NCLEX-PN clinical judgment practice questions, set 44
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 44
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 type of diet is appropriate for a client with chronic cirrhosis?
A. High calorie, low protein
B. High protein, high calorie
C. Low fat, low sodium
D. High calorie, low sodium
Show answer and rationale
Correct answer: A — High calorie, low protein
The correct diet for a client with chronic cirrhosis is high calorie, low protein. Cirrhosis can lead to impaired protein metabolism, making it essential to limit protein intake. High-calorie foods help meet the client's energy needs. Choice B (High protein, high calorie) is incorrect because high protein intake can worsen hepatic encephalopathy. Choice C (Low fat, low sodium) is not the most appropriate diet for cirrhosis as the focus should be on calories and protein. Choice D (High calorie, low sodium) does not address the need to restrict protein intake, which is crucial in cirrhosis.
Question 2
A nurse is caring for a client with an elevated urine osmolarity. The nurse should assess the client for:
A. fluid volume excess.
B. hyperkalemia.
C. hypercalcemia.
D. fluid volume deficit.
Show answer and rationale
Correct answer: D — fluid volume deficit.
Elevated urine osmolarity indicates that the urine is concentrated, suggesting the body is trying to conserve water. This commonly occurs in conditions like dehydration or fluid volume deficit. Assessing the client for fluid volume excess, hyperkalemia, or hypercalcemia would not be the priority in this situation. Therefore, the correct answer is to assess the client for fluid volume deficit. Fluid volume excess is characterized by decreased urine osmolarity, while hyperkalemia and hypercalcemia are related to electrolyte imbalances and would not directly cause elevated urine osmolarity.
Question 3
A nurse is assigned to do pre-operative teaching on a blind patient who is scheduled for surgery the following morning. What teaching strategy would best fit the situation?
A. Verbal teaching in short sessions throughout the day
B. Provide a pre-operative booklet in Braille
C. Provide an audio recording for the client
D. Have the blind patient's family member assist with the instruction
Show answer and rationale
Correct answer: A — Verbal teaching in short sessions throughout the day
For a blind patient scheduled for surgery the following morning, the best teaching strategy would be verbal teaching in short sessions throughout the day. Providing information in smaller amounts makes it easier to retain, and one-on-one teaching is most effective. Choice B, providing a pre-operative booklet in Braille, may not be as practical for last-minute teaching. Choice C, providing an audio recording, may not allow for immediate interaction and clarification. Choice D, having a family member instruct the patient, may not ensure the accuracy and clarity of the information provided.
Question 4
Which of the following should not be included in the teaching for clients who take oral iron preparations?
A. Mix the liquid iron preparation with antacids to reduce GI distress.
B. Take the iron with meals if GI distress occurs.
C. Liquid forms should be taken with a straw to avoid discoloration of tooth enamel.
D. Oral forms should be taken with juice, not milk.
Show answer and rationale
Correct answer: A — Mix the liquid iron preparation with antacids to reduce GI distress.
The correct answer is to mix the liquid iron preparation with antacids to reduce GI distress. This statement is incorrect because iron should not be mixed with antacids as it can significantly reduce the absorption of iron. Choice B is a good recommendation as taking iron with meals can help reduce gastrointestinal distress. Choice C is also correct as liquid forms of iron should be taken with a straw to prevent the discoloration of tooth enamel. Choice D is incorrect as iron preparations can be taken with juice or water, but not with milk, as calcium in milk can inhibit iron absorption.
Question 5
Which of the following procedures describes an opening between the colon and abdominal wall?
A. ileostomy
B. jejunostomy
C. colostomy
D. cecostomy
Show answer and rationale
Correct answer: C — colostomy
A colostomy is an opening between the colon and abdominal wall. An ileostomy is an opening between the ileum and abdominal wall, not the colon. Jejunostomy is an opening between the jejunum and abdominal wall, and cecostomy is an opening into the cecum. The term 'colostomy' specifically refers to the surgical procedure where a part of the colon is brought through the abdominal wall to create a stoma, allowing feces to leave the body. Therefore, the correct answer is colostomy as it accurately describes the opening between the colon and the abdominal wall, distinct from the other options.
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Question 6
For which condition might a client's antidiuretic hormone (ADH) level be increased?
A. diabetes mellitus
B. diabetes insipidus
C. hypothyroidism
D. hyperthyroidism
Correct answer:
The correct answer is diabetes insipidus. In this condition, the client's ADH level is increased. Diabetes insipidus is characterized by the inability of the kidneys to conserve water due to either inadequate secretion of ADH (central diabetes insipidus) or the kidneys' inability to respond to ADH (nephrogenic diabetes insipidus). Choices A, C, and D are incorrect. In diabetes mellitus, ADH levels are typically normal or elevated in response to high blood sugar levels. Hypothyroidism is not directly related to ADH secretion. In hyperthyroidism, ADH levels are usually normal or decreased.
A nurse is weighing a breastfed 6-month-old infant who has been brought to the pediatrician's office for a scheduled visit. The infant's weight at birth was 6 lb 8 oz. The nurse notes that the infant now weighs 13 lb. What action should the nurse take?
A. Tell the mother to decrease the daily number of feedings because the weight gain is excessive.
B. Tell the mother that the infant's weight is increasing as expected.
C. Tell the mother that the infant should continue with breast milk as the weight gain is adequate.
D. Tell the mother that semisolid foods should not be introduced until the infant's weight stabilizes.
Correct answer:
The correct answer is to inform the mother that the infant's weight gain is normal. Infants typically double their birth weight by 6 months, which is precisely the case here, with the infant's weight increasing from 6 lb 8 oz to 13 lb. This weight gain indicates healthy growth and development. Therefore, there is no need to decrease feedings. The infant should continue with breast milk as it is providing adequate nutrition. Additionally, introducing semisolid foods is usually recommended between 4 and 6 months of age, so there is no indication to delay based on the infant's weight gain.
The home health nurse is planning for the day's visits. Which client should be seen first?
A. The 78-year-old who had a gastrectomy 3 weeks ago with a PEG tube
B. The 5-month-old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension
C. The 50-year-old with MRSA being treated with Vancomycin via a PICC line
D. The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter
Correct answer:
The priority client is the 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter. This client is at the highest risk for complications and requires immediate attention. Choice C, the 50-year-old with MRSA being treated with Vancomycin via a PICC line, is incorrect as Vancomycin administration can be scheduled at specific times and does not indicate an urgent need for a visit. Choices A and B are also incorrect as these clients are more stable compared to the client with multiple sclerosis in need of cortisone therapy.
Which of the following physical findings indicates that an 11-12-month-old child is at risk for developmental dysplasia of the hip?
A. refusal to walk
B. not pulling to a standing position
C. negative Trendelenburg sign
D. negative Ortolani sign
Correct answer:
The correct answer is 'not pulling to a standing position.' An 11-12-month-old child not pulling to a standing position may be at risk for developmental dysplasia of the hip. By this age, children typically pull to a standing position, and failure to do so should raise concerns. Refusal to walk is a broader observation and not specific to hip dysplasia. The Trendelenburg sign indicates weakness of the gluteus medius muscle, not hip dysplasia. The Ortolani sign is used to detect congenital subluxation or dislocation of the hip, which is different from developmental dysplasia of the hip.
Spirituality affects a client's life in all of the following areas except:
A. nutritional intake.
B. ability to handle stress.
C. sexual expression.
D. genetic makeup.
Correct answer:
Spirituality is a belief in or relationship with some higher power, creative force, divine being, or infinite source of energy. It can influence areas such as nutritional intake, the ability to handle stress, and sexual expression by providing comfort, guidance, and a sense of purpose. However, spirituality does not have any effect on genetic makeup, as genetics are determined by biological inheritance and not influenced by spiritual beliefs. Choices A, B, and C are directly influenced by an individual's spiritual beliefs and practices, impacting their overall well-being and behavior.
A client, age 28, was recently diagnosed with Hodgkin's disease. After staging, therapy is planned to include combination radiation therapy and systemic chemotherapy with MOPP"?nitrogen mustard, vincristine (Onconvin), prednisone, and procarbazine. In planning care for this client, the nurse should anticipate which of the following side effects to contribute to a sense of altered body image?
A. Cushingoid appearance
B. Alopecia
C. Temporary or permanent sterility
D. Pathologic fractures
Correct answer:
The correct answer is B: alopecia. Chemotherapy drugs like vincristine and nitrogen mustard commonly cause hair loss (alopecia), which can significantly impact body image. While a Cushingoid appearance can be a side effect of long-term steroid use, it is not typically associated with the chemotherapy regimen mentioned. Temporary or permanent sterility can result from chemotherapy, affecting fertility but not directly contributing to altered body image. Pathologic fractures are not commonly linked to Hodgkin's disease or its treatment, unlike alopecia which is a well-known side effect.
As part of a routine health screening, the nurse notes the play of a 2-year-old child. Which of the following is an example of age-appropriate play at this age?
A. builds towers with several blocks
B. tries to color within the lines
C. says 'Mine!' when playing with toys
D. tries to jump rope
Correct answer:
The correct answer is C: 'says 'Mine!' when playing with toys.' At the age of 2, children are in the stage of parallel play and are possessive of their belongings, hence saying 'Mine!' is an age-appropriate behavior. Building towers with blocks (choice A) involves more advanced motor skills and cognitive abilities, which are beyond what most 2-year-olds can do. Trying to color within the lines (choice B) requires fine motor skills that are typically not developed at age 2. Jumping rope (choice D) involves coordination and balance that are beyond the capabilities of a 2-year-old child.
A client with schizophrenia says, 'I'm away for the day ... but don't think we should play "? or do we have feet of clay?' Which alteration in the client's speech does the nurse document?
A. Neologism
B. Word salad
C. Clang association
D. Associative looseness
Correct answer:
The correct answer is 'Associative looseness.' In the provided speech, the client shows associative looseness by making loose connections between phrases without a clear logical link. Clang association involves rhyming words without regard for their meaning. Neologism refers to made-up words with specific meaning to the client, and word salad is a jumble of words that lack coherence either to the listener or the client. Understanding these speech patterns associated with schizophrenia is crucial in identifying the specific alteration in speech displayed by the client in this scenario.
While Fluorouracil (5FU®) is being infused, a client complains of burning at the IV site. What should the nurse do first?
A. Aspirate the IV site for blood return.
B. Slow the infusion.
C. Inspect the IV site.
D. Stop the infusion.
Correct answer:
The correct first action for the nurse is to inspect the IV site. This is important to assess for any signs of infiltration or extravasation, which could be causing the burning sensation. Aspirating the IV site for blood return (Choice A) may not be the initial priority as it does not directly address the client's complaint of burning. Slowing the infusion (Choice B) may help alleviate discomfort but should not be done before inspecting the site. Stopping the infusion (Choice D) may be necessary, but inspecting the site should come first to determine the appropriate course of action.
Ms. Petty is having difficulty falling asleep. Which of the following measures promote sleep?
A. exercising vigorously for 20 minutes each night beginning at 9:30 p.m.
B. taking a cool shower and drinking a hot cup of tea
C. watching TV nightly until midnight
D. getting a back rub and drinking a glass of warm milk
Correct answer:
The correct answer is getting a back rub and drinking a glass of warm milk. These measures are relaxation techniques that can help promote sleep by calming the body and mind. Exercising vigorously right before bedtime, as mentioned in choice A, can increase arousal and make it harder to fall asleep. Choice B, taking a cool shower and drinking a hot cup of tea, involves temperature changes that might not be conducive to sleep. Watching TV until midnight, as in choice C, exposes the individual to blue light and mental stimulation, both of which can disrupt the natural sleep-wake cycle.
NCLEX-PN clinical judgment practice questions, set 44 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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