NCLEX-PN clinical judgment practice questions, set 36
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 36
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
Which client should be seen first by the Emergency Department nurse?
A. A six-year-old with a femur fracture.
B. A two-year-old with a fever of 102 degrees F.
C. A three-year-old with wheezes in the right lower lobe.
D. A two-year-old whose gastrostomy tube came out.
Show answer and rationale
Correct answer: C — A three-year-old with wheezes in the right lower lobe.
The priority in the emergency department is to assess and manage clients based on the severity of their condition. In this scenario, the three-year-old with wheezes in the right lower lobe should be seen first because respiratory distress takes precedence over other conditions. Wheezing indicates potential airway compromise, which requires immediate attention to ensure adequate oxygenation. The other options are important but do not pose an immediate threat to the client's airway and breathing. A femur fracture, fever, or a dislodged gastrostomy tube can be addressed after ensuring the child with respiratory distress is stable.
Question 2
A community health nurse is providing information to a group of older clients about measures to decrease the risk of contracting influenza during peak flu season. The nurse should provide which information?
A. Clients must stay at home and ask a neighbor or family member to run their errands.
B. It is best to do grocery shopping and other errands early in the morning when crowds are smaller.
C. Clients should wash their hands frequently and keep hands away from the face, especially during peak flu season.
D. Drinking eight 8-oz glasses of fluid each day will reduce the risk of contracting influenza.
Show answer and rationale
Correct answer: C — Clients should wash their hands frequently and keep hands away from the face, especially during peak flu season.
During peak influenza season, older clients should take measures to reduce the risk of contracting the flu. The most effective preventive measure is frequent hand hygiene and refraining from touching the face, as this reduces the transmission of the flu virus. While it is advisable to avoid crowds, the direct action of hand hygiene is more impactful. Doing errands early in the morning when crowds are smaller is a good suggestion to reduce exposure but does not address the direct transmission through hands. Drinking enough fluid daily is important for overall health but does not directly reduce the risk of contracting influenza.
Question 3
Which of these would be the most appropriate way to document a client's refusal of medication?
A. "Heparin refused during shift. Risks reviewed."?
B. "The client refused the heparin injection when I tried to administer it. She yelled at me, saying, 'I do not want that injection right now!' and told me to leave the room. I explained the risks of not taking the medication. She seemed very annoyed that I tried to give it at that time. I will attempt again later in my shift."?
C. "Subcutaneous Heparin injection was attempted to be given to the client per the physician's order. Client refused, stating, 'I do not want that injection.' Potential risks for refusing the medication were reviewed with the client, and the client verbalized understanding."?
D. "Ct stated she did not want the SQ heparin inj at this time. Risks of not taking this med were reviewed with the ct, and the ct verbalized understanding."?
Show answer and rationale
Correct answer: C — "Subcutaneous Heparin injection was attempted to be given to the client per the physician's order. Client refused, stating, 'I do not want that injection.' Potential risks for refusing the medication were reviewed with the client, and the client verbalized understanding."?
The most appropriate way to document a client's refusal of medication should include details such as the medication, the client's statement of refusal, and the review of potential risks. Choice C accurately captures all these essential elements, making it the correct answer. Choice A lacks details about the client's refusal and the review of risks. Choice B includes unnecessary emotional descriptions and a plan of action that might not be appropriate. Choice D uses abbreviations that may not be universally understood, lacks proper punctuation, and also does not provide a detailed account of the refusal and the review of risks.
Question 4
A 13-year-old girl is admitted to the ER with lower right abdominal discomfort. What should the admitting nurse do first?
A. Administer Loritab to the patient for pain relief.
B. Place the patient in a right sidelying position for pressure relief.
C. Start a Central Line.
D. Provide pain reduction techniques without administering medication.
Show answer and rationale
Correct answer: D — Provide pain reduction techniques without administering medication.
In a case of lower right abdominal discomfort, the first step should be to provide pain reduction techniques without administering medication. Administering pain medication or starting a central line should not be done without medical orders. Placing the patient in a right sidelying position may help with pressure relief, but addressing pain reduction techniques without medication is the initial priority in this scenario. It is essential to assess the patient further, consult with a healthcare provider, and follow the appropriate protocols before administering any medication or invasive procedures like starting a central line.
Question 5
A nurse gave medications to the wrong client. She stated the client responded to the name called. What is the nurse's appropriate documentation?
A. Note in medication records the drug given
B. The client was not hurt, no need for documentation
C. Note the client's orientation
D. Completely fill out an incident report
Show answer and rationale
Correct answer: D — Completely fill out an incident report
In the case where medications are given to the wrong client, the appropriate documentation by the nurse should involve completely filling out an incident report. This report is essential for tracking errors, implementing corrective measures, and ensuring patient safety. Choice A is incorrect because solely noting the drug given does not address the severity of the error. Choice B is incorrect because even if the client was not hurt, documentation is crucial for quality improvement and risk prevention. Choice C is incorrect as noting the client's orientation does not adequately address the medication error and its implications.
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Question 6
A patient has been admitted to the hospital with an L4-5 HNP diagnosis. After 24 hours, the patient is able to ambulate with assistance and has reduced muscle spasms. Which of the following medications was the most beneficial in changing the patient's mobility status?
A. Mivacron
B. Atropine
C. Bethanechol
D. Flexeril
Correct answer:
The correct answer is Flexeril. Flexeril is a muscle relaxant commonly used to treat acute muscle pain and spasms. In this scenario, the patient experiencing reduced muscle spasms and improved mobility after taking Flexeril indicates its effectiveness.
Choice A, Mivacron, is a neuromuscular blocking agent that is not typically used for muscle spasms or pain relief. Choice B, Atropine, is a medication used to treat certain types of nerve agent and pesticide poisonings, not muscle spasms. Choice C, Bethanechol, is a medication that stimulates bladder contractions and is not indicated for muscle spasms or mobility improvement.
The client is admitted to the hospital following a motor vehicle accident and has sustained a closed chest wound. Which assessment finding is consistent with a flail chest?
A. Biot's respirations
B. Sucking sounds during respirations
C. Paradoxical chest wall movement
D. Hypotension and bradycardia
Correct answer:
The correct assessment finding consistent with a flail chest is paradoxical chest wall movement. This occurs when a segment of the chest wall moves in the opposite direction to the rest of the chest during respiration. Biot's respirations (Choice A) are a pattern of breathing characterized by groups of quick, shallow inspirations followed by regular or irregular periods of apnea. Sucking sounds during respirations (Choice B) may indicate air entering or leaving the chest cavity through a wound. Hypotension and bradycardia (Choice D) may be present due to other factors such as shock, but they are not specific to a flail chest.
During an emergency procedure, is the surgical timeout a requirement?
A. The surgical timeout should be performed by the surgical team unless it would cause a delay leading to injury or death.
B. No, the timeout is not necessary during an emergency procedure.
C. No, the surgical timeout is not required in emergency procedures.
D. Yes, the surgical timeout must be performed in all cases.
Correct answer:
During an emergency procedure, the surgical timeout should be performed unless doing so would cause a delay leading to injury or death. This is because the primary goal during an emergency is to swiftly address the critical situation. Choice B is incorrect as it implies that the timeout is not necessary, which is not accurate. Choice C is also incorrect as it suggests that the timeout is not required in emergency procedures, disregarding safety protocols. Choice D is incorrect as it wrongly states that the timeout must be performed in all cases without considering the potential risks associated with delays during emergencies.
The nurse and a colleague are on the elevator after their shift, and they hear a group of health caregivers discussing a recent client scenario. Which client right might be breached?
A. right to refuse treatment
B. right to continuity of care
C. right to confidentiality
D. right to reasonable responses to requests
Correct answer:
The right to confidentiality of client information might be breached when client care situations are discussed in public areas or without regard to maintaining the information as private and confidential. In this scenario, discussing a client scenario in a public elevator could potentially lead to the breach of the client's right to confidentiality. The other choices, such as the right to refuse treatment, right to continuity of care, and right to reasonable responses to requests, are not typically breached in this context. It is important to uphold client confidentiality to maintain trust and privacy in healthcare settings.
A client with leukemia is being considered for a bone marrow transplant. The healthcare team is discussing the risks and benefits of this treatment and other possible treatments with the goal of inflicting the least possible harm on the client. Which principle of healthcare ethics is the team practicing?
A. Fidelity
B. Nonmaleficence
C. Autonomy
D. Justice
Correct answer:
The correct answer is B: Nonmaleficence. Nonmaleficence is the principle of avoiding harm. In healthcare ethics, practitioners aim not only to do good but also to ensure they do no harm. In this scenario, the healthcare team is discussing treatment options with the intention of inflicting the least harm on the client. Choice A, Fidelity, refers to keeping promises made to clients, families, and healthcare professionals. Choice C, Autonomy, pertains to respecting a person's independence and right to make decisions. Choice D, Justice, involves fairness, equity, and the fair allocation of resources, such as healthcare services.
A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period?
A. Teaching perineal wound care techniques
B. Monitoring electrolyte levels
C. Encouraging early ambulation
D. Facilitating perineal wound drainage
Correct answer:
The priority nursing care during the post-op period for a client who underwent an abdominal perineal resection is to facilitate perineal wound drainage. This is crucial for preventing infection of the surgical site and promoting healing. Teaching perineal wound care techniques, as in choice A, is more appropriate than ileostomy care in this scenario. While monitoring electrolyte levels is important, it is not the priority compared to ensuring proper wound drainage, making choice B less crucial. Encouraging early ambulation, as in choice C, is beneficial but not as critical as facilitating wound drainage immediately post-op.
Which of the following classifications of medications is used to help decrease tremors for clients with hyperthyroidism?
A. Steroids
B. Anticonvulsants
C. Beta blockers
D. Iodine compounds
Correct answer:
The correct answer is Beta blockers. Beta blockers are commonly used to help decrease tremors in clients with hyperthyroidism by blocking the action of adrenaline. This helps to control symptoms such as rapid heart rate, tremors, and anxiety. Steroids (Choice A) are not typically used to treat tremors in hyperthyroidism. Anticonvulsants (Choice B) are primarily used to control seizures and are not the first-line treatment for tremors in hyperthyroidism. Iodine compounds (Choice D) are used in the treatment of hyperthyroidism by reducing the production of thyroid hormones but are not specifically indicated for tremor relief.
What is the appropriate intervention for a client who is restrained?
A. Remove the restraints and provide skin care every hour.
B. Document the condition of the client's skin every 3 hours.
C. Assess the restraint every 30 minutes
D. Tie the restraint to the side rails.
Correct answer:
The correct intervention when a client is restrained is to assess the restraint every 30 minutes. This ensures the safety and well-being of the client by checking for proper fit, circulation, and signs of distress. Removing restraints and providing skin care every hour may not be necessary and could increase the risk of skin breakdown. Documenting the skin condition every 3 hours is important but not the immediate intervention needed when a client is restrained. Tying the restraint to the side rails is unsafe and can cause harm to the client, as restraints should be secured to the bed frame or an immovable part of the bed.
A 4-year-old client is unable to go to sleep at night in the hospital. Which nursing intervention best promotes sleep for the child?
A. turning out the room light and closing the door
B. tiring the child during the evening with quiet activities
C. identifying the child's home bedtime rituals and following them
D. encouraging visitation by friends during the evening
Correct answer:
For a 4-year-old client struggling to sleep in the hospital, it is essential to identify and replicate their home bedtime rituals. This familiarity can provide comfort and promote better sleep. Turning out the room light and closing the door (Choice A) might increase the child's fear by plunging the room into darkness, making it an incorrect choice. Tiring the child with quiet activities (Choice B) is incorrect as it may stimulate rather than calm the child. Encouraging visitation by friends (Choice D) can lead to increased excitement, hindering the child's ability to fall asleep instead of promoting a restful environment.
In a brief treatment program for a client who was raped, what is a realistic short-term goal?
A. Identify all psychosocial problems.
B. Eliminate the client's enticing behaviors.
C. Resolve feelings of trauma and fear.
D. Verbalize feelings about the event.
Correct answer:
In this scenario, a realistic short-term goal for the client who was raped and starting a brief treatment program is to verbalize feelings about the event. This goal promotes the expression of emotions, which is crucial in the healing process. Identifying all psychosocial problems is too broad and not typically achievable in a brief treatment program. Eliminating the client's enticing behaviors is not a suitable short-term goal as the focus should be on emotional recovery. While resolving feelings of trauma and fear is important, verbalizing feelings about the event is a more specific and achievable goal in the short term.
NCLEX-PN clinical judgment practice questions, set 36 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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