NCLEX-PN clinical judgment practice questions, set 39
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 39
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
The nurse is assigning staff for the day. Which assignment should be given to the nursing assistant?
A. Taking the vital signs of the 5-month-old with bronchiolitis
B. Taking the vital signs of the 10-year-old with a 2-day postappendectomy
C. Administering medication to the 2-year-old with periorbital cellulitis
D. Adjusting the traction of the 1-year-old with a fractured tibia
Show answer and rationale
Correct answer: B — Taking the vital signs of the 10-year-old with a 2-day postappendectomy
The most appropriate assignment for a nursing assistant is to take the vital signs of a stable patient. A 10-year-old with a 2-day postappendectomy is considered stable, and routine vital signs monitoring can be safely delegated to a nursing assistant. Clients with bronchiolitis, periorbital cellulitis, and a fractured tibia require more specialized care and assessment by a licensed nurse. Bronchiolitis involves an airway alteration, periorbital cellulitis indicates an infection, and a fractured tibia may raise concerns of abuse. Therefore, options A, C, and D are incorrect for delegation to a nursing assistant.
Question 2
The nurse is caring for a 44-year-old client diagnosed with hypoparathyroidism. Which electrolyte imbalance is closely associated with hypoparathyroidism?
A. Hypocalcemia.
B. Hyponatremia.
C. Hyperkalemia.
D. Hypophosphatemia.
Show answer and rationale
Correct answer: A — Hypocalcemia.
The correct answer is Hypocalcemia. In hypoparathyroidism, where the parathyroid glands are not producing sufficient parathyroid hormone, calcium levels become inadequate. This leads to hypocalcemia, characterized by symptoms such as muscle spasms, anxiety, seizures, hypotension, and congestive heart failure. Hyponatremia and hyperkalemia are not typically associated with hypoparathyroidism. While hyperphosphatemia can be seen in hypoparathyroidism due to decreasing calcium levels, the question specifically asks about the primary electrolyte imbalance closely related to hypoparathyroidism, which is hypocalcemia.
Question 3
The client is diagnosed with multiple myeloma. The doctor has ordered cyclophosphamide (Cytoxan). Which instruction should be given to the client?
A. "Walk about a mile a day to prevent calcium loss."?
B. "Increase the fiber in your diet."?
C. "Report nausea to the doctor immediately."?
D. "Drink at least eight large glasses of water a day."?
Show answer and rationale
Correct answer: D — "Drink at least eight large glasses of water a day."?
Cyclophosphamide (Cytoxan) can cause hemorrhagic cystitis, a condition characterized by inflammation of the bladder wall leading to bleeding. To prevent this complication, the client should drink at least eight glasses of water a day. Walking to prevent calcium loss (choice A) and increasing fiber intake (choice B) are not directly related to the side effects of Cytoxan, making them unnecessary instructions in this case. While nausea is a common side effect of chemotherapy, the immediate reporting of nausea to the doctor (choice C) is important but not specifically related to the use of Cytoxan in this scenario.
Question 4
While assessing a patient who has undergone a recent CABG, the nurse notices a mole with irregular edges and a bluish color. What should the nurse do next?
A. Recommend a dermatological consult to the physician.
B. Note the location of the mole and contact the physician via telephone.
C. Note the location of the mole and follow-up with the attending physician through the medical record and a phone call.
D. Remove the mole with a sharp debridement technique, following approval from the charge nurse.
Show answer and rationale
Correct answer: C — Note the location of the mole and follow-up with the attending physician through the medical record and a phone call.
In this scenario, the nurse should note the location of the mole and follow up with the attending physician through the medical record and a phone call. This action is appropriate because a mole with irregular edges and a bluish color raises concern for melanoma, a type of skin cancer. Recommending a dermatological consult (Choice A) might delay the evaluation and management of the mole. Contacting the physician via telephone (Choice B) may not provide a documented record of the observation. Removing the mole without proper evaluation (Choice D) could be dangerous and is not within the nurse's scope of practice.
Question 5
Incidences of child abuse appear to be higher in the African-American community and might be explained by:
A. the increased number of single-parent households in African-American communities
B. more single-parent households in African-American communities
C. stricter child-rearing practices in African-American households
D. a higher occurrence of rage in African Americans
Show answer and rationale
Correct answer: B — more single-parent households in African-American communities
Child abuse is often associated with lower socioeconomic status and single-parent households due to increased stress and fewer support systems. Choice A is correct as single-parent households can face more challenges leading to a higher risk of child abuse. Choice B is the correct answer as it aligns with the risk factors associated with child abuse. Choice C is incorrect because there is no direct correlation between stricter child-rearing practices and child abuse rates. Choice D is incorrect because attributing child abuse to a higher occurrence of rage in African Americans is a stereotype and lacks evidence.
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Question 6
In a centralized decision-making process within an organization, where is the authority to make decisions vested?
A. Every employee
B. A few individuals, such as the board of directors
C. Many individuals, with decisions filtering down to the individual employee
D. All nursing employees, pharmacists, and hospital health care providers
Correct answer:
In a centralized decision-making process within an organization, the authority to make decisions is concentrated in a few individuals, such as the board of directors. This means that key decision-making power is held by a select group at the top of the organizational hierarchy. Choices A, C, and D are incorrect because in a centralized structure, decision-making authority is not distributed among every employee, does not filter down to individual employees, and is not shared among all nursing employees, pharmacists, or hospital health care providers. Centralized decision-making implies a more top-down approach.
If a client is suffering from thyroid storm, the PN can expect to find on assessment:
A. tachycardia and hyperthermia.
B. bradycardia and hypothermia.
C. a large goiter.
D. a calm, quiet client
Correct answer:
In thyroid storm, there is an excess of thyroxine, leading to symptoms such as tachycardia (rapid heart rate) and hyperthermia (increased body temperature). Atrial fibrillation and palpitations are also commonly observed. Choices B and C are more indicative of hypothyroidism, where the thyroid is underactive, leading to bradycardia (slow heart rate), hypothermia (decreased body temperature), and the development of a large goiter. Choice D, a calm, quiet client, is unlikely in a thyroid storm where the individual would typically present with symptoms of agitation and restlessness due to the hypermetabolic state.
An LPN is talking with a client scheduled to undergo a vasectomy in the next few minutes. He states, "I know I signed the form and all, but I'm not feeling so sure of this. It can be reversed pretty easily, right?"? What is the LPN's best response?
A. "Yes, vasectomies can be reversed, but once you have it, you may regret it later."?
B. "It's normal to feel a little nervous before a procedure like this."?
C. "It sounds like you have a few more questions you'd like answered. Let me grab the doctor quickly so he can answer them for you."?
D. "It sounds like you might be a little nervous. Don't worry, this is a pretty minor procedure, and the doctor doing it is the best we have. You're in great hands."?
Correct answer:
The best response for the LPN is to acknowledge the client's concerns and offer to provide more information. By offering to get the doctor to answer any additional questions, the LPN shows respect for the client's right to informed consent. Option A provides some information but dismisses the client's uncertainty and implies they won't regret the decision, which may not be the case. Option B acknowledges nervousness but doesn't directly address the client's request for more information. Option D attempts to reassure the client but fails to address the need for additional questions to be answered by the doctor.
A client had a Caesarean delivery and is postpartum day 1. She asks for pain medication when the nurse enters the room to do her shift assessment. The client states that her pain level is an 8 on a scale of 1 to 10. What should be the nurse's priority of care?
A. Give the pain medication and return in an hour for further assessment to allow time for the medication to work.
B. Complete the postpartum assessment and then give the client pain medication.
C. Give the pain medication first, do a quick assessment while administering the medication to ensure the pain is not caused by a complication, and return for the full assessment after the client's pain has subsided.
D. Instruct the patient to do relaxation exercises to relieve her discomfort.
Correct answer:
Pain management is a priority, so the nurse should immediately provide pain medication. However, the nurse should conduct a quick assessment while administering the medication to ensure that a complication, such as hemorrhage, hasn't caused the increased pain. A complete assessment can wait until the pain subsides. Controlling pain will enable the client to move, eliminating other potential complications of delivery and facilitating bonding with the infant. Relaxation techniques can act as an adjunct therapy but by themselves are not usually effective for pain management during the early post-Caesarean period.
When testing the function of the oculomotor, trochlear, and abducens nerves, which parameter does a nurse check to determine their function?
A. Tongue symmetry
B. Eye movements
C. Facial symmetry
D. Corneal reflex
Correct answer:
The correct answer is B: Eye movements. When assessing the oculomotor, trochlear, and abducens nerves, evaluating eye movements is crucial. This assessment includes checking the pupils for size, regularity, equality, light reactions, accommodation, and extraocular movements in various gaze positions. Tongue symmetry is primarily used to evaluate cranial nerve XII (hypoglossal nerve) function. Facial symmetry is a key indicator of cranial nerve VII (facial nerve) function. The corneal reflex assesses sensory afferents in cranial nerve V (trigeminal nerve) and motor efferents in cranial nerve VII (facial nerve).
A client is complaining of difficulty walking secondary to a mass in the foot. The nurse should document this finding as:
A. Plantar fasciitis.
B. Hallux valgus.
C. Hammertoe.
D. Morton's neuroma.
Correct answer:
The correct answer is Morton's neuroma. Morton's neuroma is a small mass or tumor in a digital nerve of the foot, causing pain and difficulty walking. Hallux valgus is commonly known as a bunion, involving a bony bump at the base of the big toe. Hammertoe is a condition where one toe is bent abnormally at the middle joint, resembling a hammer. Plantar fasciitis is characterized by pain and inflammation in the arch of the foot, not by a mass causing difficulty walking. Therefore, options A, B, and C are incorrect as they do not describe a mass in the foot leading to difficulty walking, unlike Morton's neuroma.
An adolescent female reports being raped at a party where alcohol was served. The client admits to drinking alcohol before being raped by an acquaintance. The nurse should:
A. inform the client that because she is underage, she is not at fault for attending a party where alcohol was served.
B. ask the client if anyone witnessed the event because the client was intoxicated and might not remember it accurately.
C. inform the client that it was not her fault, and support the client through the physical examination.
D. question whether the woman had consensual sex and now just feels guilty.
Correct answer:
In cases of rape, it is crucial to provide support and reassurance to the victim. The nurse should inform the client that it was not her fault and offer support through the physical examination. Blaming the victim, as in choice A, is inappropriate and can be damaging to the client's well-being. Choice B is not the priority at this moment; the immediate focus should be on supporting the client. Choice D is victim-blaming and implies doubt about the client's report, which is harmful and not supportive. It is essential to create a safe and supportive environment for the client to facilitate healing and recovery.
A nurse is assessing an 18-year-old female who has recently suffered a TBI. The nurse notes a slower pulse and impaired respiration. The nurse should report these findings immediately to the physician due to the possibility the patient is experiencing which of the following conditions?
A. Increased intracranial pressure
B. Increased function of cranial nerve X
C. Sympathetic response to activity
D. Meningitis
Correct answer:
The nurse should report the slower pulse and impaired respiration to the physician immediately as they are indicative of increased intracranial pressure (ICP) following a traumatic brain injury (TBI). These signs suggest that there may be a rise in pressure within the skull, which can be a life-threatening condition requiring urgent intervention. Options B and C are unlikely in this scenario as they do not correlate with the symptoms presented. Meningitis (Option D) typically presents with different signs and symptoms, such as fever, headache, and neck stiffness, which are not described in the patient's case.
A client states, "I eat a well-balanced diet. I do not smoke. I exercise regularly, and I have a yearly checkup with my physician. What else can I do to help prevent cancer?"? The nurse should respond with which of the following statements?
A. Sleep at least 6-8 hours per night.
B. Practice monthly self-breast examinations.
C. Reduce stress.
D. All of the above.
Correct answer:
All of the choices are methods of preventing cancer. Sleep is important in maintaining homeostasis, which helps the body respond to disease. Monthly breast examination can indicate cancer or fibrocystic disease. Stress can have a physiological response in the body that decreases the immune response and increases the risk of disease. Therefore, all the options provided are important in cancer prevention, making 'All of the above' the correct answer. Option A is crucial for overall health and immune function, option B aids in early detection, and option C is vital as chronic stress can weaken the immune system.
A nurse has been ordered to set up Buck's traction on a patient's lower extremity due to a femur fracture. Which of the following applies to Buck's traction?
A. A weight greater than 10 lbs. should be used.
B. The line of pull is upward at an angle.
C. The line of pull is straight
D. A weight greater than 20 lbs. should be used.
Correct answer:
The correct answer is that the line of pull is straight for Buck's traction. This type of traction is applied to maintain alignment and immobilization of fractures, typically involving the lower extremities. A straight line of pull helps to provide the necessary countertraction to keep the fractured bone in proper alignment. Choices A and D are incorrect because Buck's traction commonly uses a weight range between 5-10 lbs, and using a weight greater than 10 or 20 lbs would not be appropriate or safe. Choice B is incorrect as well since the line of pull for Buck's traction is straight, not upward at an angle.
NCLEX-PN clinical judgment practice questions, set 39 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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