NCLEX-PN clinical judgment practice questions, set 45
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 45
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
An elderly client is diagnosed with ovarian cancer. She has surgery followed by chemotherapy with fluorouracil (Adrucil) IV. What should the nurse do if she notices crystals and cloudiness in the IV medication?
A. Discard the solution and order a new bag
B. Warm the solution
C. Continue the infusion and document the finding
D. Discontinue the medication
Show answer and rationale
Correct answer: A — Discard the solution and order a new bag
Crystals in the solution are not normal and should not be administered to the client. Discarding the solution and ordering a new bag is the correct action to ensure the client's safety. Warming the solution, as suggested in answer B, will not resolve the issue of crystals and cloudiness, which could potentially harm the client. Continuing the infusion, as in answer C, could pose a risk to the client due to the presence of abnormal substances. Answer D, discontinuing the medication, would typically require a doctor's order and should be done after discarding the contaminated solution.
Question 2
What must the evening nurse do to facilitate the client's ECT treatment the next morning?
A. Ensure the patient signs an informed consent form
B. Administer evening medications
C. Ensure the patient gets a good night's sleep
D. Provide dietary restrictions as per ECT protocol
Show answer and rationale
Correct answer: A — Ensure the patient signs an informed consent form
For electroconvulsive therapy (ECT) treatment, obtaining informed consent is crucial before the procedure. This ensures the patient is aware of the risks, benefits, and alternatives to the treatment. Administering medications, ensuring rest, and dietary restrictions are important but not directly related to the specific requirement of obtaining informed consent for ECT. The correct answer, ensuring the patient signs an informed consent form, is essential to uphold the patient's autonomy and ensure they have the necessary information to make an informed decision about their treatment.
Question 3
The client should include all of the following in teaching an obese client about nutritional needs and weight loss except:
A. knowledge of food and food products
B. development of a positive mental attitude
C. adequate exercise
D. starting a fast weight-loss diet
Show answer and rationale
Correct answer: D — starting a fast weight-loss diet
When educating an obese client about nutritional needs and weight loss, it is crucial to emphasize a holistic approach that involves understanding food and food products, fostering a positive mental attitude, and incorporating adequate exercise. Initiating a fast weight-loss diet is not advisable due to potential health risks and lack of long-term sustainability. Therefore, this option stands out as the exception and should not be part of the client's learning. Choices A, B, and C are essential components of a healthy weight-loss plan and should be included in the client's education.
Question 4
When a physician removes a chest tube, which type of dressing is recommended to be placed over the site?
A. transparent dressing
B. colloidal dressing
C. petrolatum gauze
D. nonadherent dressing
Show answer and rationale
Correct answer: C — petrolatum gauze
Petrolatum gauze is recommended to be placed over the site when a physician removes a chest tube because it forms an airtight seal, helping prevent air from entering the pleural space. This airtight seal is crucial to avoid complications such as a pneumothorax. Transparent dressing is not ideal for this purpose as it may not provide a sufficient seal due to its design. Colloidal dressing and nonadherent dressing are also not suitable for chest tube removal sites as they do not offer the same level of protection against air leakage and may not provide the necessary sealing properties.
Question 5
The healthcare provider sustains a needle puncture that requires HIV prophylaxis. Which of the following medication regimens should be used?
A. an antibiotic such as Metronidazole and a protease inhibitor (Saquinavir)
B. two non-nucleoside reverse transcriptase inhibitors
C. one protease inhibitor such as Nelfinavir
D. two protease inhibitors
Show answer and rationale
Correct answer: B — two non-nucleoside reverse transcriptase inhibitors
In the scenario of a needle puncture requiring HIV prophylaxis, the CDC recommends initiating treatment with two non-nucleoside reverse transcriptase inhibitors, unless there is drug resistance. This regimen is preferred over other options such as a single protease inhibitor or two protease inhibitors due to its effectiveness and safety profile in this specific context. Non-nucleoside reverse transcriptase inhibitors are commonly used in post-exposure prophylaxis due to their activity against HIV and lower risk of resistance development compared to other antiretroviral drug classes.
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Question 6
A Hispanic client brings her father to the clinic because he is becoming more forgetful. He is diagnosed with Alzheimer's disease. The woman tells the nurse that she wants to try ginkgo biloba for her father before using prescription medications. Which of the following is an appropriate response by the nurse?
A. "It is wiser to start with a prescription."?
B. "That herb may not be effective for your father."?
C. "You can't expect an herb to cure Alzheimer's."?
D. "I will let the physician know of your wishes."?
Correct answer:
The appropriate response is to acknowledge the client's wishes and communicate them to the physician for consideration. It is important to be culturally sensitive and respect the client's preferences. Ginkgo biloba has shown some benefits in treating dementia, so it is essential to involve the healthcare provider in the decision-making process. Choices A, B, and C are dismissive and fail to consider the client's perspective and cultural beliefs. It is crucial for healthcare professionals to engage in open communication and collaboration with clients to provide patient-centered care.
Mr. H. is upset about being in the hospital for another day because he states it costs too much. The rights he is likely to demand include all of the following except:
A. the right to examine and question the bill
B. the right to reasonable response to requests
C. the right to refuse treatment
D. the right to confidentiality
Correct answer:
Confidentiality is the maintenance of privacy of information, which is not directly related to the issue Mr. H. is facing. The question indicates that Mr. H. is concerned about the cost of staying in the hospital, which pertains more to financial aspects and the right to examine and question the bill. The right to a reasonable response to requests and the right to refuse treatment are also crucial patient rights that Mr. H. may demand in his current situation. Therefore, the correct answer is the right to confidentiality, as it is not specifically relevant to the scenario presented.
The charge nurse is observing a student nurse caring for a 4-month-old infant in isolation diagnosed with RSV. Which of the following would indicate to the charge nurse that the student nurse needs further instruction on isolation standards?
A. Donning clean gloves each time she goes in the room.
B. Wearing a clean mask each time she goes in the room.
C. Labeling the door so staff will use Airborne Precautions.
D. Wearing a gown when she goes in the room to administer medication.
Correct answer:
The correct answer is 'Donning clean gloves each time she goes in the room.' Sterile gloves are not necessary for standard isolation precautions; clean gloves are sufficient. The student nurse should be instructed to use clean gloves to reduce the risk of spreading infections. Wearing a clean mask each time she goes in the room is a good practice to prevent the spread of respiratory infections like RSV. Labeling the door for Airborne Precautions is appropriate for RSV. Wearing a gown when entering the room to administer medication helps prevent the transmission of infectious agents.
Post thyroidectomy the nurse assesses for complications by performing which of the following assessments?
A. Accu-Chek
B. Chvostek's
C. Ballottement
D. Ice water colonic
Correct answer:
The correct answer is Chvostek's. A positive Chvostek's and Trousseau's sign is indicative of tetany, which is associated with low calcium levels. This can occur if parathyroid glands are accidentally removed during thyroidectomy. Accu-Chek is a brand of blood glucose monitor used for checking blood sugar levels and is not relevant in this context. Ballottement is a technique used in physical examination to assess for fluid in the body, typically in the abdomen or joints. Ice water colonic is not a standard medical assessment and is not relevant to post-thyroidectomy complications.
Regarding maternal and infant mortality and morbidity, a concern is that:
A. a segment of the population is not receiving prenatal care.
B. families may not prioritize quality health care.
C. there might be an increase in the shortage of personnel in the maternity field.
D. maternal-child health workers may lack adequate preparation.
Correct answer:
The correct answer is that a segment of the population is not receiving prenatal care. This is a significant concern as lack of access to prenatal care can lead to adverse outcomes for both the mother and the infant. Choice B is incorrect as it generalizes families as unconcerned, which may not be the case for all families. Choice C is also incorrect as there is no evidence or indication in the prompt to suggest an increase in the shortage of personnel. Choice D is not directly related to the concern mentioned in the prompt, which specifically focuses on the lack of prenatal care.
A nurse is taking a morning break with the unit secretary in the nurses' lounge. The unit secretary says to the nurse, 'I read in Mr. Gage's medical record that he has gonorrhea.' How should the nurse respond to the secretary?
A. Yes, he does, but be sure not to discuss this with anyone else.
B. Yes, that's why we've imposed contact precautions.
C. We can't discuss a client's medical condition.
D. Oh, really? I didn't see that!
Correct answer:
A client's medical condition is confidential and should never be discussed with anyone other than the client and the client's healthcare provider. Therefore, the nurse must tell the unit secretary that the client's condition is not to be discussed. Choices A and B confirm the client's disease, which is inappropriate as it breaches patient confidentiality. Choice D promotes further discussion of the client's condition, which is also inappropriate. The correct response is to firmly state, 'We can't discuss a client's medical condition,' to uphold patient privacy and confidentiality.
A sexually active married couple, discussing birth control methods with the nurse, expresses the need for a method that is convenient. Because the couple has told the nurse that family-planning goals have been met, which method of birth control does the nurse suggest?
A. Diaphragm
B. Sterilization
C. Male condom
D. Spermicide
Correct answer:
In this scenario, since the couple has indicated that their family-planning goals have been met, a permanent method of contraception like sterilization would be most suitable. Sterilization offers long-term effectiveness and convenience once the decision to stop having children is made. Options like the diaphragm, male condom, or spermicide are more suitable for temporary contraception or when the family-planning goals have not yet been achieved. Therefore, the correct answer is sterilization, as it aligns with the couple's need for a convenient and permanent birth control method.
A licensed practical nurse tells the certified nursing assistant (CNA) staff that they will need to comply with the mandatory overtime policy that the long-term care facility has implemented. Later that day, the nurse overhears a CNA complaining about the policy and telling other CNAs that she will not work the overtime if she has made other plans after her regular shift. What is the best approach for the nurse to use in dealing with the conflict?
A. Providing a positive reward system for the CNA to encourage working the mandatory overtime
B. Ignoring the complaints
C. Avoiding assigning the CNA mandatory overtime
D. Meeting with the CNA regarding her behavior concerning the overtime policy
Correct answer:
In this situation, the best approach for the nurse is to meet with the CNA regarding her behavior concerning the overtime policy. Initiating a discussion is crucial to address resistance by a staff member. A face-to-face meeting allows for the verbalization of feelings, identification of problems, and the opportunity to develop strategies to solve the issue. Ignoring the complaints and avoiding assigning mandatory overtime do not tackle the root of the problem. Providing a positive reward system might offer a temporary fix but does not directly address the resistance and conflict.
Which of the following is not one of the three universal spiritual needs?
A. meaning and purpose
B. love and relatedness
C. forgiveness
D. God's permission
Correct answer:
The three universal spiritual needs are meaning and purpose, love and relatedness, and forgiveness. These needs are commonly recognized across various belief systems and cultures. While the concept of God may be central to many religions, 'God's permission' is not considered a universal spiritual need. Seeking 'God's permission' is more specific to certain religious practices rather than a universally acknowledged spiritual need. Therefore, the correct answer is 'God's permission.' Choices A, B, and C are correct as they align with the generally accepted universal spiritual needs.
After administering enoxaparin (Lovenox) subcutaneously into the abdomen, which action should the nurse take?
A. Gently rub the injection site after removing the needle
B. Have the client maintain a side-lying position for at least five minutes
C. Remove the needle and engage the needle safety device
D. Apply heat to the injection site
Correct answer:
After administering a subcutaneous injection of enoxaparin (Lovenox) into the abdomen, the nurse should remove the needle and engage the needle safety device. Rubbing the injection site after the needle is withdrawn is not recommended as it may cause irritation and bruising. Having the client maintain a side-lying position for at least five minutes is unnecessary for a subcutaneous injection into the abdomen. Applying heat to the injection site is not indicated after administering enoxaparin subcutaneously; it could increase the risk of bleeding or bruising at the injection site.
NCLEX-PN clinical judgment practice questions, set 45 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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