NCLEX-PN clinical judgment practice questions, set 32
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 32
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 at an outpatient clinic is returning phone calls that have been made to the clinic. Which of the following calls should have the highest priority for medical intervention?
A. A home health patient reports, "I am starting to have a breakdown of my heels."?
B. A patient that received an upper extremity cast yesterday reports, "I can't feel my fingers in my right hand today."?
C. A young female reports, 'I think I sprained my ankle about 2 weeks ago.'
D. A middle-aged patient reports, 'My knee is still hurting from the TKR.'
Show answer and rationale
Correct answer: B — A patient that received an upper extremity cast yesterday reports, "I can't feel my fingers in my right hand today."?
The correct answer is the patient who received an upper extremity cast yesterday and reports not being able to feel their fingers in the right hand. This situation indicates a potential neurovascular issue that requires immediate attention to prevent complications. The other options are of lesser priority: A - Breakdown of the heels, while concerning, is not an acute issue that necessitates immediate intervention. C - An ankle sprain that occurred two weeks ago is now subacute and unlikely to be an urgent medical concern. D - Pain in the knee following a total knee replacement (TKR) is common in the early postoperative period and is not unexpected.
Question 2
On morning rounds, the nurse finds a somnolent client with a Blood glucose of 89 mg/dL. A sulfonurea and a proton pump inhibitor are scheduled to be administered. What is the nurse's best action?
A. Give the proton pump inhibitor and hold the sulfonurea until the client eats
B. Hold medications and notify the physician
C. Arouse the client and give some orange juice with sugar packets added
D. Give the medications as ordered and re-check blood sugar in one hour
Show answer and rationale
Correct answer: A — Give the proton pump inhibitor and hold the sulfonurea until the client eats
The correct action is to give the proton pump inhibitor and hold the sulfonurea until the client eats. Sulfonureas should be held for blood glucose levels below 100 mg/dL until the client has food to prevent hypoglycemia. Giving the proton pump inhibitor is appropriate and does not need to be delayed. Option B is incorrect because holding both medications without taking appropriate action may lead to further complications. Option C is not the best choice as it does not address the need to hold the sulfonurea until the client eats. Option D is incorrect because administering the medications without ensuring the client eats may lead to hypoglycemia.
Question 3
The nurse is making assignments for the day. Which client should be assigned to the nursing assistant?
A. A client with Alzheimer's disease
B. A client with pneumonia
C. A client with appendicitis
D. A client with thrombophlebitis
Show answer and rationale
Correct answer: A — A client with Alzheimer's disease
The client with Alzheimer's disease is the most stable among the clients listed and can be appropriately assigned to the nursing assistant. Nursing assistants are capable of providing care such as feeding and assisting with activities of daily living for individuals with Alzheimer's disease. Clients with pneumonia, appendicitis, and thrombophlebitis are less stable and necessitate the expertise of a registered nurse for accurate assessment and interventions. Therefore, the nursing assistant can effectively care for the client with Alzheimer's disease while ensuring that the other clients receive the necessary level of care from a registered nurse.
Question 4
The nurse overhears two nursing students talking about a client in the cafeteria. What should the nurse do first?
A. Report the incident to the nursing supervisor.
B. Write up a variance report about the incident.
C. Instruct the students that this is a violation of HIPAA.
D. Notify the students' faculty regarding the violation.
Show answer and rationale
Correct answer: C — Instruct the students that this is a violation of HIPAA.
The correct answer is to instruct the students that discussing a client in a public area like the cafeteria violates HIPAA regulations. This is important to educate the students about patient confidentiality and the consequences of breaching it. Reporting to the nursing supervisor or faculty should come after addressing the students directly. Writing up a variance report is not the immediate action needed in this situation, as educating the students about their mistake should be the priority. It is essential to address the issue at the source by educating the students first rather than escalating the matter to supervisors or faculty immediately.
Question 5
When assessing a client's self-expectations about weight loss, which question is most appropriate?
A. "What makes you think you can change your eating habits?"?
B. "How do you feel about losing weight?"?
C. "How important is it that you lose weight?"?
D. "What do you think is a realistic weekly weight loss for you?"?
Show answer and rationale
Correct answer: D — "What do you think is a realistic weekly weight loss for you?"?
When assessing a client's self-expectations about weight loss, it is crucial to inquire about what the client considers a realistic weekly weight loss goal. This question helps in understanding the client's perception and expectations regarding the weight loss journey, enabling the establishment of achievable goals. Choices A, B, and C do not directly address the aspect of setting realistic goals for weight loss. While questioning about changing eating habits, feelings about losing weight, or the importance of weight loss are relevant, they do not specifically focus on setting achievable goals, which is essential for effective weight management.
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Question 6
When obtaining a health history on a menopausal woman, which information should a nurse recognize as a contraindication for hormone replacement therapy?
A. family history of stroke
B. ovaries removed before age 45
C. frequent hot flashes and/or night sweats
D. unexplained vaginal bleeding
Correct answer:
When obtaining a health history on a menopausal woman, unexplained vaginal bleeding should be recognized as a contraindication for hormone replacement therapy. This is because it can be a sign of underlying issues that need to be addressed before starting hormone therapy. A family history of stroke is not a contraindication for hormone replacement therapy unless the woman herself has a history of stroke or blood-clotting events. Ovaries removed before age 45 is not a contraindication for hormone replacement therapy. Frequent hot flashes and/or night sweats can be relieved by hormone replacement therapy; therefore, they are not contraindications.
High uric acid levels can develop in clients who are receiving chemotherapy. This can be caused by:
A. the inability of the kidneys to excrete the drug metabolites.
B. rapid cell catabolism.
C. toxic effects of the prophylactic antibiotics that are given concurrently.
D. the altered blood pH from the acidic nature of the drugs.
Correct answer:
The correct answer is 'rapid cell catabolism.' During chemotherapy, rapid cell destruction occurs, leading to an increase in uric acid levels as a byproduct of cell breakdown. High uric acid levels are primarily a result of the rapid breakdown of cells during chemotherapy, not due to the kidneys' inability to excrete drug metabolites (Choice A). The prophylactic antibiotics given concurrently do not directly cause high uric acid levels (Choice C). The altered blood pH from the acidic nature of the drugs (Choice D) is not a direct cause of elevated uric acid levels; the main mechanism is the rapid cell catabolism that occurs during chemotherapy.
A client can receive the Mumps, Measles, Rubella (MMR) vaccine if he or she:
A. is pregnant.
B. is immunocompromised.
C. is allergic to neomycin.
D. has a cold.
Correct answer:
A client can receive the MMR vaccine if he or she has a cold without a fever since it does not preclude vaccination. Pregnant women and immunocompromised individuals cannot receive the MMR vaccine because the rubella component is a live virus that may cause birth defects and/or disease. Being allergic to neomycin is also a contraindication as per the American Academy of Pediatrics guidelines. Individuals who have experienced anaphylactic reactions to neomycin should not receive the measles vaccine. Therefore, option D 'has a cold' is the correct choice, as the presence of a simple cold does not prevent the client from receiving the MMR vaccine.
An 85-year-old client is eligible for Medicare-reimbursable home care services. Referral is contingent on meeting which of the following criteria?
A. homebound status, requiring skilled therapy care
B. immediate previous hospitalization for acute care
C. age
D. requirement of nursing and social work support
Correct answer:
The correct criteria for Medicare-reimbursable home care services include the client being homebound and requiring a skilled service, such as physical therapy, occupational therapy, speech therapy, nursing, or social work. Choice A is correct because it aligns with these requirements. Choice B is incorrect as immediate previous hospitalization is not a prerequisite for home care services. Choice C is incorrect as age alone does not determine eligibility for Medicare-reimbursable home care services. Choice D is incorrect as the requirement of nursing and social work support alone is not sufficient for Medicare-reimbursable home care services.
A child with newly diagnosed leukemia is receiving chemotherapy. Which would be included in his plan of care by the nurse?
A. Place the child in a negative pressure isolation room
B. Administer prophylactic IV antibiotics
C. Avoid high protein food intake
D. Teach family and visitors handwashing techniques
Correct answer:
The correct answer is to teach family and visitors handwashing techniques. Any client on chemotherapy should have good infection control measures in place, such as handwashing by all who they encounter. Placing the child in a negative pressure isolation room (Choice A) is not necessary unless specifically indicated for a certain condition. Administering prophylactic IV antibiotics (Choice B) may not be part of the standard care plan for a child with leukemia receiving chemotherapy. Avoiding high protein food intake (Choice C) is not directly related to infection control and may not be necessary unless there are specific dietary restrictions.
After an escharotomy of the forearm, what is the priority nursing assessment for the client who has returned to your unit?
A. Infection
B. Incision
C. Pain
D. Tissue perfusion
Correct answer:
The correct answer is "Tissue perfusion." After an escharotomy, the priority assessment is to ensure adequate tissue perfusion to the affected limb. Escharotomy is performed to relieve circulatory compromise by cutting through the eschar, so monitoring tissue perfusion is crucial to assess the effectiveness of the procedure and prevent complications. Assessing for infection is important but comes after ensuring adequate tissue perfusion. Checking the incision is necessary but assessing tissue perfusion takes precedence. Pain assessment is important but not the priority compared to assessing tissue perfusion to prevent ischemic complications.
One drug can alter the absorption of another drug. One drug increases intestinal motility. Which effect does this have on the second drug?
A. None; absorption of the second drug is not affected.
B. The increased gut motility decreases the absorption of the second drug.
C. The absorption of the second drug cannot be predicted.
D. Less of the second drug is absorbed.
Correct answer:
When one drug increases intestinal motility, it accelerates the movement of the second drug through the system. Since most oral medications are absorbed in the intestine, the faster transit time decreases the absorption of the second drug. Therefore, less of the second drug is absorbed. Choice A is incorrect because the increased gut motility does affect the absorption of the second drug. Choice C is incorrect as the effect of increased intestinal motility on drug absorption can be predicted based on pharmacokinetic principles. Choice B is incorrect as increased gut motility would not increase but decrease the absorption of the second drug.
When ambulating a client with right-sided weakness, a nursing assistant should be positioned on which side of the client?
A. Stands behind the client
B. Positions the free hand on the client's shoulder
C. Stands on the right side of the client
D. Grasps the security belt in the midspine area of the small of the client's back
Correct answer:
When ambulating a client with right-sided weakness, the nursing assistant should stand on the affected side, which in this case is the client's right side. This position allows the assistant to provide proper support and assistance. Standing behind the client (Choice A) is incorrect as the assistant should be on the affected side. Positioning the free hand on the client's shoulder (Choice B) is a correct action as it helps in pulling the client toward them in case of a forward fall. Grasping the security belt in the midspine area of the small of the client's back (Choice D) is also correct to provide support and stability during ambulation.
What is the number one reason a person with alcohol addiction does not seek treatment?
A. Co-dependency
B. Denial
C. Depression
D. Stigma
Correct answer:
The correct answer is B: Denial. Individuals with alcohol addiction often deny that they have a drinking problem and may become defensive when confronted about it. This sense of denial can be a significant barrier to seeking treatment. Co-dependency, referred to in choice A, is a relationship dynamic and is not the primary reason for avoiding treatment. Depression, as mentioned in choice C, is a common co-occurring condition with alcohol addiction but is not typically the main factor preventing treatment-seeking. Stigma, as in choice D, can act as a deterrent, but denial of the problem itself is usually the primary obstacle to seeking help.
A client who is experiencing infertility says to the nurse, 'I feel I will be incomplete as a man/woman if I cannot have a child.' Which of the following nursing diagnoses is likely to be appropriate for this client?
A. Risk for Self-Harm
B. Body Image Disturbance
C. Ineffective Role Performance
D. Powerlessness
Correct answer:
The correct nursing diagnosis for this client is 'Body Image Disturbance.' The client's statement reflects concerns about self-identity and feeling incomplete due to infertility, which aligns with Body Image Disturbance. The statement does not directly indicate a risk for self-harm, so 'Risk for Self-Harm' is not the correct choice. 'Ineffective Role Performance' is not the best option as it does not address the client's primary concern regarding self-image. While 'Powerlessness' could be appropriate if the client expressed feelings of powerlessness related to infertility, it is not the most suitable diagnosis based on the given statement.
NCLEX-PN clinical judgment practice questions, set 32 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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