NCLEX-PN clinical judgment practice questions, set 31
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 31
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
What is the purpose of a contract between a nurse and a client?
A. Contracts specify the participation and responsibilities of both parties.
B. Contracts indicate the feeling tone established between participants.
C. Contracts are legally binding and prevent either party from ending the relationship prematurely.
D. Contracts define the roles the participants take.
Show answer and rationale
Correct answer: A — Contracts specify the participation and responsibilities of both parties.
The purpose of a contract between a nurse and a client is to specify the participation and responsibilities of both parties. It outlines the expectations, contributions, and duties of each party involved in the professional relationship. This ensures clarity and mutual understanding. Choice B is incorrect as contracts do not indicate feeling tone but rather focus on the professional aspects. Choice C is incorrect because while contracts are legally binding, their primary purpose is not to prevent premature termination but to establish guidelines. Choice D is incorrect as contracts focus more on responsibilities and participation rather than specific roles.
Question 2
During a health assessment interview, the client tells the nurse that she has some vaginal drainage. The client is concerned that it may indicate a sexually transmitted infection (STI). Which statement should the nurse make to the client?
A. 'When was your last gynecological checkup?'
B. 'Have you been engaging in unprotected sexual intercourse?'
C. Don't worry about the discharge. Some vaginal discharge is normal.'
D. 'I need some more information about the discharge. What color is it?'
Show answer and rationale
Correct answer: D — 'I need some more information about the discharge. What color is it?'
If the client reports having vaginal drainage and concerns about a possible STI, it is essential for the nurse to gather more information about the discharge. Asking about the color of the discharge helps in determining its characteristics, which can be crucial in identifying potential causes. The color, consistency, odor, and associated symptoms can provide valuable insights into the underlying issue. Statements A and B are relevant questions but not as immediate or specific to addressing the client's concern about the discharge. Statement C dismisses the client's worries and does not encourage further assessment, which is not appropriate in this context.
Question 3
A 35-year-old Latin-American client wishes to lose weight to reduce her chances of developing heart disease and diabetes. The client states, "I do not know how to make my diet work with the kind of foods that my family eats."? What should the nurse do first to help the client determine a suitable diet for disease prevention?
A. Provide her with copies of the approved dietary guidelines from the American Diabetes Association and the American Heart Association.
B. Ask the client to provide a list of the types of foods she eats to determine how to best meet her needs.
C. Provide a high-protein diet plan for the client.
D. Provide the client with information related to risk factors for heart disease and diabetes.
Show answer and rationale
Correct answer: B — Ask the client to provide a list of the types of foods she eats to determine how to best meet her needs.
The correct first step is to assess the client's current diet by asking her to provide a list of the types of foods she eats. This assessment will help the nurse determine a personalized dietary plan based on the guidelines from the American Diabetes Association and the American Heart Association. Providing the client with copies of the guidelines is important but not the initial action. A high-protein diet plan may not be suitable for all clients aiming to prevent heart disease and diabetes. While providing information on risk factors is important, it is not the primary step in assisting the client with determining a suitable diet for disease prevention.
Question 4
A client who has undergone a total hip replacement is told that she will need to go to an extended care rehabilitation facility for therapy before going home. Which member of the healthcare team should the nurse ask to plan the discharge and transition from the hospital to the rehabilitation facility?
A. Physical therapist
B. Occupational therapist
C. Clergy
D. Social worker
Show answer and rationale
Correct answer: D — Social worker
In this scenario, the appropriate member of the healthcare team to plan the discharge and transition from the hospital to the rehabilitation facility is the social worker. Social workers are trained to provide counseling services, emotional support, arrange placements in care facilities, and locate financial resources for clients. While clergy provide spiritual support and guidance, physical therapists assist in physical treatments, and occupational therapists help with activities of daily living, the social worker is best suited to address the client's needs related to discharge planning and transition. Therefore, the correct answer is the social worker.
Question 5
A middle-aged woman tells the nurse that she has been experiencing irregular menses for the past six months. The nurse should assess the woman for other symptoms of:
A. climacteric
B. menopause
C. perimenopause
D. postmenopause
Show answer and rationale
Correct answer: C — perimenopause
Perimenopause refers to a period during which hormonal changes occur gradually, ovarian function diminishes, and menses become irregular. Perimenopause typically lasts around five years. Climacteric is a term that describes the period when physiologic changes result in the cessation of a woman's reproductive ability and decreased sexual activity. This term applies to both genders. Menopause is the time when menstruation permanently stops. Postmenopause refers to the period after menopausal changes are complete. In this scenario, the woman's irregular menses indicate she is likely in the perimenopausal stage, experiencing hormonal fluctuations and changes.
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Question 6
Which of the following is true of advanced directives?
A. They should be appropriately documented in the client's chart.
B. They are only applicable if the client has a terminal illness.
C. They are required if the client is unconscious.
D. They are non-legal requests.
Correct answer:
The correct answer is that advanced directives should be appropriately documented in the client's chart. Advanced directives are legal requests regarding a client's healthcare that come into effect under specific circumstances, regardless of the severity of their illness or level of consciousness. Choice B is incorrect because advanced directives can cover various healthcare decisions, not just terminal illnesses. Choice C is incorrect as advanced directives can be established and documented while the client is conscious, not only if they are unconscious. Choice D is incorrect because advanced directives are indeed legal requests, not non-legal requests.
A 51-year-old client with amyotrophic lateral sclerosis (Lou Gehrig disease) is admitted to the hospital because his condition is deteriorating. The client tells the nurse that he wants a do-not-resuscitate (DNR) order. The nurse should provide the client with which information?
A. Oral consent is not sufficient, and the client's request will be honored by all healthcare providers.
B. Consent must be obtained from the family.
C. The DNR request should be discussed with the healthcare provider, who will write the order.
D. The healthcare provider makes the final decision about a DNR request.
Correct answer:
When a client requests a DNR order, the nurse should contact the healthcare provider so that the provider may discuss the request with the client. A DNR order should be written, not verbal, following agency and state guidelines. Therefore, the correct answer is that the DNR request should be discussed with the healthcare provider, who will write the order. Option A is incorrect as oral consent is not sufficient for a DNR order. Option B is incorrect because the client, not the family, has the authority to request a DNR order. Option D is incorrect because the healthcare provider discusses the request with the client but does not make the final decision.
The client has been taking divalproex (Depakote) for the management of bipolar disorder. The nurse should give priority to monitoring which laboratory test?
A. Alanine aminotransferase (ALT)
B. Serum glucose
C. Serum creatinine
D. Serum electrolytes
Correct answer:
The correct answer is Alanine aminotransferase (ALT). Monitoring ALT levels is crucial when a patient is taking divalproex (Depakote) due to the risk of drug-induced hepatitis. Elevated ALT levels indicate liver damage or disorders, which can be a side effect of Depakote. Serum glucose (choice B) is not the priority for monitoring in this case, as the medication does not directly affect glucose levels. Serum creatinine (choice C) is not the most relevant test to monitor for Depakote use; it primarily assesses kidney function. Serum electrolytes (choice D) are important but do not take precedence over monitoring ALT levels when a patient is on Depakote.
Why must the nurse be careful not to cut through or disrupt any tears, holes, bloodstains, or dirt present on the clothing of a client who has experienced trauma?
A. The clothing may be potential evidence with legal implications.
B. Such care facilitates the preservation of potential evidence.
C. The clothing of a trauma victim can be used for further investigation.
D. Such care maintains the integrity of the clothing for forensic analysis.
Correct answer:
In cases of trauma, the clothing of a client can hold crucial evidence that may have legal implications. It is essential for the nurse to avoid cutting through or disrupting any tears, holes, bloodstains, or dirt present on the clothing to preserve this potential evidence. The correct answer highlights the legal importance of preserving the clothing for potential legal implications. Choice B is related but does not emphasize the legal aspect explicitly. Choice C is vague in mentioning further investigation without specifying the legal significance. Choice D focuses more on forensic analysis rather than the legal implications of preserving the clothing.
An LPN is working on the care plan for a client with diabetes mellitus. Which of these outcomes would be the most appropriate?
A. The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.
B. The client will maintain a blood glucose level within normal range limits today.
C. The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.
D. The client will maintain a blood glucose level within normal limits throughout my shift.
Correct answer:
The correct answer is 'The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.' This outcome is specific, measurable, and aligns with the goal of managing diabetes mellitus. Choice A is correct because it provides a clear target range (70-110) and includes adherence to facility policy, making it precise and goal-oriented. Choice B lacks specificity on the timeframe, and Choice D is vague in defining the target blood glucose range. In nursing care plans, outcomes should be well-defined, achievable, and measurable to effectively monitor the client's progress in managing their condition.
The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority?
A. Continue monitoring the vital signs
B. Contact the physician
C. Ask the client how they feel
D. Ask the LPN to continue post-op care
Correct answer:
The priority action for the nurse is to contact the physician immediately due to the client's abnormal vital signs. A blood pressure of 90/50, pulse of 132, and respirations of 30 indicate instability and require prompt medical attention. Continuing to monitor vital signs, as in choice A, may lead to a delay in necessary interventions. Asking the client how they feel, as in choice C, provides subjective data and does not address the urgent need for medical intervention. Involving the LPN, as in choice D, is not appropriate in this critical situation where the client's condition is unstable and requires immediate physician assessment and intervention.
What is the most appropriate intervention for a client with suspected genitourinary trauma and visible blood at the urethral meatus?
A. Insertion of a Foley catheter.
B. In-and-out catheter specimen for urinalysis.
C. A voided urine specimen for urinalysis.
D. A urologist consult.
Correct answer:
A urologist consult is the most appropriate intervention for a client with visible blood at the urethral meatus and suspected genitourinary trauma. This specialist can evaluate the extent of the trauma and provide the necessary treatment. Foley catheter insertion (Choice A) and in-and-out catheter specimen for urinalysis (Choice B) are contraindicated in the presence of genitourinary trauma as they can worsen the injury. While a voided urine specimen for urinalysis (Choice C) may be ordered by the physician, it does not address the specific management needed for genitourinary trauma. Therefore, a urologist consult is the best option in this scenario.
A nurse who works in a medical care unit is told that she must float to the intensive care unit because of a short-staffing problem on that unit. The nurse reports to the unit and is assigned to three clients. The nurse is angry with the assignment because she believes that the assignment is more difficult than the assignment delegated to other nurses on the unit and because the intensive care unit nurses are each assigned only one client. The nurse should most appropriately take which action?
A. Refuse to do the assignment
B. Tell the nurse manager to call the nursing supervisor
C. Return to the medical care unit and discuss the assignment with the nurse manager on that unit
D. Ask the nurse manager of the intensive care unit to discuss the assignment
Correct answer:
In this scenario, the nurse feeling that the assignment is more difficult than what other nurses received should approach the nurse manager of the intensive care unit to discuss the assignment. By doing so, the nurse can seek clarification on the rationale for the assignment or confirm if it is genuinely more challenging. Refusing the assignment is not appropriate as it could impact patient care. Returning to the medical care unit would be considered client abandonment and does not directly address the conflict at hand. Instructing the nurse manager to involve the nursing supervisor is an aggressive approach that does not directly resolve the issue.
Which symptoms is the client who overdosed on barbiturates most likely to exhibit?
A. Bradypnea and bradycardia
B. Hyperthermia and drowsiness
C. Hyperreflexia and slurred speech
D. Tachycardia and psychosis
Correct answer:
The correct answer is bradypnea and bradycardia. Barbiturates are central nervous system (CNS) depressants, which will slow down the respiratory rate (bradypnea) and heart rate (bradycardia). Choice B, hyperthermia and drowsiness, is incorrect as barbiturate overdose typically does not cause hyperthermia but rather hypothermia. Hyperreflexia and slurred speech (Choice C) are more indicative of stimulant overdoses rather than CNS depressants like barbiturates. Tachycardia and psychosis (Choice D) are also not typically seen in barbiturate overdose, as these drugs tend to depress the CNS rather than cause symptoms of increased heart rate or psychosis.
While assessing a client who is dying for signs of impending death, what should the nurse observe for?
A. Elevated blood pressure
B. Cheyne-Stokes respiration
C. Elevated pulse rate
D. Decreased temperature
Correct answer:
When assessing a client for signs of impending death, the nurse should observe for Cheyne-Stokes respiration. This pattern involves rhythmic waxing and waning of respirations from very deep breathing to very shallow breathing with periods of temporary apnea. It is often associated with cardiac failure and can be a significant indicator of impending death. Elevated blood pressure and pulse rate are not typical signs of impending death; in fact, they may indicate other conditions. A decreased temperature is also not a common sign of impending death, as temperature changes can vary among individuals and may not always correlate with the dying process.
NCLEX-PN clinical judgment practice questions, set 31 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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