NCLEX-PN clinical judgment practice questions, set 49
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 49
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 client reports that he is 'talking to the voices.' The nurse observes this behavior. The nurse's next action should be:
A. touching the client to help him return to reality
B. leaving the client alone until reality returns
C. asking the client to describe what is happening
D. telling the client there are no voices
Show answer and rationale
Correct answer: A — touching the client to help him return to reality
When a client reports talking to voices, the nurse should engage in a gentle touch to help the client return to reality. It is important for the nurse to acknowledge the client's experience and attempt to redirect them gently. Touch can provide grounding and connection. Asking the client to describe what is happening can be overwhelming and might exacerbate the situation. Leaving the client alone may not be safe or therapeutic as the client may need support. Telling the client there are no voices denies their reality and is not helpful in managing their experience.
Question 2
Why is monitoring Serum Vancomycin levels important?
A. to assess renal function
B. to determine therapeutic range
C. to measure trough levels
D. to evaluate antibiotic resistance
Show answer and rationale
Correct answer: B — to determine therapeutic range
Monitoring Serum Vancomycin levels is essential to determine the drug's therapeutic range, ensuring optimal effectiveness while avoiding toxicity. Peak levels indicate the drug's highest concentration, while trough levels represent the lowest concentration before the next dose. Assessing renal function is typically done using creatinine, BUN, or creatinine clearance tests, not Serum Vancomycin levels. Evaluating antibiotic resistance involves sensitivity testing, not monitoring Vancomycin levels. Therefore, the correct answer is to determine the therapeutic range.
Question 3
A 27-year-old woman has delivered twins in the OB unit. The patient develops a condition of 5-centimeter diastasis recti abdominis. Which of the following statements is the most accurate when instructing the patient?
A. Avoid sit-ups to prevent worsening the condition.
B. Surgery is not always necessary for this condition.
C. Guarding the abdominal region is important at this time.
D. Antibiotics are not needed for diastasis recti abdominis.
Show answer and rationale
Correct answer: C — Guarding the abdominal region is important at this time.
After experiencing diastasis recti abdominis, it is crucial for the patient to protect and guard the abdominal region to facilitate healing. Choice A is correct since avoiding sit-ups is important to prevent worsening the condition by increasing intra-abdominal pressure. Choice B is accurate as not all cases of diastasis recti abdominis require surgery; conservative management is often effective. Choice D is also correct as antibiotics are not indicated for diastasis recti abdominis since it is a separation of the abdominal muscles and not an infectious condition.
Question 4
A patient asks a nurse the following question: Exposure to TB can be best identified with which of the following procedures?
A. Chest x-ray
B. Mantoux test
C. Breath sounds examination
D. Sputum culture for Mycobacterium tuberculosis
Show answer and rationale
Correct answer: B — Mantoux test
The Mantoux test, also known as the tuberculin skin test, is the most appropriate and accurate test to identify exposure to TB. This test involves injecting a small amount of PPD tuberculin under the top layer of the skin, and a positive reaction indicates exposure to the TB bacteria. Choice A, a chest x-ray, is useful for detecting active TB disease but not exposure. Choice C, a breath sounds examination, is not a specific test for TB exposure. Choice D, a sputum culture for Mycobacterium tuberculosis, is used to diagnose active TB infection rather than exposure.
Question 5
When discussing possible complications of pregnancy with a client, the nurse should explain that all of the following are symptoms of urinary tract infection (UTI). Which of the following is least indicative of UTI during pregnancy?
A. low back pain
B. urinary frequency
C. GI distress
D. malaise
Show answer and rationale
Correct answer: B — urinary frequency
Urinary frequency is least indicative of UTI during pregnancy. It is a common minor discomfort of pregnancy caused by pressure of the growing uterus on the bladder. As the uterus rises in the second trimester, there are usually no problems. Frequency may return in the third trimester when the uterus drops into the pelvic cavity. UTI symptoms include low back pain, suprapubic discomfort, and malaise, and are confirmed by laboratory findings. Low back pain, GI distress, and malaise are more closely associated with UTI during pregnancy compared to urinary frequency.
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Question 6
Which of the following is likely to increase the risk of sexually transmitted disease?
A. alcohol use
B. certain types of sexual practices
C. oral contraception use
D. all of the above
Correct answer:
All of the above factors are likely to increase the risk of sexually transmitted diseases (STDs). Alcohol use can impair judgment, leading to risky sexual behavior. Certain types of sexual practices, especially unprotected sex or multiple partners, increase the likelihood of contracting STDs. While oral contraception use does not directly increase the risk of STDs, it does not protect against them either. Therefore, all the choices (alcohol use, certain types of sexual practices, and oral contraception use) can contribute to an increased risk of contracting STDs.
How can a nurse recognize that a chronic renal failure client's AV shunt is patent?
A. Absence of a bruit
B. Presence of a thrill
C. Blood return from the shunt
D. Urine output greater than 30 ml/hr
Correct answer:
The correct assessment to determine the patency of an AV shunt in a chronic renal failure client is the presence of a thrill. A thrill is a vibration or buzzing sensation felt over the shunt site, indicating good blood flow through the shunt. While the presence of a bruit is also important for assessing an AV shunt, a thrill is a more specific indicator of patency. Blood return from the shunt is related to cannulation and not necessarily an indicator of patency. Urine output greater than 30 ml/hr is not directly related to the assessment of an AV shunt's patency.
A client who is newly diagnosed with Parkinson's disease and beginning medication therapy asks the nurse, 'How soon will I see improvement?' The nurse's best response is:
A. "That varies from client to client."?
B. "You should discuss that with your physician."?
C. "You should notice a difference in a few days."?
D. "It might take several weeks before you notice improvement."?
Correct answer:
In the case of Parkinson's disease, improvement in symptoms may take several weeks of therapy to become noticeable. Therefore, the correct answer is to inform the client that it might take several weeks before they notice improvement. Choice A acknowledges individual variability but does not provide a specific timeframe, making it less reassuring. Choice B suggests deferring the question to the physician, which is not the most supportive response. Choice C is incorrect because improvement in Parkinson's disease symptoms typically does not occur within a few days.
Which of the following ethnic groups is at highest risk in the United States for pesticide-related injuries?
A. Native American
B. Asian-Pacific
C. Norwegian
D. Hispanic
Correct answer:
Hispanic people are at the highest risk in the United States for pesticide-related injuries due to their significant representation among migrant workers in agricultural settings. Working in such environments exposes them to pesticides more frequently, thus elevating their risk compared to other ethnic groups. In contrast, Native American, Asian-Pacific, and Norwegian populations are not as commonly engaged in agricultural work involving pesticide exposure, which makes them less susceptible to pesticide-related injuries. Therefore, the correct answer is Hispanic.
A patient has been ordered to receive Klonopin for the first time. Which of the following side effects is not associated with Klonopin?
A. Drowsiness
B. Ataxia
C. Salivation elevation
D. Diplopia
Correct answer:
The correct answer is 'Diplopia.' While drowsiness, ataxia, and salivation elevation are common side effects associated with Klonopin, diplopia is not typically linked to this medication. Diplopia, or double vision, is not a common side effect reported with the use of Klonopin. It is important to monitor patients for the known side effects such as drowsiness, ataxia, and salivation elevation when administering Klonopin. Choice A, B, and C are incorrect as they are known side effects of Klonopin, unlike diplopia which is not commonly observed with this medication.
Six hours after birth, the infant is found to have an area of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as:
A. A cephalohematoma
B. Molding
C. Subdural hematoma
D. Caput succedaneum
Correct answer:
The correct answer is A, a cephalohematoma. A cephalohematoma is an area of bleeding outside the cranium but beneath the periosteum, typically not crossing the suture line. Answer B, molding, is the overlapping of the bones of the cranium and does not involve bleeding, making it an incorrect choice. Answer C, a subdural hematoma, involves intracranial bleeding and is typically diagnosed through imaging studies like a CAT scan or x-ray. Answer D, caput succedaneum, is characterized by edema that crosses the suture line, unlike the described swelling in this case.
A client is 36 hours post-op a TKR surgery. 270 cc of sero-sanguinous fluid accumulates in the surgical drains. What action should the nurse take?
A. Notify the doctor
B. Empty the drain
C. Do nothing
D. Remove the drain
Correct answer:
The correct action for the nurse to take in this situation is to notify the doctor. Significant sero-sanguinous drainage after TKR surgery could indicate a potential issue such as infection or bleeding. The physician needs to be informed promptly to assess the situation and determine the appropriate course of action. Emptying the drain, doing nothing, or removing the drain without consulting the physician could lead to complications going unnoticed or untreated. It is crucial to involve the physician in decision-making to ensure the best outcomes for the client.
B. Managing the comprehensive care needs of the client for continuity of care.
C. Providing client education needs upon discharge.
D. Securing financial resources for needed care.
Correct answer:
The correct answer is 'Managing the comprehensive care needs of the client for continuity of care.' Case managers oversee all aspects of a client's care to ensure continuity throughout their healthcare journey. Choice A is incorrect as it focuses only on nursing care needs at discharge, which is just a part of the overall care needed. Choice C narrows down the focus to client education needs, excluding other essential care components. Choice D solely considers financial resources, neglecting the broader scope of care needs that a case manager is accountable for.
Which of the following arterial blood gas values indicates a patient may be experiencing a condition of metabolic acidosis?
A. PaO2 90 mm Hg
B. Bicarbonate 15 mEq/L
C. CO2 47 mm Hg
D. pH 7.34
Correct answer:
The correct answer is B: Bicarbonate 15 mEq/L. In metabolic acidosis, the bicarbonate levels are lower than normal. A bicarbonate value of 15 mEq/L indicates a deficit in the buffer system, contributing to the acidosis. Choices A, C, and D are incorrect. Choice A, PaO2 90 mm Hg, reflects oxygen partial pressure and is not directly related to metabolic acidosis. Choice C, CO2 47 mm Hg, represents carbon dioxide levels and is more indicative of respiratory status. Choice D, pH 7.34, falls within the normal range (7.35-7.45) and does not confirm metabolic acidosis.
A client with cancer is admitted to the oncology unit. Stat lab values reveal Hgb 12.6, WBC 6500, K+ 1.9, uric acid 7.0, Na+ 136, and platelets 178,000. The nurse evaluates that the client is experiencing which of the following?
A. Hypernatremia
B. Hypokalemia
C. Myelosuppression
D. Leukocytosis
Correct answer:
The correct answer is 'Hypokalemia.' The potassium level of 1.9 indicates low potassium levels, a condition known as hypokalemia. The other lab values are within normal ranges: Hgb 12.6, WBC 6500, uric acid 7.0, Na+ 136, and platelets 178,000. Hypernatremia (choice A) refers to high sodium levels, which are not present in this case. Myelosuppression (choice C) is a decrease in bone marrow activity, which is not indicated by the lab values provided. Leukocytosis (choice D) is an increase in white blood cells, which is also not present based on the given values.
NCLEX-PN clinical judgment practice questions, set 49 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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