NCLEX-PN clinical judgment practice questions, set 38
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 38
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 nursing diagnosis has the highest priority for a client with insomnia?
A. Ineffective breathing pattern
B. Disturbed sensory perception
C. Ineffective coping
D. Sleep deprivation
Show answer and rationale
Correct answer: A — Ineffective breathing pattern
The correct answer is 'A: Ineffective breathing pattern.' When a client presents with insomnia, assessing for underlying causes is crucial. Sleep apnea, an airway issue, may be a contributing factor to the client's insomnia, making 'Ineffective breathing pattern' the priority. 'Disturbed sensory perception' focuses on alterations in touch, taste, or vision, which are not directly related to insomnia. 'Ineffective coping' addresses a client's inability to manage stress, which, although important, is not the priority in this case. 'Sleep deprivation' is a consequence of insomnia rather than a primary nursing diagnosis.
Question 2
A client receiving preoperative instructions asks questions repeatedly about when to stop eating the night before the procedure. The nurse tries to refocus the client. The nurse notes that the client is frequently startled by noises in the hall. Assessment reveals rapid speech, trembling hands, tachypnea, tachycardia, and elevated blood pressure. The client admits to feeling nervous and having trouble sleeping. Based on the assessment, the nurse documents that the client has:
A. mild anxiety.
B. moderate anxiety.
C. severe anxiety.
D. a panic attack.
Show answer and rationale
Correct answer: C — severe anxiety.
The correct answer is 'severe anxiety.' In severe anxiety, a person focuses on small or scattered details and is unable to solve problems. The client's symptoms of rapid speech, trembling hands, tachypnea, tachycardia, elevated blood pressure, feeling nervous, and having trouble sleeping indicate severe anxiety. Mild anxiety enhances the ability to learn and solve problems, while moderate anxiety narrows the perceptual field but allows the client to notice things brought to their attention. During a panic attack, a person is disorganized, hyperactive, or unable to speak or act, which is not the case in this scenario.
Question 3
A nurse is preparing to assist the healthcare provider in performing an internal gynecological examination of a client. In which position does the nurse place the client for this examination?
A. Prone
B. Left side-lying
C. Sims
D. Lithotomy
Show answer and rationale
Correct answer: D — Lithotomy
An internal gynecological examination is performed with the client in the lithotomy position. In this position, the client is supine, with the feet in stirrups, the knees apart, and the buttocks at the end of the examining table. The client is draped so that only the vulva is exposed. The lithotomy position provides optimal access for the healthcare provider to perform the examination effectively. The prone position refers to lying on the stomach, which is not suitable for a gynecological exam. The Sims position is a left side-lying position primarily used for administering enemas, not for gynecological examinations.
Question 4
What is the primary theory that explains a family's concept of health and illness?
A. Health Belief Model
B. Education-School-Completing Factor
C. Family Health Expert Factor
D. Disconnected Family Factor
Show answer and rationale
Correct answer: A — Health Belief Model
The correct answer is the Health Belief Model. This model explains a family's concept of health and illness by focusing on readiness factors, perceived susceptibility, and seriousness of health problems, and positive motivation for wellness. The Health Belief Model is widely used in healthcare to understand and predict health behaviors. Choices B, C, and D are incorrect as they do not specifically address how a family perceives health and illness. The Health Belief Model is the most appropriate choice as it is specifically designed to explain individual and family beliefs and behaviors related to health and illness.
Question 5
The licensed practical nurse is working with a registered nurse and a patient care assistant. Which of the following clients should be cared for by the registered nurse?
A. A client 2 days post-appendectomy
B. A client 1 week post-thyroidectomy
C. A client 3 days post-splenectomy
D. A client 2 days post-thoracotomy
Show answer and rationale
Correct answer: D — A client 2 days post-thoracotomy
The correct answer is a client 2 days post-thoracotomy because this client is the most critical and requires the expertise of a registered nurse. Clients A and B are stable and ready for discharge after their respective surgeries (appendectomy and thyroidectomy). Client C, who is 3 days post-splenectomy, is also stable enough to be cared for by a licensed practical nurse as they are in a stable condition and do not have immediate critical needs. Therefore, the registered nurse should care for the client 2 days post-thoracotomy due to the critical nature of the procedure and the immediate postoperative care required.
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Question 6
While on the wound care team, the nurse notices that a fellow nurse opens extra colloid dressings that are often thrown away when they are not needed. What should the nurse do?
A. Do nothing, as it is not impacting client care.
B. Discuss with the colleague the concern about wasting supplies.
C. Tell the charge nurse to stop ordering these dressings.
D. Remove the colloid dressings from the shelf so that the nurse will find other supplies to use.
Correct answer:
The correct answer is to discuss with the colleague the concern about wasting supplies. By addressing this issue, the nurse can promote cost-effective care within the unit. While it may not directly impact client care, the wastage of supplies affects the unit's supply cost, making choice A incorrect. Choice C is incorrect as it assumes the charge nurse is solely responsible for the ordering process and overlooks the opportunity for direct communication between colleagues. Choice D is incorrect as it involves taking matters into one's own hands rather than addressing the issue through communication and collaboration.
A 32-year-old male with a complaint of dizziness has an order for Morphine via IV. What should the nurse do first?
A. Check the patient's chest x-ray results.
B. Retake vitals including blood pressure.
C. Perform a neurological screening on the patient.
D. Request the physician on-call to assess the patient.
Correct answer:
The correct first action for the nurse to take in this situation is to retake the patient's vitals, including blood pressure. Dizziness can be a sign of hypotension, which may be a contraindication for administering Morphine. Checking the chest x-ray results (Choice A) would not be the priority in this case as addressing the dizziness is more urgent. Performing a neurological screening (Choice C) may be important but not the first step when a patient presents with dizziness and an order for Morphine. Requesting the physician to assess the patient (Choice D) should come after the initial assessment and vitals retake.
A 2-year-old child diagnosed with HIV comes to a clinic for immunizations. Which of the following vaccines should the healthcare provider expect to administer in addition to the scheduled vaccines?
A. pneumococcal vaccine
B. hepatitis A vaccine
C. Lyme disease vaccine
D. typhoid vaccine
Correct answer:
The correct answer is the pneumococcal vaccine. Children with HIV are at increased risk of pneumococcal infections, so the pneumococcal vaccine is recommended as a supplemental vaccine for them. The hepatitis A vaccine is not routinely given to HIV-positive children unless they have other risk factors for hepatitis A. Lyme disease vaccine is for individuals at risk for Lyme disease, not routinely recommended for a 2-year-old. Typhoid vaccine is typically given to individuals traveling to endemic areas or working in settings with potential exposure to Salmonella typhi, not a routine vaccine for a 2-year-old with HIV.
How is the information documented on incident reports used?
A. to analyze risk categories
B. to ensure compliance with regulations
C. to identify staff's educational needs
D. all of the above
Correct answer:
The information documented on incident reports is used for various purposes, including analyzing risk categories, ensuring compliance with regulations, and identifying staff's educational needs. Incident reports provide valuable data that can be utilized in risk management, quality monitoring, and improvement programs. Therefore, the correct answer is 'all of the above.' Choices A, B, and C are all correct as incident reports are used for analyzing risk categories, ensuring compliance with regulations, and identifying staff's educational needs, respectively. Thus, the most comprehensive answer is 'all of the above.'
Metformin (Glucophage) is administered to clients with type II diabetes mellitus. Metformin is an example of:
A. an antihyperglycemic agent.
B. a hypoglycemic agent.
C. an insulin analogue.
D. a pancreatic alpha cell stimulant
Correct answer:
Metformin is classified as an antihyperglycemic agent because it works by reducing hepatic glucose output and decreasing glucose absorption from the gut, thereby preventing hyperglycemia. Choice B, a hypoglycemic agent, is incorrect as hypoglycemic agents stimulate insulin production, which is not the mechanism of action of metformin. Choice C, an insulin analogue, is incorrect as metformin is not a type of insulin but a distinct medication. Choice D, a pancreatic alpha cell stimulant, is incorrect as metformin does not stimulate any pancreatic cells, but rather acts on the liver and gut to lower blood sugar levels.
The nurse is caring for a client with full-thickness burns to the left arm and trunk. What is the priority for this client?
A. Pain management
B. Airway assessment
C. Fluid volume status monitoring
D. Risk for infection prevention
Correct answer:
Correct! With full-thickness burns, there is a significant risk of fluid loss through the burn wound and fluid shift, leading to hypovolemia and shock. Monitoring and maintaining the client's fluid volume status is crucial to prevent complications like hypovolemic shock. Pain management (Option A) is essential but not the priority in this situation. While airway assessment (Option B) is crucial, it is typically assessed first in clients with respiratory distress. Preventing infection (Option D) is important but managing fluid volume status takes precedence in the initial care of a client with full-thickness burns.
The nurse belongs to a professional nursing organization that provides social, educational, and political venues for nurses. The nurse has been active in this organization for almost two years, during which time she meets and works with nurses from several different nursing agencies and health care institutions to achieve a variety of goals, including obtaining advice regarding a personal career choice. This is an example of:
A. professional nurturing.
B. networking.
C. mentoring.
D. collegiality.
Correct answer:
Networking involves the process of developing and using contacts throughout one's professional career for information, advice, and support. In this scenario, the nurse is actively engaging with other professionals from various institutions to achieve common goals and seek career advice, which aligns with the concept of networking. Professional nurturing and mentoring focus on providing support and guidance to colleagues, while collegiality refers to the camaraderie and rapport established among individuals through shared experiences, which is not the primary focus of the nurse's interaction in the given situation.
A nurse is assigned to care for four clients. Which client should the nurse assess first?
A. A client scheduled for a colonoscopy
B. A client with a tracheostomy who is receiving humidified oxygen via a tracheostomy mask
C. A client preparing for discharge after surgery
D. A client requiring a tube feeding through a gastrostomy tube
Correct answer:
The correct answer is a client with a tracheostomy who is receiving humidified oxygen via a tracheostomy mask. Airway management is always the priority in nursing care. Assessing this client first ensures that their airway is clear and oxygenation is adequate. Clients with compromised airways need immediate attention to prevent respiratory distress or failure. The other clients do not have immediate airway concerns and represent lower priorities in this scenario. Therefore, the nurse should prioritize assessing the client with the tracheostomy and oxygen therapy to maintain airway patency and adequate oxygenation.
A nurse is conducting a psychosocial assessment of a young adult. Which observations would lead the nurse to determine that the client is demonstrating a sign of emotional health?
A. The young adult is sensitive to criticism.
B. The young adult verbalizes unrealistic fears.
C. The young adult verbalizes disappointment with life.
D. The young adult verbalizes satisfaction with friendships.
Correct answer:
The correct answer is that the young adult verbalizes satisfaction with friendships. Emotional health in young adults is characterized by various positive signs, including satisfaction with social interactions and friendships. Expressing contentment with friendships indicates a healthy emotional state, fostering positive social connections. On the other hand, sensitivity to criticism, verbalizing unrealistic fears, and expressing disappointment with life are all indicative of emotional distress and potential mental health challenges. These behaviors can hinder social relationships and overall emotional well-being.
The nurse is caring for a client recovering from a stroke who recently regained consciousness. The client is having difficulty communicating verbally with the team. Which of the following actions would be least appropriate?
A. Begin client data collection before receiving the physician's order for the referral.
B. Use documents to provide information for the referral.
C. Wait for the physician's order for speech therapy before assisting with the appropriate documentation.
D. Participate in the client referral process.
Correct answer:
In this scenario, the least appropriate action would be to wait for the physician's order for speech therapy before assisting with the appropriate documentation. The nurse should start by collecting client data without needing the physician's order, use documents to provide information for the referral, and actively participate in the client referral process. Waiting for the physician's order unnecessarily delays potentially crucial therapy for the client's recovery, affecting the timeliness and effectiveness of care. Therefore, choice C is the least appropriate as immediate action is required in such situations.
NCLEX-PN clinical judgment practice questions, set 38 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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