NCLEX-PN clinical judgment practice questions, set 29
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 29
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
A nursing instructor asks a nursing student to describe accountability. Which statement(s) by the student indicate(s) an accurate description of accountability?
A. Check the unit policy for the protocol for the care of clients who have been sexually assaulted.
B. Ask a medical assistant.
C. Call the nurse in charge of the day shift.
D. Ask the police officers who brought the client to the center.
Show answer and rationale
Correct answer: A — Check the unit policy for the protocol for the care of clients who have been sexually assaulted.
Accountability in nursing involves taking responsibility for one's actions and decisions. In this scenario, checking the unit policy for the protocol related to the care of sexually assaulted clients demonstrates accountability. Policies and protocols provide guidance on appropriate actions and responsibilities in specific situations. Asking a medical assistant, calling the day shift nurse in charge, or consulting police officers are not appropriate actions to demonstrate accountability in this context. Seeking further clarification from the agency nursing supervisor on the night shift after reviewing the policy or protocol would be a more suitable course of action.
Question 2
During a school screening, a nurse notices small bruises on the anterior and posterior ribs of an 8-year-old Asian child. The nurse should ask the child:
A. if the family practices coining
B. who performs coinings
C. if the child has fallen
D. how long the child has been abused
Show answer and rationale
Correct answer: A — if the family practices coining
The correct answer is to ask if the family practices coining. In Asian cultures, coining is a traditional practice believed to draw infections from the body. It involves rubbing a heated coin on the chest and torso, which can cause bruising similar to what the nurse noticed on the child's ribs. This question is important to differentiate between cultural practices and potential child abuse. Choices B, C, and D are incorrect because assuming abuse without considering cultural practices can lead to misinterpretation and inappropriate actions. It's crucial for healthcare providers to be culturally sensitive and gather all relevant information before making conclusions.
Question 3
Signs of impaired breathing in infants and children include all of the following except:
A. nasal flaring
B. grunting
C. seesaw breathing
D. quivering lips
Show answer and rationale
Correct answer: D — quivering lips
Signs of impaired breathing in infants and children can manifest in various ways. Nasal flaring, grunting, and seesaw breathing are all indicative of respiratory distress in pediatric patients. Nasal flaring is the widening of the nostrils with breathing effort, grunting is a sound made during exhalation to try to keep the airways open, and seesaw breathing involves the chest moving in the opposite direction of the abdomen. However, quivering lips are not typically associated with impaired breathing in this context. Lip quivering is a distracter and not a common sign of respiratory distress in infants and children. Therefore, the correct answer is 'quivering lips.'
Question 4
The parents of a 2-year-old child ask the nurse how they can teach their child to stop taking toys away from other children. Which of the following statements by the nurse offers the parents the best explanation of their child's behavior?
A. "Your child is egocentric. Egocentricity is normal for 2-year-old children. He believes other children want him to have their toys."?
B. "Your child is showing negativity. He doesn't want other children to have the toys he wants."?
C. "Your child is demonstrating magical thinking. He believes he can make the other children want him to play with their toys."?
D. "Your child is engaging in domestic imitation. He is doing what he has seen other children do."?
Show answer and rationale
Correct answer: A — "Your child is egocentric. Egocentricity is normal for 2-year-old children. He believes other children want him to have their toys."?
Two-year-old children are very egocentric, believing everything revolves around them. They think other children want them to have their toys, which explains why they may take toys from others. This behavior is typical for children at this age as they lack the ability to see things from another's perspective. Option B is incorrect because negativity in children this age is more related to refusal of requests rather than taking toys. Magical thinking, as described in option C, is usually seen in preschool-age children and involves unrealistic beliefs. Option D is incorrect as domestic imitation refers to imitating adult household tasks, not other children's behavior.
Question 5
When a client who is 25 years of age asks the nurse when she should seek fertility counseling, the best response by the nurse is:
A. "Fertility counseling should be sought when you have been unable to conceive after 1 year of unprotected intercourse."?
B. "Fertility counseling should be sought when you have not been able to conceive after 6-9 months of unprotected intercourse."?
C. "The average time it takes someone your age to conceive is 5.3 months, so if you haven't conceived by then, we can refer you."?
D. "We can give you some guidance now on how to increase your chances of conceiving and then refer you if it doesn't happen within a year."?
Show answer and rationale
Correct answer: D — "We can give you some guidance now on how to increase your chances of conceiving and then refer you if it doesn't happen within a year."?
The best response in this scenario is to offer immediate guidance while also indicating when fertility counseling should be sought. While Choice A is technically correct as guidelines recommend seeking fertility counseling after 1 year of unprotected intercourse, it lacks providing immediate guidance. Choice B suggests seeking counseling after 6-9 months, which is earlier than the standard recommendation of 1 year. Choice C mentions the average time to conceive for someone of the client's age without addressing the client's current concern. Therefore, Choice D is the most appropriate response as it offers immediate guidance along with a plan for referral if needed.
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Question 6
While assisting with data collection of an adult client, a nurse asks the client to identify various odors. In this technique, which cranial nerve is the nurse assessing?
A. Optic
B. Abducens
C. Olfactory
D. Hypoglossal
Correct answer:
The correct answer is 'Olfactory.' The olfactory nerve is responsible for the sense of smell. Assessing this nerve involves testing the client's ability to identify various odors. Loss of smell, head trauma, abnormal mental status, and suspected intracranial lesions are conditions where testing the olfactory nerve is essential. The optic nerve is evaluated for visual acuity and visual fields. The abducens nerve is usually assessed alongside the oculomotor and trochlear nerves, focusing on pupil size, regularity, light reactions, accommodation, and extraocular movements. The hypoglossal nerve is examined by inspecting the tongue, not by assessing the sense of smell.
A 70-year-old male who is recovering from a stroke exhibits signs of unilateral neglect. Which behavior is suggestive of unilateral neglect?
A. The client is observed shaving only one side of his face.
B. The client is unable to distinguish between two tactile stimuli presented simultaneously.
C. The client is unable to complete a range of vision without turning his head side to side.
D. The client is unable to carry out cognitive and motor activity at the same time.
Correct answer:
Unilateral neglect is a condition where a person ignores one side of their body. In this case, the behavior of shaving only one side of the face indicates neglect of the other side. This behavior is suggestive of unilateral neglect as the individual is failing to attend to one side of their body. Choices B, C, and D are not associated with unilateral neglect. Choice B refers to tactile agnosia, a condition where a person cannot recognize objects by touch, not related to ignoring one side of the body. Choice C describes a visual field cut, which is a different visual deficit. Choice D relates to dual-task interference, not specific to ignoring one side of the body.
During the history assessment of an 80-year-old client, which statement made by the client might indicate a possible fluid and electrolyte imbalance?
A. "My skin is always so dry."?
B. "I often use a laxative for constipation."?
C. "I have always liked to drink a lot of iced tea."?
D. "I sometimes have a problem with dribbling urine."?
Correct answer:
The correct answer is "I often use a laxative for constipation." Frequent use of laxatives can lead to diarrhea and electrolyte loss, indicating a possible fluid and electrolyte imbalance. Statements A, C, and D are not directly related to fluid and electrolyte imbalance. Statement A about dry skin may suggest dehydration, but it is less specific to electrolyte imbalance than the frequent use of laxatives. Statement C about drinking a lot of iced tea could potentially relate to fluid intake, but it doesn't directly indicate an imbalance. Statement D about dribbling urine is more indicative of a potential urinary issue rather than a fluid and electrolyte imbalance.
The nurse manager is having a problem on the unit with one staff person having repetitive tardiness and leaving the unit with orders not initiated. Which action by the manager would be best?
A. Call the staff nurse in and place them on a work improvement plan after a 3-day suspension
B. Have the other staff gather additional information on the tardy staff member
C. Call the staff nurse in for an interview to investigate the problem and possible solutions
D. Assign a mentor to assist the staff member in arriving on time
Correct answer:
The correct action for the nurse manager would be to call the staff nurse in for an interview to discuss the issues of repetitive tardiness and incomplete tasks. This approach allows the staff member to explain the situation, and together with the manager, develop a plan to address the problems. Choice A is incorrect as it immediately involves suspension without investigation or support. Choice B is not the best course of action as it does not involve direct communication with the staff member in question. Choice D, assigning a mentor to help the staff member, could be beneficial but does not directly address the immediate issues of tardiness and incomplete tasks.
A client recently lost a child due to poisoning. The client tells the nurse, 'I don’t want to make any new friends right now.' This is an example of which of the following indicators of stress?
A. emotional indicator
B. spiritual indicator
C. sociocultural indicator
D. intellectual indicator
Correct answer:
The correct answer is C, 'sociocultural indicator.' This client's reluctance to make new friends after experiencing a traumatic event like losing a child is a clear sign of sociocultural stress. Sociocultural stress can impact a person's social interactions, relationships, and cultural practices. Choices A, B, and D are incorrect. Choice A, 'emotional indicator,' would focus on emotional responses directly related to stress. Choice B, 'spiritual indicator,' refers to stress related to spiritual beliefs, practices, or values, which is not evident in this scenario. Choice D, 'intellectual indicator,' is not a recognized category of stress indicators in this context.
When administering a nasal spray medication, what should the client do before the medication is administered?
A. The client should blow their nose gently before the medication is administered.
B. The medication should be sprayed into the nostril.
C. The medication should be administered as the client inhales.
D. The client should sit upright when the medication is administered.
Correct answer:
The correct answer is that the client should blow their nose gently before the medication is administered. This step helps clear the nasal passages, ensuring that the medication can reach its intended target. Choice B is incorrect as the nasal spray should be directed into the nostril, not just in front of the nose. Administering the medication as the client inhales (Choice C) is crucial to ensure proper delivery, as it helps the medication reach the desired areas. Choice D is incorrect because the client should be sitting upright, not lying flat, when administering nasal spray medication to allow for better absorption and prevent the medication from flowing out.
During a well-baby examination, the nurse measures the head circumference, and it is the same as the chest circumference. On the basis of this measurement, what action should the nurse take?
A. Document these measurements in the infant's health care record.
B. Tell the mother that the infant is growing faster than expected.
C. Suggest to the health care provider that a skull x-ray be performed.
D. Report the presence of hydrocephalus to the health care provider.
Correct answer:
The head circumference growth rate during the first year is approximately 0.4 inches (1 cm) per month. By 10 to 12 months of age, the infant's head and chest circumferences are equal. In this case, where the head circumference matches the chest circumference, it is a normal finding in infants around 10-12 months. Therefore, the most appropriate action is to document these measurements in the infant's health care record. Suspecting hydrocephalus or suggesting a skull x-ray would be premature and not indicated based on this measurement. Similarly, telling the mother that the infant is growing faster than expected is not accurate and could cause unnecessary concern.
A nurse is participating in a planning conference to improve dietary measures for an older client experiencing dysphagia. Which action should the nurse suggest including in the plan of care?
A. Monitoring the client during meals to ensure that food is swallowed
B. Encouraging the client to feed themselves
C. Consulting with the physician regarding feeding through an enteral tube
D. Ensuring that the diet consists of both solids and liquids
Correct answer:
For clients with dysphagia, ensuring successful swallowing of food and preventing aspiration is crucial. Therefore, the nurse should suggest monitoring the client closely during meals to provide assistance as needed. While a balanced diet is important, special considerations like adding thickeners for liquids may be required for dysphagia clients. Consulting with a physician about enteral tube feeding should be based on the severity of the condition, making it a premature step without clear indications. Encouraging self-feeding may not be appropriate for dysphagia clients who require close monitoring and assistance, as it could increase the risk of complications.
The chemotherapeutic agent 5-fluorouracil (5-FU) is ordered for a client as an adjunct measure to surgery. Which statement about chemotherapy is true?
A. It is a local treatment affecting only tumor cells.
B. It is a systemic treatment affecting both tumor and normal cells.
C. It has not yet been proven an effective treatment for cancer.
D. It is often the drug of choice because it causes few, if any, side effects.
Correct answer:
The correct answer is that chemotherapy is a systemic treatment affecting both tumor and normal cells. 5-FU, as an antimetabolic drug, inhibits DNA synthesis and interferes with cell replication systemically. It affects all rapidly growing cells, including malignant and normal ones. This drug is used as adjuvant therapy for various cancers. Choice A is incorrect because chemotherapy affects both tumor and normal cells, not just tumor cells. Choice C is incorrect as chemotherapy has been proven effective in treating cancer. Choice D is incorrect because chemotherapy often causes side effects like bone marrow depression, anorexia, stomatitis, nausea, and vomiting.
A nurse is working in a pediatric clinic, and a 25-year-old mother comes in with a 4-week-old baby. The mother is stressed out about the loss of sleep, and the baby exhibits signs of colic. Which of the following techniques should the nurse teach the mother?
A. Distraction of the infant with a red object
B. Prone positioning techniques
C. Tapping reflex techniques
D. Neural warmth techniques
Correct answer:
Neural warmth techniques involve the caregiver providing a warm, soothing touch to the baby, which can help to lower the baby's agitation level and promote relaxation. This technique is beneficial for calming colicky babies. Choices A, B, and C are incorrect because distraction with a red object, prone positioning, and tapping reflex techniques are not effective methods for managing colic in infants. Red object distraction is not a proven technique for soothing colicky babies. Prone positioning is not recommended for infants due to the risk of sudden infant death syndrome (SIDS). Tapping reflex techniques are not recognized as effective interventions for colic.
NCLEX-PN clinical judgment practice questions, set 29 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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