NCLEX-PN clinical judgment practice questions, set 43
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 43
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 causes an older female client's hair to turn gray?
A. ''A loss of melanin occurs in the normal aging process.''
B. ''The number of sweat glands and blood vessels decreases in the normal aging process.''
C. ''The skin on the scalp becomes thin, causing moisture to escape.''
D. ''It is caused by hereditary factors.''
Show answer and rationale
Correct answer: A — ''A loss of melanin occurs in the normal aging process.''
The correct answer is 'A loss of melanin occurs in the normal aging process.' Graying hair in older adults is primarily due to a decrease in the number of melanocytes responsible for providing pigment and hair color. This reduction in melanin production leads to gray hair. The other choices are incorrect. While it is true that the skin becomes thinner with aging and the number of sweat glands and blood vessels decreases, these changes are not directly related to graying hair. Additionally, hereditary factors can influence when graying starts, but they do not cause the graying of hair itself.
Question 2
If the client is receiving peritoneal dialysis and the dialysate returns cloudy, what should the nurse do?
A. Document the finding
B. Send a specimen to the lab
C. Strain the dialysate
D. Obtain a complete blood count
Show answer and rationale
Correct answer: B — Send a specimen to the lab
When the dialysate returns cloudy, it could indicate the presence of infection, and sending a specimen to the lab for evaluation is crucial to determine the cause. Documenting the finding alone, as in choice A, may not provide enough information for proper intervention. Straining the dialysate, as in choice C, is not a standard practice and may not help identify the underlying issue. Obtaining a complete blood count, as in choice D, is not directly related to addressing cloudiness in the dialysate. However, the healthcare provider might order a white blood cell count to assess for infection.
Question 3
The client with a history of advanced chronic obstructive pulmonary disease (COPD) had conventional gallbladder surgery 2 days previously. Which intervention has priority for preventing respiratory complications?
A. Incentive spirometry every 1 to 2 hours.
B. Coughing and deep breathing every 1 to 2 hours.
C. Getting the client out of bed 4 times daily as ordered by the physician.
D. Giving oxygen at 4 L/minute according to the physician's order.
Show answer and rationale
Correct answer: C — Getting the client out of bed 4 times daily as ordered by the physician.
The priority intervention for preventing respiratory complications in a client with advanced COPD who underwent gallbladder surgery is to get the client out of bed 4 times daily. This helps prevent pooling of secretions in the lungs and promotes better lung expansion. Incentive spirometry, coughing, and deep breathing are essential interventions; however, they should be performed more frequently, ideally every 1 to 2 hours, rather than every 4 hours or 4 times daily. Giving oxygen at 4 L/minute could potentially decrease the client's respiratory drive, which is not the priority in this case.
Question 4
The client is taking prednisone 7.5mg po each morning to treat his systemic lupus erythematosus. Which statement best explains the reason for taking the prednisone in the morning?
A. There is less chance of forgetting the medication if taken in the morning.
B. There will be less fluid retention if taken in the morning.
C. Prednisone is absorbed best with the breakfast meal.
D. Morning administration mimics the body's natural secretion of corticosteroid.
Show answer and rationale
Correct answer: D — Morning administration mimics the body's natural secretion of corticosteroid.
Taking corticosteroids in the morning mimics the body's natural release of cortisol, which follows a diurnal pattern with higher levels in the morning. This timing helps regulate the body's inflammatory response and minimizes potential side effects. Answer A is not the primary reason for morning dosing, as adherence concerns can be addressed through other means. Answer B is incorrect since fluid retention is not influenced by the timing of prednisone administration. Answer C is also incorrect as prednisone absorption is not significantly affected by whether it is taken with breakfast or not.
Question 5
A client receiving drug therapy with furosemide and digitalis requires careful observation and care. In planning care for this client, the nurse should recognize that which of the following electrolyte imbalances is most likely to occur?
A. hyperkalemia
B. hypernatremia
C. hypokalemia
D. hypomagnesemia
Show answer and rationale
Correct answer: C — hypokalemia
When a client is receiving drug therapy with furosemide and digitalis, the nurse should anticipate the development of hypokalemia due to the potassium-wasting effects of furosemide. Hypokalemia can potentiate digitalis toxicity. While hyperkalemia is a concern with some medications, it is not typically associated with furosemide and digitalis. Furosemide can lead to hyponatremia, not hypernatremia, due to its diuretic effect. Hypomagnesemia, though a possible imbalance, is not the most likely to occur in this scenario as furosemide and digitalis are more commonly associated with hypokalemia.
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Question 6
Why is the intravenous route potentially the most dangerous route of drug administration?
A. IV infiltration may occur.
B. it allows for rapid administration of a drug.
C. rapid administration of a drug can lead to toxicity
D. it is the most commonly used route in hospitals.
Correct answer:
The correct answer is C: rapid administration of a drug can lead to toxicity. When a drug is administered intravenously, it has 100% bioavailability, entering the bloodstream immediately and increasing the risk of toxicity if not carefully monitored. While IV infiltration (choice A) can cause tissue damage, it is not typically life-threatening. Choice B is incorrect as the speed of administration is not the primary reason for the danger; it is the immediate and full dose reaching the bloodstream. Choice D is incorrect as the popularity of the route does not inherently make it more dangerous.
How often should the nurse change the intravenous tubing on total parenteral nutrition solutions?
A. every 24 hours
B. every 36 hours
C. every 48 hours
D. every 72 hours
Correct answer:
The correct answer is 'every 24 hours.' Changing the intravenous tubing on total parenteral nutrition solutions every 24 hours is crucial due to the high risk of bacterial growth. Bacterial contamination can lead to serious infections in patients receiving total parenteral nutrition. Choices B, C, and D are incorrect because waiting longer intervals between tubing changes increases the risk of bacterial contamination and infection, compromising patient safety. It is essential to maintain a strict 24-hour schedule to minimize the risk of complications associated with bacterial contamination.
While undergoing fetal heart monitoring, a pregnant Native-American woman requests that a medicine woman be present in the examination room. Which of the following is an appropriate response by the nurse?
A. "I will assist you in arranging to have a medicine woman present."?
B. "We do not allow medicine women in exam rooms."?
C. "That does not make any difference in the outcome."?
D. "It is old-fashioned to believe in that."?
Correct answer:
The correct response is to show cultural awareness and acceptance by offering to assist in arranging for the medicine woman to be present. This demonstrates respect for the client's beliefs and preferences. Choice B is inappropriate as it dismisses the client's request without considering its cultural significance. Choice C is dismissive and does not acknowledge the client's values. Choice D is disrespectful and judgmental, undermining the client's beliefs. Therefore, the only appropriate and professional response is to support the client's request and offer assistance in accommodating it.
The nurse observes bilateral bruises on the arms of an elderly client in a long-term care facility. Which of the following questions should the nurse ask this client?
A. "How did you get those bruises?"?
B. "Did someone grab you by your arms?"?
C. "Do you fall often?"?
D. "What did you bump against?"?
Correct answer:
When addressing suspected abuse, it is crucial to ask direct questions to determine the cause of injuries. Choice B is the most appropriate as it directly inquires about the possibility of someone grabbing the client's arms, which could indicate abuse. This question can help uncover potential abuse and provide necessary intervention. Choices A, C, and D are less direct and may not elicit the critical information needed to address abuse effectively. Clients often hesitate to report abuse due to feelings of shame and fear of retaliation, making a direct approach essential in such situations.
When preparing a client for surgery, the graduate nurse realizes the operative permit has not been signed. The client tells the nurse he understands the procedure but received his preoperative medication approximately 10 minutes prior. The appropriate action would be:
A. Have the client sign the permit, as he verbalizes understanding.
B. Witness the form after having the client sign it.
C. Have his wife sign the form as she witnessed him saying he wants the surgery.
D. Call the surgical area and explain the surgery will have to be cancelled.
Correct answer:
The correct action in this scenario is to call the surgical area and explain that the surgery will have to be cancelled. The client must sign the operative permit or any other legal document before receiving preoperative medication. Without the signed permit, the surgery cannot proceed to ensure the client's safety and legal compliance. Having the client sign the permit, witnessing the form after the client signs it, or having someone else sign the form are all inappropriate actions and do not address the legal requirement of the client's signature before receiving preoperative medication.
When administering intravenous electrolyte solution, which of the following precautions should the nurse take?
A. Infuse hypertonic solutions cautiously.
B. Mix no more than 60 mEq of potassium per liter of fluid.
C. Prevent infiltration of calcium, which causes tissue necrosis and sloughing.
D. Monitor the client's digitalis dosage for potential adjustments due to IV calcium administration.
Correct answer:
When administering intravenous electrolyte solutions, it is crucial to prevent infiltration of calcium to avoid tissue necrosis and sloughing. Hypertonic solutions should be infused cautiously (Choice A) to prevent adverse effects. The correct amount of potassium to be mixed in a liter of fluid is no more than 60 mEq, making Choice B incorrect. While monitoring the client's digitalis dosage for potential adjustments due to IV calcium administration is important, the statement suggesting an increased dosage is incorrect as IV calcium diminishes digitalis's action, making Choice D incorrect.
What should the charge nurse do after overhearing the patient care assistant speaking harshly to the client with dementia?
A. Change the patient care assistant's assignment
B. Explore the interaction with the patient care assistant
C. Discuss the matter with the client's family
D. Initiate a group session with the patient care assistant
Correct answer:
The best action for the charge nurse to take is to explore the interaction with the patient care assistant. This step allows for clarification of the situation and direct addressing of the issue. Changing the patient care assistant's assignment (choice A) might be necessary, but understanding the situation should come first. Discussing the matter with the client's family (choice C) as an initial step could escalate the situation. Initiating a group session with the patient care assistant (choice D) could be considered later as a preventive measure to avoid similar incidents in the future.
Assessment of the client with an arteriovenous fistula for hemodialysis should include:
A. inspection for visible pulsations.
B. palpation of thrill.
C. percussion for dullness.
D. auscultation of blood pressure.
Correct answer:
The correct answer is to palpate for a thrill. A thrill should be present in a functioning arteriovenous fistula (AVF) and indicates good blood flow. The client should be educated to check for this sensation daily at home to monitor the AVF's patency. Visible pulsations are not typically observed in an AVF. Percussion for dullness does not provide relevant information about the AVF. Auscultation of blood pressure is not a standard practice in assessing an AVF. However, auscultation of the AVF for a bruit, a sound indicating turbulent blood flow, is crucial in evaluating the AVF's patency.
When assessing a client with early impairment of oxygen perfusion, such as a pulmonary embolus, the nurse should expect to find restlessness and which of the following symptoms?
A. cool, clammy skin
B. bradycardia
C. tachycardia
D. eupnea
Correct answer:
When a client has early impairment of oxygen perfusion, such as in a pulmonary embolus, the nurse should expect to find restlessness, diaphoresis, tachycardia, and cool skin. Tachycardia is a compensatory mechanism to increase oxygen delivery to tissues. Cool, clammy skin (choice A) is more indicative of impaired oxygen perfusion compared to warm, dry skin. Bradycardia (choice B) is less likely to occur in the early stages and is more common in severe cases. Eupnea (choice D) refers to normal respirations in rate and depth, which may not be altered in early impairment of oxygen perfusion.
A patient's nurse taking a history notes complaints of SOB and weakness in the lower extremities. The patient has a history of hyperlipidemia and hypertension. Which of the following may be occurring?
A. The patient may be developing CHF
B. The patient may be having a MI
C. The patient may be developing COPD
D. The patient may be having an onset of PVD
Correct answer:
In this scenario, the patient's symptoms of shortness of breath (SOB) and weakness in the lower extremities, along with a history of hyperlipidemia and hypertension, are suggestive of a myocardial infarction (MI). It is important to note that MI can present with a variety of symptoms, including those affecting the respiratory system and muscle weakness. Choices A, C, and D are incorrect because the patient's symptoms are more indicative of a myocardial infarction rather than congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or peripheral vascular disease (PVD).
NCLEX-PN clinical judgment practice questions, set 43 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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