NCLEX-PN clinical judgment practice questions, set 3
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 3
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 nurse calls a health care provider to report that a client with congestive heart failure (CHF) is exhibiting dyspnea and worsening of wheezing. The health care provider, who is in a hurry because of a situation in the emergency department, gives the nurse a telephone prescription for furosemide (Lasix) but does not specify the route of administration. What is the appropriate action on the part of the nurse?
A. Calling the health care provider who gave the telephone prescription to clarify the prescription
B. Administering the medication orally and clarifying the prescription once the health care provider has finished caring for the client in the emergency department
C. Calling the nursing supervisor for assistance in determining the route of administration
D. Administering the medication intravenously because this route is generally used for clients with CHF
Show answer and rationale
Correct answer: A — Calling the health care provider who gave the telephone prescription to clarify the prescription
Telephone prescriptions involve a health care provider dictating a prescribed therapy over the telephone to the nurse. The nurse must clarify the prescription by repeating it clearly and precisely to the health care provider. The nurse then writes the prescription on the health care provider's prescription sheet or enters it into the electronic medical record. It is crucial not to interpret an unclear prescription or administer a medication by a route that has not been expressly prescribed. In this case, the nurse should call the health care provider who gave the telephone prescription to clarify the prescription, ensuring the correct route of administration is specified. Options B, C, and D are incorrect because administering the medication without clarification, seeking assistance from the nursing supervisor, or choosing an arbitrary route of administration can compromise patient safety and violate medication administration protocols.
Question 2
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. Unless treated, all male sex abuse survivors grow up to abuse other children.
D. All children who have been sexually abused have the same needs, regardless of gender.
Show answer and rationale
Correct answer: B — Survivors of male sexual abuse might become confused about their sexual identity.
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. It is crucial for the nurse to consider these potential outcomes, making choice B the correct answer. Choice A is incorrect because male victims of sexual abuse can indeed have long-term psychological problems, so the nurse should be aware of this issue. Choice C is incorrect as not all male sex abuse survivors grow up to abuse other children, which is a misconception. Choice D is incorrect because the needs of children who have been sexually abused can vary based on various factors, including gender, so it is important to consider individual differences.
Question 3
When an elder client asks the nurse whether he will be capable of sexual activity in old age, the best response by the nurse is:
A. "Elder adults are psychologically and physically capable of engaging in sexual activity regardless of age-related changes."?
B. "If you haven't been sexually active throughout your life, you will not be able to participate in sexual activity in old age."?
C. "When intercourse isn't possible, many of your sexual needs can be met through intimacy and touch."?
D. "You might find it takes longer for you to achieve an erection, but you can maintain it for a longer time."?
Show answer and rationale
Correct answer: A — "Elder adults are psychologically and physically capable of engaging in sexual activity regardless of age-related changes."?
The best response for the nurse when an elder client asks about capability for sexual activity in old age is to provide reassurance and open communication. Choice A is the correct answer as it acknowledges that elder adults can engage in sexual activity both physically and psychologically despite age-related changes. This response encourages further discussion and addresses the client's concerns. Choices B, C, and D contain some truths but are not the most therapeutic responses. Choice B implies that past sexual activity is a prerequisite for sexual activity in old age, which is not entirely accurate as intimacy can be experienced in various ways. Choice C, while true about alternative ways to meet sexual needs, does not directly address the client's question about sexual activity. Choice D focuses on the physiological aspect of sexual function, which is important but not the most appropriate initial response to the client's query.
Question 4
What is an effective intervention for a client diagnosed with Obsessive-Compulsive Disorder?
A. Discussing the repetitive actions.
B. Insisting the client not perform the repetitive act.
C. Informing the client that the act is not necessary.
D. Encouraging daily exercise.
Show answer and rationale
Correct answer: D — Encouraging daily exercise.
An effective intervention for a client diagnosed with Obsessive-Compulsive Disorder is encouraging daily exercise. Obsessive-Compulsive Disorder is an anxiety disorder, and exercise can help release emotional energy, limit the time available for maladaptive behaviors, and direct the client's attention outward. Discussing the repetitive actions (choice A) may reinforce the behavior by providing attention to it. Insisting the client not to perform the repetitive act (choice B) can increase anxiety and resistance, as abruptly stopping the behavior may be challenging. Informing the client that the act is not necessary (choice C) may not address the underlying anxiety and could invalidate the client's experiences, leading to increased distress. Encouraging daily exercise is a proactive intervention that can help manage symptoms of Obsessive-Compulsive Disorder by addressing core features of the disorder and promoting overall well-being.
Question 5
The nurse wishes to decrease a client's use of denial and increase the client's expression of feelings. To do this, the nurse should:
A. tell the client to stop using the defense mechanism of denial.
B. positively reinforce each expression of feelings.
C. instruct the client to express feelings.
D. challenge the client each time denial is used.
Show answer and rationale
Correct answer: B — positively reinforce each expression of feelings.
In the scenario provided, the nurse aims to reduce the client's use of denial and encourage the expression of feelings. Positive reinforcement for each expression of feelings is an effective approach to achieve this goal. By positively reinforcing the client's expression of feelings, the nurse encourages the desired behavior, making it more likely for the client to continue sharing their emotions. This approach creates a supportive and accepting environment for the client. In contrast, telling the client to stop using denial (Choice A) may create resistance and inhibit communication by putting pressure on the client. Instructing the client to express feelings (Choice C) is less effective as it lacks the element of reinforcement that is essential for behavior modification. Challenging the client each time denial is used (Choice D) may lead to defensiveness and hinder the therapeutic relationship, making it a less favorable option.
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Question 6
In which situation is the nurse upholding the ethical principle of fidelity?
A. Providing complete information regarding treatment options to a client with newly diagnosed cancer
B. Allowing a client to decide when to receive daily hygiene care
C. Inserting a 19-gauge intravenous catheter into a client requiring a blood transfusion
D. Contacting the health care provider about the client's request to incorporate complementary therapies for pain into the treatment plan
Correct answer:
Fidelity is the ethical principle of keeping promises made to clients, families, and other healthcare professionals. Contacting the health care provider about the client's request to incorporate complementary therapies for pain into the treatment plan exemplifies fidelity. By advocating for the client's preferences and ensuring their requests are addressed, the nurse demonstrates a commitment to fulfilling promises made to the client. Allowing a client to decide when to receive daily hygiene care relates to respecting autonomy, not fidelity. Inserting a 19-gauge intravenous catheter into a client needing a blood transfusion aligns with beneficence, as it involves taking action to provide necessary treatment. Providing complete information to a client with newly diagnosed cancer about treatment options reflects justice, promoting fairness and equity in healthcare by offering equal access to information and treatment choices.
A client was involved in a motor vehicle accident in which the seat belt was not worn. The client is exhibiting crepitus, decreased breath sounds on the left, complains of shortness of breath, and has a respiratory rate of 34/min. Which of the following assessment findings should concern the nurse the most?
A. temperature of 102°F and a productive cough
B. arterial blood gases (ABGs) with a PaO2 of 92 mmHg and PaCO2 of 40 mmHg
C. trachea deviating to the right
D. barrel-chested appearance
Correct answer:
The correct answer is 'trachea deviating to the right.' A mediastinal shift is indicative of a tension pneumothorax, which is a dangerous complication seen in trauma patients with symptoms like crepitus, decreased breath sounds, shortness of breath, and tachypnea. Assessing for acute traumatic injuries is crucial in this context. Choice A, a temperature of 102°F and a productive cough, is common in pneumonia cases and not as concerning as a mediastinal shift. Choice B, ABGs with a PaO2 of 92 mmHg and PaCO2 of 40 mmHg, shows values within normal limits and does not suggest a tension pneumothorax. Choice D, a barrel-chested appearance, is typical of COPD and not directly related to the acute traumatic injury described. A tension pneumothorax is a medical emergency where air cannot escape the pleural cavity, leading to lung collapse and a mediastinal shift to the unaffected side with a downward displacement of the diaphragm.
A nurse is preparing to assess the function of a client's spinal accessory nerve. Which action does the nurse ask the client to take to aid assessment of this nerve?
A. Smiling
B. Clenching the teeth
C. Shrugging the shoulders against the nurse's resistance
D. Identifying by taste a substance placed on the back of the tongue
Correct answer:
To assess cranial nerve XI (spinal accessory nerve), the examiner checks the sternomastoid and trapezius muscles for equal size. Equal strength is assessed by asking the client to rotate the head forcibly against resistance applied to the side of the chin and by asking the client to shrug the shoulders against resistance. These movements should feel equally strong on the two sides. The client is asked to smile as a test of the function of cranial nerve VII (facial nerve). The client's ability to clench the teeth is used to assess the motor function of cranial nerve V (trigeminal nerve). The client's taste perception is used to assess the sensory function of cranial nerve IX (glossopharyngeal nerve). Therefore, the correct action to assess the spinal accessory nerve is to ask the client to shrug the shoulders against resistance. The other options are used to assess different cranial nerves, making them incorrect choices.
A client is going to have an endoscopy performed. Which of the following is not a probable reason for an endoscopy procedure?
A. Aspiration noted on a honey-thick diet
B. Pain felt during a bowel movement
C. Pain felt in the left upper quadrant
D. Right shoulder pain
Correct answer:
The correct answer is 'Pain felt during a bowel movement.' Endoscopy is used to examine the upper gastrointestinal tract, which includes the esophagus, stomach, and duodenum. Pain during a bowel movement would suggest an issue in the lower gastrointestinal tract, which is typically examined with a colonoscopy. Choices A, C, and D are not probable reasons for an endoscopy procedure as they relate to symptoms in the upper gastrointestinal tract or are not specific to gastrointestinal issues. Aspiration noted on a honey-thick diet could indicate a risk of aspiration pneumonia related to swallowing difficulties, which can be assessed through an endoscopy. Pain felt in the left upper quadrant may be related to conditions like gastritis or peptic ulcers that can be investigated using an endoscopy. Right shoulder pain can be a referred pain from conditions like gallbladder disease that can also be evaluated with an endoscopy.
A client with pancreatitis has been transferred to the intensive care unit. Which order would the nurse anticipate?
A. Blood pressure monitoring every 15 minutes
B. Insertion of a Levine tube
C. Continuous cardiac monitoring
D. Administration of pain medication every 4 hours
Correct answer:
In a client with pancreatitis who frequently experiences nausea and vomiting, insertion of a Levine tube is often anticipated to decompress the stomach and rest the bowel, helping to alleviate symptoms. This intervention is crucial in managing the gastrointestinal symptoms associated with pancreatitis. Blood pressure monitoring every 15 minutes may be necessary in some cases, but it is not a routine order for pancreatitis, making option A less likely. Continuous cardiac monitoring could be required based on the individual's condition, but it is not typically the first priority in pancreatitis management, so option C is not the most anticipated order. While pain medication administration is essential for managing discomfort, the priority in this scenario, especially considering the symptoms of nausea and vomiting, would be decompression with a Levine tube to address gastrointestinal issues, making option D less likely.
Which of the following is an inappropriate item to include in planning care for a severely neutropenic client?
A. Transfuse neutrophils (granulocytes) to prevent infection.
B. Exclude raw vegetables from the diet.
C. Avoid administering rectal suppositories.
D. Prohibit vases of fresh flowers and plants in the client's room.
Correct answer:
Transfusing neutrophils (granulocytes) to prevent infection is inappropriate in the care of a severely neutropenic client. Neutrophils normally comprise 70% of all white blood cells and can be beneficial in a selected population of infected, severely granulocytopenic clients (less than 500/mm3) who do not respond to antibiotic therapy and who are expected to experience prolonged suppression of granulocyte production. Therefore, transfusing neutrophils is not a standard practice in caring for neutropenic clients. The other choices are appropriate in caring for a severely neutropenic client: excluding raw vegetables from the diet to reduce the risk of infections from potential pathogens, avoiding administering rectal suppositories to prevent any injury or infection due to mucosal damage, and prohibiting vases of fresh flowers and plants in the client's room to minimize the risk of exposure to environmental pathogens.
A client asks a nurse about the procedure for becoming an organ donor. The nurse provides the client with which information?
A. To speak with the chaplain about the psychosocial aspects of becoming a donor
B. That this decision must be made by the next of kin at the time of the client's death
C. That anatomic gifts must be made in writing and signed by the client
D. To let the health care provider know about the request so that it may be documented in the client's record
Correct answer:
When a person wishes to become an organ donor, they need to understand that anatomic gifts must be made in writing and signed by the individual. The gift must be made by the donor themselves, typically an individual who is at least 18 years old. If the client is unable to sign, the document should be signed by another person and two witnesses. While speaking to a chaplain or informing the healthcare provider may be part of the process, the essential step is to have a written document signed by the client. Choice A is incorrect as it does not address the procedural aspect of becoming an organ donor. Choice B is incorrect as the decision to make an anatomic gift is typically made by the individual themselves, not the next of kin. Choice D is incorrect as simply informing the healthcare provider is not sufficient for the procedure of becoming an organ donor; a written and signed document by the client is necessary.
An LPN on a Continuous Quality Improvement (CQI) team is tasked with implementing strategies to reduce medication errors. Which of the following strategies would be most beneficial for the LPN to implement?
A. Track individuals who commit medication errors and report them to administration.
B. Remind staff of the five rights of medication administration.
C. Ensure that all staff members are proficient in completing incident reports if a medication error occurs.
D. Double-check that staff document medication administration in the electronic medical record.
Correct answer:
The most beneficial strategy for the LPN on a CQI team to implement is to ensure that all staff members are proficient in completing incident reports if a medication error occurs. Organized and accurate incident reports are crucial in tracking and understanding why errors occurred. CQI teams utilize incident reports to develop new policies or enhance existing ones to standardize medical processes and reduce errors. Tracking individuals with medication errors (Choice A) may create a culture of blame rather than focusing on system improvements. Reminding staff of the five rights of medication administration (Choice B) is important for knowledge reinforcement but does not directly address the process improvement aspect. Double-checking documentation in the electronic medical record (Choice D) is necessary for accuracy but does not provide the detailed insights obtained from incident reports for process improvement.
The client in the Emergency Department, who has suffered an ankle sprain, should be taught to:
A. use cold applications to the sprain during the first 24-48 hours.
B. expect disability to decrease within the first 24 hours of injury
C. expect pain to decrease within 3 hours after injury.
D. begin progressive passive and active range of motion exercises immediately.
Correct answer:
When a client suffers an ankle sprain, the nurse should teach them to use cold applications to the sprain during the first 24-48 hours. Cold applications are believed to produce vasoconstriction and reduce the development of edema. Expecting disability to decrease within the first 24 hours of injury (choice B) is incorrect as disability and pain are anticipated to increase during the first 2-3 hours after injury. Expecting pain to decrease within 3 hours after injury (choice C) is also incorrect as pain and swelling usually increase initially. Beginning progressive passive and active range of motion exercises immediately (choice D) is not recommended; these exercises are usually started 2-5 days after the injury, according to the physician's recommendation. Treatment for a sprain involves support, rest, and alternating cold and heat applications. X-ray pictures are often necessary to rule out any fractures.
A client is having psychological counseling for problems communicating with his mother. Which model of stress is the most useful in reference to this stressor?
A. Adaptation Model
B. Stimulus-Based Model
C. Transaction-Based Model
D. Selye's Model of Stress
Correct answer:
The Transaction-Based Model, proposed by R.S. Lazarus, is the most relevant model of stress in the context of a client facing communication issues with his mother. This model takes into consideration individual differences and cognitive processes that occur between a stressor and the individual's response. It emphasizes the importance of how the individual perceives and interprets the stressor, incorporating mental and psychological components. In this scenario, the client's difficulties in communicating with his mother involve complex cognitive processes and individual perceptions, making the Transaction-Based Model the most suitable choice. The other options are not as relevant in this context: the Adaptation Model focuses on adjustment to stress over time, the Stimulus-Based Model emphasizes external factors as stressors, and Selye's Model of Stress mainly centers on the physiological response to stress.
NCLEX-PN clinical judgment practice questions, set 3 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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