NCLEX-PN clinical judgment practice questions, set 46
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 46
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
A nurse is assisting with developing a plan of care for an older client to help maintain an adequate sleep pattern. Which action should the nurse suggest be included in the plan?
A. Encouraging bedtime reading or listening to music
B. Encouraging at least one daytime nap
C. Discouraging the use of a nightlight at bedtime
D. Discouraging social interaction, particularly at bedtime
Show answer and rationale
Correct answer: A — Encouraging bedtime reading or listening to music
To help maintain an adequate sleep pattern in older clients, it is essential to include activities that promote relaxation and a conducive sleep environment. Encouraging bedtime reading or listening to music can help the client unwind and prepare for sleep. Daytime naps should be discouraged to ensure a better nighttime sleep. Social interaction, especially positive interactions, can be beneficial and should not be discouraged. The use of a nightlight can create a safe and comfortable environment for the client, so it should not be discouraged unless specifically contraindicated.
Question 2
What is the preferred position for a client post liver biopsy procedure?
A. Fowler's
B. Right side
C. Left side
D. Prone
Show answer and rationale
Correct answer: B — Right side
The correct position for a client post liver biopsy procedure is the right side. Placing the client on the right side helps apply pressure to the liver area, which can help in holding pressure and stopping bleeding. Placing the client on the left side may not be as effective in providing direct pressure on the liver. The prone position is also not ideal for post-liver biopsy care as it does not target the liver area directly. Fowler's position, a semi-sitting position, is not typically recommended post liver biopsy as it does not provide the necessary pressure on the liver site.
Question 3
A nurse assisting with data collection is preparing to assess the optic nerve. The nurse performs this examination by using which technique?
A. Assessing visual acuity
B. Inspecting the eyelids for ptosis
C. Assessing pupil constriction
D. Assessing ocular movements
Show answer and rationale
Correct answer: A — Assessing visual acuity
The correct technique to assess the optic nerve is by testing visual acuity and visual fields through confrontation. Visual acuity involves assessing the clarity of vision, which directly correlates with the function of the optic nerve. Inspecting the eyelids for ptosis is unrelated to optic nerve assessment. Assessing pupil constriction is more related to the assessment of cranial nerves controlling eye movements, particularly the oculomotor nerve. Assessing ocular movements is related to testing the abducens, oculomotor, and trochlear nerves, not specifically the optic nerve.
Question 4
A nurse is planning task assignments for the day. Which task should the nurse assign to the nursing assistant?
A. Suctioning a client who requires periodic suctioning
B. Assessing a client who has undergone an arteriogram and requires close monitoring
C. Performing colostomy irrigation on a client with an ostomy
D. Assisting a client who needs frequent ambulation with a walker
Show answer and rationale
Correct answer: D — Assisting a client who needs frequent ambulation with a walker
When delegating tasks, a nurse must consider the staff member's education and competency level. Noninvasive tasks like helping a client ambulate with a walker are usually suitable for nursing assistants. Suctioning a client and colostomy irrigation are invasive procedures that require a licensed nurse's skills. Assessing a client post-arteriogram for any complications or changes in condition also necessitates the expertise of a licensed nurse. Therefore, the most appropriate task to assign to a nursing assistant is assisting a client who needs frequent ambulation with a walker.
Question 5
During a stress test, a patient complains of severe chest pain. Which of the following medications is the most appropriate to relieve this discomfort?
A. Aspirin
B. Diazoxide
C. Procardia
D. Mannitol
Show answer and rationale
Correct answer: C — Procardia
In this scenario, the most appropriate medication to relieve severe ischemic chest pain during a stress test is Procardia. Procardia, a calcium channel blocker, is effective in quickly alleviating chest pain by dilating coronary arteries, improving blood flow to the heart muscle. Aspirin, although important for antiplatelet effects, is not the best choice for immediate relief of severe chest pain. Diazoxide is a vasodilator used in hypertensive emergencies, not for acute chest pain. Mannitol is an osmotic diuretic used to reduce intracranial pressure, not for chest pain relief.
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Question 6
Activities of effective supervisors can be task-related or people-related activities. An example of a task-related supervisory activity is:
A. coaching.
B. evaluating.
C. delegating.
D. facilitating.
Correct answer:
Delegating is the act of assigning work to those capable and competent to do the work, making it a task-related supervisory activity. Coaching, evaluating, and facilitating are people-related supervisory activities. Coaching involves guiding and developing individuals, evaluating entails assessing performance, and facilitating focuses on enabling tasks and processes. These activities are more centered on interacting with and supporting people rather than directly assigning tasks. Therefore, in the context of task-related activities, delegating stands out as the correct choice.
The nurse observes a nursing assistant performing AM care for a client with a new leg cast. Which action by the assistant will the nurse intervene?
A. Lifting the affected leg with the palms of the hand
B. Covering the affected leg with a blanket to avoid chills
C. Placing plastic over the groin prior to bathing
D. Elevating the cased leg on two pillows
Correct answer:
The correct answer is covering the affected leg with a blanket to avoid chills. Covering the leg with a blanket can prevent the evaporation of heat from the new cast, which can lead to skin irritation or discomfort. Lifting the affected leg with the palms of the hand is appropriate as it helps in providing support and prevents unnecessary pressure on the cast. Placing plastic over the groin prior to bathing is also acceptable to protect the area from getting wet. Elevating the cased leg on two pillows helps reduce swelling and promotes circulation, making it a suitable action.
Client self-determination is the primary focus of:
A. malpractice insurance.
B. nursing's advocacy for clients.
C. confidentiality.
D. health care.
Correct answer:
Client self-determination is the primary focus of nursing's advocacy for clients. Nurses advocate for their clients' right to autonomy and self-determination, ensuring that the clients' preferences and choices are respected. Confidentiality, on the other hand, involves maintaining the privacy of the client and their information. Health care is a broad term encompassing various aspects of medical services. Malpractice insurance is a type of insurance that provides coverage for professionals in case of negligence or malpractice, not directly related to client self-determination.
A client with a spinal cord injury is preparing to return home from the rehabilitation unit. Which of the following statements by a family member indicates a need for further teaching regarding autonomic dysreflexia?
A. "I should raise him to a sitting position."?
B. "I should check for a fecal impaction."?
C. "I should look for a kink in the urinary catheter tubing."?
D. "I should observe whether symptoms worsen."?
Correct answer:
If the client develops signs or symptoms of autonomic dysreflexia, they need to be addressed immediately. If the family member is not able to relieve them, a healthcare provider needs to be notified immediately. The statement 'I should observe whether symptoms worsen' indicates a passive approach and does not address the urgency of the situation. Choices A, B, and C are correct as they involve active measures to address autonomic dysreflexia, such as raising the client to a sitting position, checking for a fecal impaction, and looking for a kink in the urinary catheter tubing.
A client with sickle cell disease is worried about passing the disease on to children. Which of the following statements by the PN is most appropriate for this client?
A. "You should discuss the inheritance risk with your physician."?
B. "Sickle cell disease is genetically based and might be passed on to children."?
C. "Sickle cell disease is genetically based and is not passed on to children."?
D. "Sickle cell disease is caused by an infection and cannot be passed on to children."?
Correct answer:
A client with sickle cell disease has a genetic condition that can be passed on to their offspring. The most appropriate statement for the PN to provide is to acknowledge this fact and inform the client that sickle cell disease is genetically based and might be passed on to children. This empowers the client with accurate information. Choice A has been refined to emphasize discussing the inheritance risk, making it a better option than the vague original choice. Choices C and D provide incorrect information. Sickle cell disease is indeed genetically based and can be inherited.
An adult who had been abused as a child is discussing the group therapy program. Which statement indicates that the client has gained insight?
A. "I think I was a lonely child because I could not tell anyone about my abuse."?
B. "I am now aware of how deep-seated my anger is. Before, I did not realize I was angry."?
C. "The program has given me the courage to tell my mother how I felt about her role in my hurt."?
D. "There are so many people just like me, who are just normal people that had bad things happen to them."?
Correct answer:
The correct answer demonstrates insight gained by the client regarding their emotional state. Recognizing deep-seated anger that was previously unrecognized indicates progress in understanding their emotions and the impact of past abuse. Choice A reflects a sense of loneliness due to an inability to share about the abuse, which does not directly address emotional insight. Choice C shows progress in addressing relationships but does not specifically relate to emotional awareness. Choice D acknowledges shared experiences but does not reflect personal emotional growth or insight.
A nurse discovers that another nurse has administered an enema to a client even though the client told the nurse that he did not want one. Which is the most appropriate action for the nurse to take?
A. Report the incident to the nursing supervisor
B. Confront the nurse who gave the enema and inform the nurse that she may face charges of battery
C. Tell the client that the nurse did the right thing in giving the enema
D. Contact the client's health care provider
Correct answer:
Battery is any intentional touching of a client without the client's consent, which violates the client's rights. If a nurse discovers such an incident, they should report it to the nursing supervisor. Confronting the nurse and threatening charges of battery could lead to unnecessary conflict. Telling the client that the nurse did the right thing is incorrect as it goes against the client's wishes. While the health care provider may need to be notified eventually, the first step should be reporting the incident to the nursing supervisor to address the violation appropriately.
Several passengers aboard an airliner suddenly become weak and suffer breathing difficulty. The diagnosis is likely to be:
A. Outbreak of Asian flu.
B. Chemical exposure.
C. Bacterial pneumonia.
D. Allergic reaction.
Correct answer:
The most likely cause of groups of individuals suddenly experiencing similar signs of illness all at once is a chemical exposure. In this scenario, considering the sudden onset of symptoms in multiple passengers on an airliner, the symptoms are more indicative of a chemical exposure rather than Asian flu, bacterial pneumonia, or an allergic reaction. Asian flu, bacterial pneumonia, and allergic reactions do not typically manifest in a way that would affect a group of individuals simultaneously. Therefore, the correct diagnosis in this case is likely to be a chemical exposure.
When a woman is having her first child, she is experiencing which type of crisis event?
A. situational
B. maturational
C. adventitious
D. reactive
Correct answer:
A maturational crisis occurs when an individual reaches a new stage of development, such as becoming a parent for the first time, and needs to develop new coping strategies to adapt to this change. Situational crises (Choice A) arise from external sources, not developmental milestones. Adventitious crises (Choice C) are caused by external events like natural disasters and are not related to personal development stages. Reactive crises (Choice D) are responses to specific stressors and are not associated with developmental milestones like becoming a parent for the first time.
A client is told that his test is positive, but in fact, the client does not have the disease tested for. Which type of false report is this an example of?
A. positive
B. false positive
C. negative
D. false negative
Correct answer:
The correct answer is 'false positive.' A false-positive result occurs when a test result is labeled positive in error, when the actual result is negative. In this scenario, the client received a positive test result incorrectly, as he does not have the disease being tested for. Choice A ('positive') is too vague and does not specify that the result was incorrect. Choice C ('negative') is the opposite of what happened in the scenario. Choice D ('false negative') refers to a situation where a test result is labeled negative incorrectly, which is not the case in this scenario.
NCLEX-PN clinical judgment practice questions, set 46 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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