NCLEX-PN clinical judgment practice questions, set 33
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 33
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 most common cause of acute renal failure?
A. Shock
B. Nephrotoxic drugs
C. Enlarged prostate
D. Diabetes
Show answer and rationale
Correct answer: A — Shock
The most common cause of acute renal failure is shock. In cases of shock, such as hypovolemic shock where there is low blood volume, the kidneys receive inadequate blood flow leading to acute renal failure. This can result in the kidneys starting to die within 20 minutes of low pressure. While nephrotoxic drugs can also cause acute renal failure, shock is more commonly associated with this condition. An enlarged prostate can lead to urinary retention but is not the most common cause of acute renal failure. Diabetes, on the other hand, can cause chronic kidney disease over time but is not typically the primary cause of acute renal failure.
Question 2
In performing a psychosocial assessment, the nurse begins by asking questions that encourage the client to describe problematic behaviors and situations. The next step is to elicit the client's
A. feelings about what has been described.
B. thoughts about what has been described.
C. possible solutions to the problem.
D. intent in sharing the description.
Show answer and rationale
Correct answer: B — thoughts about what has been described.
In performing a psychosocial assessment, the nurse follows a structured approach, starting with encouraging the client to describe problematic behaviors and situations. The next step is to elicit the client's thoughts about what has been described. This step helps gather more assessment data and understand how the client interprets the situation. Asking about feelings, exploring possible solutions, and understanding the client's intent in sharing the description are more complex processes that come later in the assessment. Therefore, the correct next step after describing behaviors and situations is to inquire about the client's thoughts.
Question 3
During a hospital program about in vitro fertilization, a television crew arrives to film for a series on hospital services. What action should the nurse conducting the program take?
A. Ask the television crew to interview the individuals attending the program individually.
B. Allow the television crew to videotape the program as long as they do not publicize that the program is about in vitro fertilization.
C. Explain to the television crew that videotaping is not allowed.
D. Allow the television crew to videotape the program.
Show answer and rationale
Correct answer: C — Explain to the television crew that videotaping is not allowed.
Privacy is a client's right to be free from unwanted intrusion into their private affairs. Videotaping constitutes an invasion of a client's privacy, and written permission is required from the client for actions such as photographing or videotaping. Therefore, the nurse must explain to the television crew that videotaping is not allowed to protect the attendees' privacy. Option A is incorrect as it still involves recording the individuals, breaching their privacy. Option B is incorrect because allowing videotaping without consent violates privacy rights. Option D is incorrect as it disregards the need for consent and privacy protection.
Question 4
The nurse is checking laboratory values on a patient who has crackling rales in the lower lobes, 2+ pitting edema, and dyspnea with minimal exertion. Which of the following laboratory values does the nurse expect to be abnormal?
A. Potassium.
B. B-type natriuretic peptide (BNP).
C. C-reactive protein (CRP).
D. Platelets.
Show answer and rationale
Correct answer: B — B-type natriuretic peptide (BNP).
The client's symptoms suggest heart failure. BNP is a neurohormone released from the ventricles due to increased pressure and stretch, as seen in heart failure. A BNP level greater than 51 pg/mL is often associated with mild heart failure, with higher levels indicating more severe heart failure. Potassium levels are not typically affected by heart failure. CRP is an inflammation indicator used to predict coronary artery disease risk, not directly related to heart failure in this case. The client's symptoms do not suggest bleeding or clotting abnormalities associated with platelet count issues, making platelets an unlikely abnormal value.
Question 5
A nurse is assisting with data collection of a client who has sustained circumferential burns of both legs. What should the nurse examine first?
A. Heart rate
B. Peripheral pulses
C. Blood pressure (BP)
D. Radial pulse rate
Show answer and rationale
Correct answer: B — Peripheral pulses
The priority assessment for a client with circumferential burns to the legs is to examine peripheral pulses. This is essential to ensure adequate circulation to the extremities. Circumferential burns can lead to compartment syndrome, causing decreased circulation to the affected limbs. Checking peripheral pulses is crucial to monitor for any signs of compromised circulation. While heart rate and blood pressure are important assessments in general, in the context of circumferential burns, the immediate concern is the risk of impaired circulation to the extremities. Therefore, assessing peripheral pulses takes precedence in this situation.
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Question 6
When teaching a client about anti-retroviral therapy for human immunodeficiency virus (HIV), the PN should emphasize:
A. When started, therapy must not be interrupted to prevent viral resistance.
B. When started, therapy must not be interrupted to prevent opportunistic infection.
C. Therapy should not be interrupted for one day each month to prevent toxicity.
D. Therapy should not be interrupted for one week every three months to prevent toxicity.
Correct answer:
When teaching a client about anti-retroviral therapy for HIV, it is crucial to emphasize that therapy must not be interrupted to prevent viral resistance. HIV mutates rapidly, and any interruption can lead to the emergence of resistant strains, compromising treatment effectiveness. Choice B is incorrect because keeping the virus in check with anti-retrovirals helps the client's immune system fight off opportunistic infections. Choices C and D are incorrect because therapy should not be interrupted for any reason. If toxicity occurs, the healthcare provider may adjust the treatment regimen by prescribing alternative anti-retroviral drugs.
A client has been taking alprazolam (Xanax) for four years to manage anxiety. The client reports taking 0.5 mg four times a day. Which statement indicates that the client understands the nurse's teaching about discontinuing the medication?
A. "I can drink alcohol now that I am decreasing my Xanax."?
B. "I should not take another Xanax pill. Here is what is left of my last prescription."?
C. "I should take three pills per day next week, then two pills for one week, then one pill for one week."?
D. "I can expect to be sleepy for several days after stopping the medicine."?
Correct answer:
Explanation: When discontinuing alprazolam (Xanax) after long-term use, it is crucial to taper the dosage gradually to prevent withdrawal symptoms. The correct statement indicates an understanding of this by planning a structured decrease in dosage over time. Choice A is incorrect as drinking alcohol while decreasing Xanax can be dangerous and is not recommended. Choice B is incorrect as abruptly stopping Xanax is not safe and can lead to withdrawal symptoms. Choice D is incorrect as expecting to be sleepy for several days after stopping the medication does not address the need for a gradual tapering process to avoid withdrawal symptoms.
Which of the following individuals is at the highest risk for suicide?
A. 76-year-old widow with chronic renal failure
B. 19-year-old with new SSRI therapy
C. 28-year-old post-partum crying weekly
D. 50-year-old client with obsessive-compulsive disorder (OCD) and depression
Correct answer:
The correct answer is the 76-year-old widow with chronic renal failure. Elderly individuals with chronic diseases, especially men, are at very high risk for suicide. The other choices, although they may be vulnerable populations, do not carry as high a risk for suicide. The 19-year-old with new SSRI therapy may actually have a lower risk as they are receiving treatment. The 28-year-old post-partum individual is experiencing a common emotional response after childbirth, which is not necessarily indicative of a high suicide risk. The 50-year-old with OCD and depression is at risk but not as high as elderly individuals with chronic illness.
During a routine health screening for a 1-year-old child, what is the most critical topic for the nurse to discuss with the parents?
A. the potential hazards of accidents
B. appropriate nutrition now that the child has been weaned from breastfeeding
C. toilet training
D. how to purchase appropriate shoes now that the child is walking
Correct answer:
During a routine health screening for a 1-year-old child, the most critical topic for the nurse to discuss with the parents is the potential hazards of accidents. Accidents are the primary source of injury in children and can be life-threatening. Discussions about appropriate nutrition should have been addressed during the weaning process, while the purchase of appropriate shoes is important but not life-threatening. Toilet training typically begins around 2 years of age, so 1 year of age is too early to discuss it. Therefore, the focus should be on educating parents about accident prevention to ensure the child's safety and well-being.
What advice should be given to a client with stress incontinence?
A. to consider trying Kegel exercises
B. to undergo surgery immediately
C. to avoid all forms of treatment
D. to ignore the issue as it is not serious
Correct answer:
For stress incontinence, advising the client to consider trying Kegel exercises is appropriate. Kegel exercises involve tightening and releasing the pelvic floor muscles, which can improve stress incontinence by strengthening the muscles that control urination. Choice B suggesting immediate surgery is incorrect as surgery is usually considered after conservative treatments like Kegel exercises have been tried. Choice C advising to avoid all forms of treatment is dangerous and neglectful. Choice D recommending to ignore the issue is inappropriate as it can impact the client's quality of life and may worsen over time without intervention.
What is an appropriate intervention for the client with suspected genitourinary trauma and visible blood at the urethral meatus?
A. Insertion of a Foley catheter.
B. Performing an in-and-out catheter specimen for urinalysis.
C. Obtaining a voided urine specimen for urinalysis.
D. Ordering a urinalysis by the physician.
Correct answer:
When a client presents with suspected genitourinary trauma and visible blood at the urethral meatus, obtaining a voided urine specimen for urinalysis is an appropriate intervention. This helps assess for any urinary tract injuries or abnormalities without further traumatizing the area. Insertion of a Foley catheter (Choice A) should be avoided as it can worsen the existing trauma. Performing an in-and-out catheter specimen (Choice B) involves unnecessary manipulation and can increase the risk of complications. Ordering a urinalysis by the physician (Choice D) may delay the assessment compared to obtaining a direct voided urine specimen.
The client is scheduled for a pericentesis. Which instruction should be given to the client before the exam?
A. "You will need to lie flat during the exam."?
B. "You need to empty your bladder before the procedure."?
C. "You will be asleep during the procedure."?
D. "The doctor will inject a medication to treat your illness during the procedure."?
Correct answer:
The client scheduled for a pericentesis should be instructed to empty the bladder to prevent the risk of bladder puncture when the needle is inserted. A pericentesis involves removing fluid from the peritoneal cavity. The client is typically positioned sitting up or leaning over a table, making answer A incorrect. During a pericentesis, the client is usually awake, so answer C is incorrect. Medications are not commonly injected into the peritoneal cavity during this procedure, making answer D incorrect. However, it's important to note that the administration of medications during the procedure could vary based on specific circumstances.
When documenting in the client’s record, what type of information should be recorded?
A. educated predictions of outcomes
B. personal opinions
C. objective information
D. subjective information
Correct answer:
When documenting in a client's record, it is crucial to record objective information. Objective information is factual, based on observations and measurable data. This type of information is essential for accurate and effective communication among healthcare professionals involved in the client's care. Choices A and B, educated predictions of outcomes and personal opinions, are subjective in nature and may not provide an accurate representation of the client's condition. Choice D, subjective information, includes personal feelings, interpretations, and opinions, which are not ideal for documentation as they can be biased and unreliable.
The nurse is caring for a burn victim with a skin graft to the hand. The area is pale and mottled but has good capillary refill. What is the nurse's best action at this time?
A. Warm the room
B. Submerge the hand in warm water
C. Order a K pad and apply to hand
D. Have the client exercise the fingers to increase blood flow
Correct answer:
The correct action for the nurse to take when caring for a burn victim with a skin graft to the hand, exhibiting pale and mottled skin but good capillary refill, is to warm the room. By warming the room, the nurse helps promote circulation and maintain a conducive environment for healing. Submerging the hand in warm water can pose a risk of injury or infection to the graft site. Ordering a K pad and applying it to the hand may not be necessary at this time and could potentially cause harm. Having the client exercise the fingers to increase blood flow is also not recommended as it may interfere with the healing process of the skin graft.
When discussing the patterns of use of alcohol and other drugs, which piece of information should the nurse include?
A. Lifetime prevalence and intensity of alcohol use are greater in men than in women.
B. Caucasians report higher levels of alcohol use than African Americans or Hispanics.
C. Overuse of alcohol and other drugs increases into the mid-20s, then levels off and decreases with age.
D. Heavy use is more common in lower socioeconomic groups due to affordability.
Correct answer:
The correct answer is that overuse of alcohol and other drugs increases into the mid-20s, then levels off and decreases with age. Recent research indicates that alcohol and illicit drug use tends to rise into the mid-20s and then decline with age. Choices A and B are incorrect because lifetime prevalence and intensity of alcohol use are greater in men than in women, and Caucasians do not report higher levels of alcohol use compared to African Americans or Hispanics. Choice D is incorrect because heavy use is more common in lower socioeconomic groups due to factors like stress, coping mechanisms, and availability, not just affordability.
NCLEX-PN clinical judgment practice questions, set 33 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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