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NCLEX-PN clinical judgment practice questions, set 48

NCLEX-PN · clinical judgment

NCLEX-PN clinical judgment practice questions set 48

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 intervention should the nurse stop the nursing assistant from performing?

  1. A. Emptying the Jackson-Pratt drainage of the client post cholecystectomy
  2. B. Performing passive range of motion on the client with right-sided paralysis
  3. C. Placing the traction weights on the bed to transfer the client to X-ray
  4. D. Discarding the first urine voided by the client starting a 24-hour urine test
Show answer and rationale

Correct answer: C — Placing the traction weights on the bed to transfer the client to X-ray

Placing traction weights on the bed to transfer the client to X-ray is an intervention that the nurse should stop the nursing assistant from performing. Traction should never be relieved without a doctor's order as it can result in muscle spasm and tissue damage. The other choices are appropriate nursing interventions and should not be stopped. Emptying the Jackson-Pratt drainage, performing passive range of motion, and collecting the first urine void for a 24-hour urine test are all within the scope of practice and do not pose immediate risks to the client's well-being.

Question 2

A 50-milliliter (ml) bolus of normal saline fluid is ordered by the physician. The physician wants it to infuse in 30 minutes. The nurse should set the pump rate at:

  1. A. 100 ml per hour for one hour.
  2. B. 60 ml per hour for one-half hour
  3. C. 120 ml per hour for one hour.
  4. D. 50 ml per hour for one hour.
Show answer and rationale

Correct answer: A — 100 ml per hour for one hour.

To infuse a 50 ml bolus in 30 minutes, the rate should be calculated as follows: 50 ml / 30 min = 100 ml per hour. Therefore, the correct answer is to set the pump rate at 100 ml per hour for one hour. Choice A is the correct rate based on the calculation. Choices B, C, and D all provide incorrect rates that do not match the physician's order. Choice B would only deliver 30 ml in 30 minutes, not the ordered 50 ml. Choice C would deliver 120 ml in one hour, which is 20 ml more than ordered. Choice D would only provide 25 ml over 30 minutes, not the full 50 ml prescribed.

Question 3

What sign might the nurse observe in a client with a high ammonia level?

  1. A. coma
  2. B. edema
  3. C. hypoxia
  4. D. polyuria
Show answer and rationale

Correct answer: A — coma

Coma is a sign that a nurse might observe in a client with a high ammonia level. Elevated ammonia levels can lead to hepatic encephalopathy, a condition characterized by impaired brain function, which can progress to coma. Edema (choice B) is swelling caused by excess fluid trapped in body tissues, not typically associated with high ammonia levels. Hypoxia (choice C) is a condition of inadequate oxygen supply to tissues and is not directly related to high ammonia levels. Polyuria (choice D) refers to excessive urination and is not a typical sign of high ammonia levels.

Question 4

After assigning tasks, what is the nurse's primary responsibility?

  1. A. Assigning any tasks that were not completed to the next nursing shift
  2. B. Documenting completion of each task
  3. C. Allowing each staff member to make judgments when performing the tasks
  4. D. Following up with each staff member regarding the performance of the task and the outcomes related to implementation of the task
Show answer and rationale

Correct answer: D — Following up with each staff member regarding the performance of the task and the outcomes related to implementation of the task

The nurse's primary responsibility after assigning tasks is to follow up with each staff member regarding the task's performance and outcomes. This ensures accountability and quality care delivery. Allowing staff members to make judgments independently can compromise patient safety if they lack the necessary knowledge or experience. While documenting task completion is important, it should follow the follow-up to assess outcomes. Assigning incomplete tasks to the next shift is not ideal as it may result in unmet patient needs and increased workload for the next shift.

Question 5

What is the role of the incident report in risk management?

  1. A. Liability protection.
  2. B. To provide data for analysis by a risk manager to determine how future problems can be avoided.
  3. C. To discipline staff for errors.
  4. D. All of the above.
Show answer and rationale

Correct answer: B — To provide data for analysis by a risk manager to determine how future problems can be avoided.

The correct answer is 'To provide data for analysis by a risk manager to determine how future problems can be avoided.' Incident reports are a crucial tool for collecting information about incidents to analyze them and prevent similar issues in the future. They are not primarily used for liability protection or disciplining staff. Therefore, choices A and C are incorrect. Selecting 'All of the above' (choice D) is not accurate as incident reports serve a specific purpose related to data analysis and risk prevention, excluding liability protection and staff discipline.

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Question 6

Which of the following statements describes the purpose of client restraint?

  1. A. Restraints are a nursing measure used to maintain client control.
  2. B. Restraints are an emergency intervention taken as a last resort to protect a client from imminent danger.
  3. C. Restraints are a therapeutic measure designed to positively reinforce client behavior.
  4. D. Restraints are an emergency measure that can only be taken by a nurse under the direct supervision of a physician.
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Question 7

The client is being discharged after a concussion. Which of the following symptoms should be reported?

  1. A. Difficulty waking up
  2. B. Headache (3/10 on the pain scale)
  3. C. Bruising on knees and elbows
  4. D. Achy feeling all over
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Question 8

The client with obsessive-compulsive disorder (OCD) is asking for help with the repetitive behaviors. The nurse knows that these are a method of dealing with:

  1. A. Fearful situations
  2. B. Depression
  3. C. Delusions
  4. D. Anxiety
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Question 9

The client is wheezing and struggling to breathe. Which of the inhaled medications is indicated at this time?

  1. A. Fluticasone (Flovent)
  2. B. Salmeterol (Serevent)
  3. C. Theophylline (Theodur)
  4. D. Albuterol (Atrovent)
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Question 10

A patient has recently been prescribed Norvasc. Which of the following side effects should the patient specifically watch out for?

  1. A. Hypotension and Angina
  2. B. Hypertension
  3. C. Lower extremity edema
  4. D. Peripheral sensory loss and SOB
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Question 11

The client with chronic pancreatitis should be taught how to monitor for which of the following possible additional problems associated with pancreatic disease?

  1. A. Hypertension
  2. B. Diabetes
  3. C. Hypothyroidism
  4. D. Graves' disease
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Question 12

In a brief treatment program, what is a realistic short-term goal for a client who was raped?

  1. A. Identify all psychosocial problems
  2. B. Eliminate the client's enticing behaviors
  3. C. Resolve feelings of trauma and fear
  4. D. Verbalize feelings about the event
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Question 13

A patient has a history of cardiac arrhythmia. A nurse has been ordered to give 2 units of blood to this patient. The nurse should take which of the following actions?

  1. A. Administer pain medication to the patient.
  2. B. Inform the patient's family about the procedure in person.
  3. C. Decrease the temperature of the blood to be given.
  4. D. Increase the temperature of the blood to be given.
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Question 14

What is the drug of choice for herpes simplex virus 1, herpes simplex virus 2, and varicella-zoster virus?

  1. A. HIV.
  2. B. HSV 1, HSV 2, and VZV.
  3. C. CMV
  4. D. Influenza A viruses.
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Question 15

The nurse should teach parents of small children that the most common type of first-degree burn is:

  1. A. scalding from hot bath water or spills.
  2. B. contact with hot surfaces such as stoves and fireplaces.
  3. C. contact with flammable liquids or gases resulting in flash burns.
  4. D. sunburn from lack of protection and overexposure.
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About these NCLEX-PN clinical judgment questions

NCLEX-PN clinical judgment practice questions, set 48 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.

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