NCLEX-PN clinical judgment practice questions, set 4
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 4
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 of the following infant behaviors demonstrates the concept of object permanence?
A. The infant cries when his mother leaves the room.
B. The infant looks at the floor to find a toy that he was playing with and dropped.
C. The infant picks up another toy after the one he was playing with rolls under the couch.
D. The infant participates in a game of patty-cake.
Show answer and rationale
Correct answer: B — The infant looks at the floor to find a toy that he was playing with and dropped.
Object permanence occurs when the infant learns that something or someone still exists even though they might not be able to see it or them. This typically develops between 9 and 10 months of age. The correct answer, 'The infant looks at the floor to find a toy that he was playing with and dropped,' demonstrates object permanence as the infant understands that the toy still exists even though it is temporarily out of sight. Choices A and C do not directly relate to object permanence as the behaviors described do not necessarily indicate an understanding of objects existing when out of sight. Choice D is incorrect as participating in a game of patty-cake does not involve demonstrating object permanence. Peek-a-boo is a more suitable example of a game that demonstrates object permanence, as the infant continues to look for the hidden face, understanding that it still exists even though temporarily unseen.
Question 2
An elderly client denies that abuse is occurring. Which of the following factors could be a barrier for the client to admit being a victim?
A. knowledge that elder abuse is rare
B. personal belief that abuse is deserved
C. lack of developmentally appropriate screening tools
D. fear of reprisal or further violence if the incident is reported
Show answer and rationale
Correct answer: D — fear of reprisal or further violence if the incident is reported
Barriers to reporting elder abuse include victim shame, fear of reprisals, fear of loss of caregiver, and lack of knowledge of agencies that provide services. Many elders fear that reporting abuse results in their placement in long-term care because the current caregiver is the abuser. Choice A is incorrect because knowledge of the frequency of elder abuse is not a significant factor in a victim's reluctance to report. Choice B is also incorrect; while some victims may have feelings of undeservedness, it is not a common primary barrier to reporting abuse. Choice C is incorrect as the lack of appropriate screening tools may hinder identification but is not a significant barrier for the client to admit being a victim. Therefore, the correct answer is D, as the fear of reprisal or further violence if the incident is reported is a common and significant barrier for elderly clients to admit being a victim.
Question 3
Which action by the nurse represents the ethical principle of benevolence?
A. The nurse administers an immunization to a child even though it may cause discomfort
B. The nurse follows a plan of care designed to relieve pain in a client with cancer
C. The nurse provides equal amounts of care to all assigned clients on the basis of illness acuity
D. The nurse upholds a client's decision to refuse chemotherapy for lung cancer
Show answer and rationale
Correct answer: A — The nurse administers an immunization to a child even though it may cause discomfort
Benevolence is taking action to help others. In this scenario, administering an immunization to a child, even though it may cause discomfort, aligns with the principle of benevolence as the benefits of protection from disease outweigh the temporary discomfort. Fidelity refers to keeping promises made to clients, families, and other healthcare professionals. Autonomy is a person's independence, and respecting autonomy means agreeing to respect an individual's right to determine their course of action. Justice refers to fairness and equity, including the fair allocation of resources, such as nursing care for all clients. Choice B is incorrect as it pertains more to the ethical principle of beneficence rather than benevolence, which focuses on doing good for others without an expectation of something in return. Choices C and D are incorrect as they do not directly align with the principle of benevolence.
Question 4
A client scheduled for surgery tells the nurse that he signed an informed consent for the surgical procedure but was never told about the risks of the surgery. The nurse serves as the client's advocate by undertaking which action?
A. Reassuring the client that the risks are minimal
B. Noting in the client's record that the client was not told about the risks of the surgery
C. Writing a note on the front of the client's record so that the surgeon will see it when the client arrives in the operating room
D. Informing the surgeon verbally about the lack of information provided to the client
Show answer and rationale
Correct answer: B — Noting in the client's record that the client was not told about the risks of the surgery
A nurse serves as a client advocate by protecting the client's right to be informed and to participate in decisions regarding care. In this scenario, the nurse should document in the client's record that the client was not informed about the risks of the surgery. This action ensures that the issue is officially noted and can be addressed by the healthcare team. Reassuring the client that the risks are minimal is incorrect because it dismisses the client's concerns and does not address the lack of information provided. Writing a note on the client's chart to inform the surgeon is not as effective as ensuring that the issue is officially documented in the client's record, where it can be reviewed and addressed by the healthcare team. Informing the surgeon verbally is not as reliable as documenting the concern in the client's record, which provides a formal and lasting record for review and follow-up.
Question 5
Which action by a graduate nurse would require the charge nurse to intervene?
A. Walking in the hallway outside the operating room without a hair covering
B. Putting on a surgical mask, gown, and cap before entering the operating room
C. Wearing a surgical mask into the holding area
D. Wearing scrubs from home into the nursing station
Show answer and rationale
Correct answer: A — Walking in the hallway outside the operating room without a hair covering
The correct answer is walking in the hallway outside the operating room without a hair covering. In healthcare settings, it is crucial to adhere to infection control measures, which include wearing appropriate attire to prevent the spread of pathogens. Walking in the hallway outside the operating room without a hair covering violates these infection control protocols, necessitating immediate intervention by the charge nurse. Choices B and C are incorrect because putting on surgical attire before entering the operating room and wearing a surgical mask into the holding area are both standard practices that promote patient safety and infection control. Choice D is also incorrect as wearing scrubs from home into the nursing station, while not ideal, is not a violation that warrants immediate intervention compared to breaching infection control protocols near sensitive areas like the operating room.
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Question 6
A female client complains to the nurse at the health department that she has fatigue, shortness of breath, and lightheadedness. Her history reveals no significant medical problems. She states that she is always on a fad diet without any vitamin supplements. Which tests should the nurse expect the client to have first?
A. peptic ulcer studies
B. complete blood count, including hematocrit and hemoglobin
C. genetic testing
D. hemoglobin electrophoresis
Correct answer:
The correct answer is to perform a complete blood count, including hematocrit and hemoglobin, as the initial tests to assess the client's symptoms related to fatigue, shortness of breath, and lightheadedness. These symptoms can be indicative of anemia, which can be caused by nutritional deficiencies due to fad dieting without vitamin supplements. Peptic ulcer studies, genetic testing, and hemoglobin electrophoresis are not the most appropriate initial tests for the client's presenting symptoms and history. Peptic ulcer studies are not relevant to the client's symptoms. Genetic testing is not indicated based on the client's presentation and history. Hemoglobin electrophoresis is used to diagnose specific types of anemia and is not the first-line test in this scenario. Further testing decisions should be based on the results of the initial tests, the client's history, and other relevant factors.
Which of the following needs immediate medical attention and emergency intervention? The client who:
A. complains of sharp pain upon taking a deep breath and excessive coughing.
B. exhibits yellow, productive sputum, low-grade fever, and crackles.
C. has a shift of the trachea to the left, with no breath sounds on the right.
D. has asthma and complains of an inability to catch her breath after exercise.
Correct answer:
Choice C is indicative of a tension pneumothorax, which is considered a medical emergency. The respiratory system is severely compromised, and venous return to the heart is affected. The mediastinal shift is to the unaffected side, indicating a critical situation that requires immediate intervention to prevent further deterioration. This condition can rapidly progress to a life-threatening state, necessitating prompt medical attention. Choices A, B, and D do not present with life-threatening conditions requiring emergency intervention. Choice A mentions symptoms of pleurisy, which may be painful but not immediately life-threatening. Choice B describes symptoms of bronchitis, which may require medical attention but not of an emergent nature. Choice D reflects a common complaint in asthma but does not suggest an immediate life-threatening situation unless severe respiratory distress is present.
Which of the following injuries, presented by a client entering the Emergency Department, is the highest priority?
A. open leg fracture
B. open head injury
C. stab wound to the chest
D. traumatic amputation of a thumb
Correct answer:
A stab wound to the chest is the highest priority injury. This type of injury can lead to lung collapse and mediastinal shift, potentially resulting in death if left untreated. Treating an obstructed airway or a chest wound takes precedence over addressing hemorrhage. The principle of ABC (airway, breathing, and circulation) guides care decisions in prioritizing life-threatening situations. An open leg fracture, open head injury, and traumatic amputation of a thumb, while serious, do not pose an immediate threat to life compared to a stab wound to the chest. An open leg fracture may lead to significant blood loss but is not immediately life-threatening. An open head injury requires assessment and intervention but does not impact airway, breathing, or circulation directly. Traumatic amputation of a thumb is a serious injury but can be managed after addressing more life-threatening conditions.
Which of these clients should the LPN/LVN see first?
A. a client with a newly placed NG tube who is complaining of pain around the face and a plugged nose
B. a post-op prostatectomy client who complains of bladder spasms and blood in his foley bag
C. a client in an arm cast who is 2 days post-op and reports feelings of numbness and tingling in her affected arm
D. a client newly diagnosed with Hepatitis A who reports stomach pain and itchy skin
Correct answer:
Numbness and tingling hours or days after a cast is applied may indicate compartment syndrome and should be reported to a medical provider right away. This is a potential emergency situation that requires immediate attention to prevent complications. The other options present expected or typical symptoms related to their diagnosis, which do not require immediate intervention. Complaints related to a newly placed NG tube such as pain around the face and a plugged nose may require assessment and intervention but are not as urgent as potential compartment syndrome. Bladder spasms and blood in the foley bag post-prostatectomy are common postoperative issues that can be addressed after the client in the arm cast with potential compartment syndrome is seen. Stomach pain and itchy skin in a client with Hepatitis A are common symptoms of the condition and do not indicate an emergency situation.
The nurse is caring for a client receiving warfarin therapy (Coumadin®) following a stroke. The client's PT/INR was completed at 7:00 A.M. prior to the morning meal with an INR reading of 4.0. Which of the following is the nurse's first priority?
A. Call the physician to request an increase in the Coumadin® dose.
B. Administer a vitamin K injection IM and notify the physician of the results.
C. Assess the client for bleeding around the gums or in the stool and notify the physician of the lab results and latest dose of Coumadin®.
D. Notify the next shift to hold the daily dose of Coumadin® scheduled for 5:00 P.M.
Correct answer:
In a client receiving warfarin therapy with a high INR of 4.0, the nurse's first priority is to administer a vitamin K injection intramuscularly (IM) and notify the physician of the results. An INR of 4.0 indicates excessive anticoagulation, putting the client at risk of bleeding. Vitamin K is the antidote for warfarin overdose and helps to reverse its effects. It is crucial to administer vitamin K promptly to prevent bleeding complications. Calling the physician to request an increase in the Coumadin® dose is inappropriate and dangerous in this situation, as it would further raise the INR. Assessing the client for bleeding and notifying the physician is important but not the first priority when faced with a critically high INR. Holding the daily dose of Coumadin® may be necessary after administering vitamin K, but it is not the primary action needed to address the acute high INR level.
A 46-year-old has returned from a heart catheterization and wants to get up to start walking 3 hours after the procedure. The nurse should:
A. Tell the patient to remain with the leg straight for at least another hour and check the chart for activity orders.
B. Allow the patient to begin limited ambulation with assistance.
C. Recommend a physical therapy consultation for ambulation.
D. Tell the patient to remain with the leg straight for another 6 hours and check the chart for activity orders.
Correct answer:
The correct answer is to tell the patient to remain with the leg straight for at least another hour after a heart catheterization before starting ambulation. This period allows for proper healing and reduces the risk of complications such as bleeding or hematoma formation at the catheter insertion site. Starting ambulation too soon can disrupt the healing process and lead to adverse events. Choice B is incorrect because limited ambulation should not be initiated shortly after the procedure as it may increase the risk of complications. Choice C is incorrect as physical therapy consultation is not typically necessary for initial ambulation post-heart catheterization; this can be managed by nursing staff. Choice D is incorrect as keeping the leg straight for 6 hours is excessive and unnecessary, potentially leading to complications such as deep vein thrombosis due to prolonged immobility.
The teaching plan for gay or lesbian parents who want to disclose their homosexuality to their children should include all of the following instructions except:
A. disclose the information before the child knows or suspects.
B. be comfortable with your sexual preference first.
C. have the discussion in a quiet place where interruptions are unlikely.
D. explain how your relationship with the child changes because of the discussion
Correct answer:
The correct answer is to explain how your relationship with the child changes because of the discussion. Children of gay and lesbian parents should be reassured that their relationship with their parent will not change due to the disclosure. Choices A, B, and C are all important aspects of the disclosure process. It is crucial to disclose the information before the child knows or suspects, be comfortable with your sexual preference first, and have the discussion in a quiet place to ensure a safe and open environment for communication. Explaining how the relationship with the child changes might create unnecessary anxiety or confusion. Children may have different reactions based on their age, understanding, and environment. Therefore, it is essential to maintain a sense of stability and security in the parent-child relationship while addressing any questions or concerns that may arise.
A 32-year-old female frequently comes to her primary care provider with vague complaints of headache, abdominal pain, and trouble sleeping. In the past, the physician has dutifully prescribed medication, but little else. Which of the following comments by the nurse to the physician is appropriate?
A. "Often women who are victims of domestic violence suffer vague symptoms such as abdominal pain."?
B. "Often women become offended if asked about their safety in relationships."?
C. "It is mandatory that all women be questioned about domestic violence."?
D. "How would you feel to know that her partner is beating her and you didn't ask?"?
Correct answer:
The correct answer is, "Often women who are victims of domestic violence suffer vague symptoms such as abdominal pain."? There is a well-documented correlation between vague symptoms like abdominal pain and battered woman syndrome. It is crucial for healthcare providers to inquire about potential domestic violence when presented with such symptoms. Choice B is incorrect as studies show that women are not generally offended by appropriately phrased questions about their safety in relationships. While it is not mandatory to question all women about domestic violence, it is advisable to at least ask a screening question regarding safety. Choice D is inappropriate as it uses a shaming tactic, which is not constructive and may create a hostile work environment. It's important for healthcare professionals to approach sensitive topics like domestic violence with empathy and professionalism.
A nurse monitoring a client with a chest tube notes that there is no tidaling of fluid in the water seal chamber. After further assessment, the nurse suspects that the client's lung has reexpanded and notifies the healthcare provider. The healthcare provider verifies with the use of a chest x-ray that the lung has reexpanded, then calls the nurse to ask that the chest tube be removed. Which action should the nurse take first?
A. Explain the procedure to the client, then remove the chest tube.
B. Call the nursing supervisor.
C. Inform the healthcare provider that removal of a chest tube is not a nursing procedure.
D. Obtain petrolatum-impregnated gauze and ask another nurse to assist in removing the chest tube.
Correct answer:
The correct action for the nurse to take first is to inform the healthcare provider that removal of a chest tube is not a nursing procedure. Actual removal of a chest tube is the duty of a healthcare provider. If the healthcare provider insists that the nurse remove the tube, the nurse must contact the nursing supervisor. Some agencies' policies and procedures may permit an advanced practice nurse to remove a chest tube, but there is no information in the question to indicate that the nurse is an advanced practice nurse. Choice A is incorrect because the nurse should not proceed with removing the chest tube without proper authorization. Choice B is incorrect as calling the nursing supervisor should come after clarifying with the healthcare provider. Choice D is incorrect as the nurse should not begin the process of removing the chest tube without proper guidance and authorization.
A nurse working the 7 a.m. to 3 p.m. shift is reviewing the records of the assigned clients. Which client should the nurse assess first?
A. A client scheduled for hemodialysis at 10 a.m.
B. A client scheduled for contrast computed tomography (CT) at noon.
C. A client scheduled for a nuclear scanning procedure at 10 a.m.
D. A client scheduled for hydrotherapy for the treatment of a burn injury at 10:30 a.m.
Correct answer:
The correct answer is the client scheduled for hemodialysis at 10 a.m. This client needs immediate assessment before the procedure, which may take up to 5 hours. The nurse should ensure the client is physically and emotionally prepared, check for fluid overload by assessing weight and lung sounds, review vital signs, and laboratory test results. The other clients described in the options have needs that are not as urgent. The client scheduled for a nuclear scanning procedure at 10 a.m. may require information reinforcement and increased fluid intake before the procedure. The client scheduled for hydrotherapy for the treatment of a burn injury at 10:30 a.m. may need pain medication administered 30 minutes prior to the therapy. The client scheduled for a contrast CT at noon may need procedure information reinforcement and a special contrast preparation just before the procedure.
NCLEX-PN clinical judgment practice questions, set 4 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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