Denial involves ignoring the existence of a situation, which is not demonstrated here. Projection involves blaming others unconsciously, which is also not present in this situation. Compensation is an attempt to offset a perceived weakness by emphasizing a strong point, which is not shown in the nurse's response.
Question 5
One week ago, a client was involved in a motor vehicle crash (MVC) and was brought to the Emergency Department (ED). In the emergency department, the client received two stitches to the forehead and was sent home. Today, the client's spouse notes that the client 'acts like he is drunk' and cannot control his right foot and arm. The nurse will suspect?
A. Meningitis
B. Absence seizure
C. Subdural hematoma
D. Meniere's disease
Show answer and rationale
Correct answer: C — Subdural hematoma
Yes! The nurse will suspect a subdural hematoma. In this case, the client's presentation of acting intoxicated and experiencing loss of motor control in the right foot and arm is indicative of an acute subdural hematoma. This condition can occur after a head injury with a slow venous bleed, where symptoms may not show until compensation mechanisms are overwhelmed. Meningitis (choice A) usually presents with fever, headache, and neck stiffness. Absence seizure (choice B) is characterized by brief periods of unconsciousness without convulsions. Meniere's disease (choice D) manifests with symptoms like vertigo, hearing loss, and tinnitus, which do not match the client's current symptoms.
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Question 6
Hearing screening of prematurely born infants is an effective means of identifying disease and is an example of:
A. Primary prevention.
B. Secondary prevention.
C. Tertiary prevention.
D. Disability prevention.
Correct answer:
The correct answer is B: Secondary prevention. Hearing screening for prematurely born infants falls under secondary prevention, which aims to identify and treat a condition in its early stages to prevent further complications. Primary prevention (choice A) focuses on preventing the disease from occurring, while tertiary prevention (choice C) involves managing complications and preventing disability. Choice D, disability prevention, is not a recognized category of prevention. In this context, the screening helps in early identification of hearing loss, allowing for timely intervention to prevent further impairment or complications, aligning with the principles of secondary prevention.
The nurse is preparing a client for mammography. To prepare the client for a mammogram, the nurse should tell the client:
A. To omit creams, powders, or deodorants before the exam
B. To restrict fat intake for 1 week before the test
C. That mammography replaces the need for self-breast exams
D. That mammography requires a higher dose of radiation than an x-ray
Correct answer:
The client undergoing a mammogram should be instructed to omit deodorants or powders beforehand because they can interfere with the imaging results. Answer A is correct as it aligns with the preparation needed before a mammogram to ensure accurate results. Answer B is incorrect because there is no requirement for fat intake restrictions before a mammogram. Answer C is incorrect because mammography does not replace the necessity of self-breast exams; both are crucial for maintaining breast health. Answer D is incorrect because a mammogram does not require higher doses of radiation than an x-ray. In fact, mammography uses a low dose of radiation to create images for breast examination.
How does the family carry out its health care functions?
A. The family provides very little preventive health care to its members at home.
B. The family provides preventive health care to its members at home.
C. The family pays for most health services.
D. The family decides when and where to hospitalize its members.
Correct answer:
Families play a crucial role in providing preventive health care to their members at home. This includes activities such as promoting healthy lifestyles, ensuring vaccinations, scheduling regular check-ups, and intervening early when health issues arise. Therefore, the correct answer is that the family provides preventive health care to its members at home. Choices A, C, and D are incorrect because families are expected to actively engage in preventive health care practices rather than providing very little preventive care, solely paying for health services, or making hospitalization decisions. The focus is on the proactive role of families in maintaining the health of their members.
Which of the following clients would be most appropriate for an LPN to assign to a nursing assistant?
A. an 18-year-old client with a femur fracture who is just returning to the floor from the recovery unit
B. an 84-year-old client 2 days post-op after knee replacement surgery who needs help ambulating
C. a 35-year-old client who is suffering from an acute asthma attack
D. a 20-year-old client with Cystic Fibrosis who needs an early morning sputum sample collection
Correct answer:
Collecting sputum samples on stable clients is within the scope of practice for an LPN. This task does not require immediate intervention or assessment by an RN or medical provider. An RN should perform the initial assessment on any client immediately post-op as it requires a higher level of assessment and monitoring. A client suffering from an acute asthma attack should be attended to by an RN or medical provider due to the potential severity and need for prompt intervention. Assigning a medically stable client who needs help ambulating to a nursing assistant is appropriate as it falls within their scope of practice and allows the LPN to focus on tasks that require their expertise.
A client arrives in the emergency department after severely lacerating the left hand with a knife. HR 96, BP 150/88, R36. The client is extremely anxious and crying uncontrollably. Based on this assessment, the nurse anticipates that this client would be in which acid-base imbalance?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
Correct answer:
The correct answer is respiratory alkalosis. Hyperventilation due to anxiety, pain, shock, severe infection, fever, or liver failure can lead to respiratory alkalosis. In this scenario, the client is extremely anxious and crying uncontrollably, indicating an increased respiratory rate and CO2 loss. Respiratory acidosis (choice A) is incorrect as it is characterized by an increase in CO2 levels, not a loss. Metabolic acidosis (choice C) involves a decrease in blood pH due to an accumulation of acids or loss of bicarbonate, which is not the case here. Metabolic alkalosis (choice D) results from excess bicarbonate or a loss of acids, not from increased CO2 loss due to hyperventilation.
Which isolation procedure will be followed for secretions and blood?
A. Respiratory Isolation
B. Standard Precautions
C. Contact Isolation
D. Droplet Isolation
Correct answer:
The correct answer is Standard Precautions. Standard precautions are taken in all situations for all clients and involve all body secretions except sweat. They are designed to reduce the rate of transmission of microbes from one host to another or one source to another. Respiratory Isolation (Choice A) is used for diseases transmitted by airborne particles, not secretions and blood. Contact Isolation (Choice C) is for clients known or suspected to be infected with microorganisms that can be transmitted by direct or indirect contact. Droplet Isolation (Choice D) is used for diseases transmitted by large respiratory droplets expelled during coughing, sneezing, talking, or procedures.
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 important for guidance and structure, they do not inherently involve ethical or moral considerations. The emotional impact on the client and family, the dignity of the client, and the client's quality of life are all directly related to ethical and moral concerns when it comes to the use of restraints. These factors are crucial in ensuring that the use of restraints is not only physically necessary but also ethically justifiable and respects the individual's rights and well-being. Therefore, options A, B, and C are all aspects that touch upon ethical and moral dimensions in the context of restraints.
The client is undergoing an induction for fetal demise at 34 weeks. Immediately after delivery, the mother asks to see the infant. What is the nurse's best response?
A. Bring the swaddled fetus to the mother
B. Explain that the cause of death must be determined before she can see the baby
C. Ask her if she is sure she wants to see the baby
D. Tell her it would be better to wait until she is in her room before she sees the baby
Correct answer:
The nurse should bring the swaddled fetus to the mother as the best response. Allowing the mother to see the infant immediately after delivery is crucial for her grieving process. It provides her with the opportunity to bond, say goodbye, and start the grieving process. Choice B is incorrect because delaying the mother's request to see the baby can hinder her grieving process and prolong her suffering. Choice C is inappropriate as it questions the mother's decision at a sensitive time, potentially causing distress. Choice D is also not the best response as it suggests waiting, which may not be in the mother's best interest at that moment, as she needs immediate support and closure.
A syringe pump is a type of electronic infusion pump used to infuse fluids or medications directly from a syringe. This device is commonly used for:
A. solutions administered in obstetrics.
B. dilute antibiotics.
C. large volumes of IV solutions.
D. the neonatal and pediatric populations.
Correct answer:
The correct answer is 'the neonatal and pediatric populations.' Syringe pumps are commonly used in neonatal and pediatric populations because they allow for precise infusion of small volumes of medications or fluids at controlled rates. This is crucial for ensuring safety and accuracy in these delicate populations. Choice A is incorrect because syringe pumps are not limited to obstetrics; they are used in various healthcare settings. Choices B and C are incorrect because syringe pumps are not typically used for dilute antibiotics or large volumes of IV solutions. Instead, they are preferred for delivering small volumes accurately, making them ideal for neonatal and pediatric care.
A woman is in the active phase of labor. An external monitor has been applied, and a fetal heart deceleration of uniform shape is observed, beginning just as the contraction is underway and returning to the baseline at the end of the contraction. Which of the following nursing actions is most appropriate?
A. Administer O2 if necessary.
B. Turn the client on her left side.
C. Notify the physician.
D. No action is necessary.
Correct answer:
The correct answer is 'No action is necessary.' In this scenario, the fetal heart deceleration of uniform shape observed is an early deceleration resulting from head compression. Early decelerations are benign and typically do not require any intervention as they mirror the contraction pattern. It is essential to closely observe both the mother and the baby. Administering O2 (Choice A) is not necessary as early decelerations do not indicate fetal distress. Turning the client on her left side (Choice B) is not required for early decelerations. Notifying the physician (Choice C) is not needed for this type of deceleration, as it is a normal response to head compression during labor.
NCLEX-PN clinical judgment practice questions, set 26 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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