NCLEX-PN clinical judgment practice questions, set 5
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 5
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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
When planning task assignments for five clients on the skilled nursing unit in a long-term care facility, which task should a licensed practical nurse (LPN) assign to another LPN?
A. Bathing a client who is confused and requires assistance with a shower
B. Administering regular insulin in accordance with a sliding-dosage scale every 4 hours to a client with diabetes mellitus
C. Assisting a client requiring a bed bath and frequent ambulation with a cane
D. Transporting a client who must be accompanied to physical therapy twice during the shift
Show answer and rationale
Correct answer: B — Administering regular insulin in accordance with a sliding-dosage scale every 4 hours to a client with diabetes mellitus
When assigning tasks, the nurse must consider the skills and educational level of the nursing staff. The nursing assistant may be assigned tasks like caring for a confused client, assisting with a shower or a bed bath, ambulating a client with a cane, and accompanying a client to physical therapy. The LPN is educated to administer medications like regular insulin in accordance with a sliding scale. This task requires a higher level of training and knowledge than the tasks that can be delegated to a nursing assistant. Administering insulin involves assessing blood glucose levels, calculating dosages, and understanding the effects of insulin therapy on the client's condition. Therefore, the correct answer is administering regular insulin to a client with diabetes mellitus. Choices A, C, and D involve tasks that are within the scope of practice of a nursing assistant, not an LPN.
Question 2
What happens if folic acid is administered to treat anemia without determining its underlying cause?
A. Erythropoiesis is inhibited
B. Excessive levels of folic acid might accumulate, causing toxicity
C. The symptoms of pernicious anemia might be masked, delaying treatment
D. Intrinsic factor is destroyed
Show answer and rationale
Correct answer: C — The symptoms of pernicious anemia might be masked, delaying treatment
When folic acid is given without determining the underlying cause of anemia, the symptoms of pernicious anemia may be masked, potentially delaying the correct treatment. Folic acid alone does not protect against the central nervous system changes seen in pernicious anemia, which are related to Vitamin B12 deficiency. Folic acid and Vitamin B12 are both crucial for cell growth and division. Administering folic acid without knowing the specific type of anemia could lead to a delay in addressing the root cause. Option A is incorrect because folic acid is essential for erythropoiesis, the production of red blood cells. Option B is incorrect as excessive folic acid can cause toxicity, but it is not the primary concern in this context. Option D is incorrect because folic acid treatment for anemia does not directly impact intrinsic factor, which is related to Vitamin B12 absorption.
Question 3
Which of the following behaviors is least appropriate when dealing with fellow staff members?
A. Provide positive feedback and constructive criticism
B. Serve as a resource
C. Only report conflicts that interfere with client care
D. Provide input for performance evaluations
Show answer and rationale
Correct answer: C — Only report conflicts that interfere with client care
The least appropriate behavior when dealing with fellow staff members is to only report conflicts that interfere with client care. This choice implies ignoring or neglecting other conflicts that may affect team dynamics and the work environment. It is crucial to address and report all conflicts, whether they impact client care directly or not, to maintain a harmonious and effective working relationship within the healthcare setting. Providing positive feedback, constructive criticism, serving as a resource, and offering input for performance evaluations are all important and appropriate behaviors that contribute to a supportive and professional work environment. By focusing solely on conflicts that interfere with client care, essential issues that influence teamwork and overall staff morale may be overlooked, potentially leading to a negative impact on the work environment.
Question 4
A woman asks, "How much alcohol can I safely drink while pregnant?"? The nurse's best response is:
A. "The amount of alcohol that is safe during pregnancy is unknown."?
B. "Consuming one or two beers or glasses of wine a day is considered safe for a healthy pregnant woman."?
C. "Drinking three or more drinks on any given occasion is the only harmful type of drinking during pregnancy."?
D. "You can have a drink to help you relax and get to sleep at night."?
Show answer and rationale
Correct answer: A — "The amount of alcohol that is safe during pregnancy is unknown."?
The correct answer is, "The amount of alcohol that is safe during pregnancy is unknown."? This response is appropriate because there is no known safe amount of alcohol consumption during pregnancy. Consuming any amount of alcohol during pregnancy can pose risks to the developing fetus, leading to conditions like fetal alcohol syndrome, which is a combination of mental and physical abnormalities in infants. Choices B, C, and D are incorrect. Choice B suggests that consuming one or two drinks a day is safe during pregnancy, which is not supported by current medical guidelines. Choice C incorrectly states that only drinking three or more drinks on any given occasion is harmful, when in reality, any amount of alcohol can be harmful to the fetus. Choice D is inappropriate as it suggests that having a drink to relax and sleep is acceptable during pregnancy, which is not the case.
Question 5
A nurse in a long-term care center notes that an employee is constantly calling in sick. Which action should the nurse take initially to handle this problem?
A. Documenting the employee's absences in the personnel file
B. Discussing the situation with the employee and reminding them of the agency's employment standards
C. Reporting the employee to administration
D. Issuing a written warning to the employee
Show answer and rationale
Correct answer: B — Discussing the situation with the employee and reminding them of the agency's employment standards
When an employee demonstrates excessive absenteeism, the initial action a nurse should take is to discuss the situation with the employee and remind them of the agency's employment standards. It is important to communicate openly with the employee to understand the reasons for their frequent absences and remind them of the expectations regarding attendance. This approach allows for a constructive dialogue and provides the employee with an opportunity to rectify their behavior. Documenting the employee's absences in the personnel file may be necessary if the issue persists despite the discussion. Reporting the employee to administration should be considered only if the employee fails to improve after the initial discussion. Issuing a written warning should be a subsequent step if the employee continues to violate the attendance policies even after reminders and discussions.
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Question 6
When working with a client diagnosed with Borderline Personality Disorder who frequently attempts self-harm, what is the best intervention to facilitate behavior change?
A. Constantly observing the client to prevent self-harm.
B. Enlisting the client in defining and describing harmful behaviors.
C. Checking on the client every 15 minutes to ensure they are not engaging in harmful behavior.
D. Removing all items from the environment that the client could use to harm themselves.
Correct answer:
The most effective intervention when working with clients who have a history of self-harm, like the client diagnosed with Borderline Personality Disorder, is to involve them actively in their treatment. By enlisting the client to define and describe the harmful behaviors, the client becomes an integral part of identifying triggers and understanding the underlying causes of their actions. This approach empowers the client, promotes self-awareness, and fosters a sense of control over their behaviors. Constantly observing the client (Choice A) may lead to a lack of trust and hinder the therapeutic relationship. Checking on the client every 15 minutes (Choice C) may disrupt the client's sense of autonomy and privacy. Removing all items from the environment that could be used for self-harm (Choice D) is a temporary solution and does not address the root causes of the behavior.
A nurse is trying to motivate a client toward more effective management of a therapeutic regimen. Which of the following actions by the nurse is most likely to be effective in increasing the client's motivation?
A. determining if the client has any family or friends living nearby
B. developing a concise discharge plan and reviewing it with the client
C. teaching the client about the disorder at the client's level of understanding
D. making a referral to an area agency for client follow-up
Correct answer:
To effectively motivate the client, it is important to educate them about the disorder at their level of understanding. This helps the client comprehend the importance of the therapeutic regimen and empowers them to actively participate in their treatment. Choice A, determining if the client has any family or friends living nearby, may provide social support but is less likely to directly impact the client's motivation compared to educating them about their condition. Developing a concise discharge plan, as in choice B, is crucial for continuity of care but may not directly enhance the client's motivation as effectively as providing education tailored to their level of understanding. Making a referral for follow-up, as in choice D, is important for ongoing care but may not have the same immediate impact on the client's motivation as educating them about their condition.
Which behavior by a new nurse would indicate to the charge nurse that this nurse is following standard precautions?
A. Wearing clean gloves while performing a heel stick on an infant
B. Wearing the same gloves for assessments of clients in the same room
C. Wearing sterile gloves when changing the urine bag and nasogastric canister of an infected client
D. Donning a gown when responding to a request by the family to check the IV pump on a client with rotavirus
Correct answer:
The correct answer is wearing clean gloves while performing a heel stick on an infant. Standard precautions require the use of gloves when there is a risk of exposure to blood or body fluids. Clean gloves are suitable for this task as they provide adequate protection without being sterile. Choice B is incorrect because wearing the same gloves for different clients can lead to cross-contamination, violating standard precautions. Choice C is incorrect as sterile gloves are usually not required for changing a urine bag and nasogastric canister unless a specific aseptic technique is indicated; standard precautions do not demand sterile gloves for such tasks. Choice D is incorrect as donning a gown is not necessary for checking an IV pump unless there is a risk of exposure to bodily fluids that would necessitate full-body protection, which is not indicated in this scenario.
When a staff member is observed not following the plan of care for a client with an antisocial personality disorder, what should the nurse do?
A. confront the staff member immediately and say, "You know that is not the treatment plan."?
B. write an incident report to create a paper trail of the staff member's failure to follow the planned program.
C. ask the staff member to talk in private, and reinforce how antisocial clients try to divide staff.
D. bring up the incident during the weekly conference so that this staff member is not assigned to work with antisocial persons again.
Correct answer:
When a staff member is observed not following the plan of care for a client with an antisocial personality disorder, it is crucial to address the issue promptly and effectively. Confronting the staff member immediately in front of the client may worsen the situation by enhancing the division of staff and compromising client care. Writing an incident report, although important for documentation, may not address the immediate need to correct the behavior. Bringing up the incident during a weekly conference may not be the most effective approach for immediate resolution. Asking the staff member to talk in private and reinforcing how antisocial clients try to divide staff is the best option. This approach allows for a constructive conversation to address the issue, provide education, and help the staff member develop skills to work effectively with this client population.
A home health nurse is making preparations for morning visits. Which one of the following clients should the nurse visit first?
A. A client with brain attack (stroke) receiving tube feedings
B. A client with congestive heart failure complaining of nighttime dyspnea
C. A client who had a thoracotomy 6 months ago
D. A client with Parkinson’s disease
Correct answer:
The correct answer is B. The client with congestive heart failure complaining of nighttime dyspnea should be seen first as airway management is a priority in nursing care. This client's symptoms indicate potential respiratory distress, requiring immediate attention. Choices A, C, and D involve clients who are more stable and do not present with urgent or acute conditions that require immediate intervention. Choice A with a client receiving tube feedings for a stroke may require attention, but the urgency of addressing potential respiratory distress in choice B takes precedence. Choice C, a client who had a thoracotomy 6 months ago, unless presenting with acute distress, does not necessitate immediate attention. Choice D, a client with Parkinson's disease, is usually a chronic condition that does not typically require immediate intervention for the described scenario.
The LPN is teaching a first-time mother about breastfeeding her newborn. Which statement, if made by the mother, would reflect that the teaching had been successful?
A. "My baby should be having at least 4-6 wet diapers a day until 1 month."?
B. "It's nice that breastfed babies eat a bit less than formula-fed babies."?
C. "My baby should be nursing 8-12 times a day during this period."?
D. "I'm a little nervous about my milk coming in tomorrow. I've heard it's uncomfortable."?
Correct answer:
The correct answer is, '"My baby should be nursing 8-12 times a day during this period."?' This statement indicates successful teaching because newborns should nurse 8-12 times during the newborn period to ensure they receive adequate nutrition and establish a good milk supply. This frequency helps in meeting the baby's demands for growth and development.
Choice A is incorrect because while it mentions the appropriate number of wet diapers a day once the mother's milk comes in, it does not reflect successful teaching about breastfeeding frequency.
Choice B is incorrect because it discusses feeding amounts in comparison to formula-fed babies, which is not a direct indicator of successful breastfeeding teaching.
Choice D is incorrect because it focuses on the mother's concerns about milk coming in, not on understanding the feeding frequency needed for the newborn.
When the nurse who was not promoted first read the memo and learned that the other nurse had received the promotion, she left the room in tears. This behavior is an example of:
A. conversion.
B. regression
C. introjection.
D. rationalization
Correct answer:
Crying is a regressive behavior. The ego returned to an earlier, comforting, and less-mature way of behaving in the face of disappointment. Regression involves reverting to an earlier stage of development to cope with stress or conflict. In this scenario, the nurse regressed to a childlike state by crying when faced with the disappointment of not getting the promotion, demonstrating regression as a defense mechanism. Conversion involves transforming anxiety into a physical symptom. Introjection involves unconsciously identifying intensely with another person. Rationalization involves unconsciously creating acceptable explanations to justify unacceptable ideas, actions, or feelings. Therefore, the correct answer is regression as it aligns with the nurse's behavior of regressing to a childlike state by crying due to the disappointment of not receiving the promotion.
A client being treated for sickle cell disease has an order for pain medication. Morphine was ordered, but the nurse is having difficulty deciphering the dose. The nurse should ____.
A. ask the attending physician to clarify the order, including the correct medication, dose, route, and frequency
B. call the charge nurse to inform the attending physician and verify the order, including the correct medication, dose, route, and frequency
C. call the attending physician to verbally verify the order, including the correct medication, dose, route, and frequency
D. refrain from administering the medication until the charge nurse can assist in determining the correct dosage
Correct answer:
In this scenario, when a nurse encounters difficulties in deciphering an order, the appropriate action is to contact the attending physician directly to clarify and verify the medication, dose, route, and frequency. It is crucial for the nurse to have a clear understanding of the order before administering any medication to ensure patient safety and proper treatment. Option A is incorrect as it suggests asking the attending physician to clarify without specifying the urgency of the situation. Option B involves an unnecessary additional step by first contacting the charge nurse before reaching out to the attending physician, potentially delaying the clarification process. Option D is incorrect as it advises refraining from administering the medication, which may not be necessary if the correct dosage can be promptly verified by contacting the attending physician.
A nurse reviewed the arterial blood gas reading of a 25-year-old male. The nurse should be able to conclude the patient is experiencing which of the following conditions?
A. metabolic acidosis
B. respiratory acidosis
C. metabolic alkalosis
D. respiratory alkalosis
Correct answer:
The correct answer is respiratory alkalosis. In respiratory alkalosis, there is an elevated pH and low carbon dioxide levels (PaCO2 < 35 mmHg). In the given arterial blood gas reading, the patient's pH is 7.41 (within normal range), PaCO2 is 29 mmHg (below normal range), indicating respiratory alkalosis. The bicarbonate level is normal (25 mEq/l), ruling out metabolic acidosis or alkalosis. The low PaO2 (54 mmHg) may indicate hypoxemia, but it is not directly related to the acid-base disorder being assessed. Metabolic acidosis (choice A) is characterized by low pH and low bicarbonate levels, which are not present in this case. Respiratory acidosis (choice B) is indicated by low pH and high PaCO2 levels, which also do not match the provided data. Metabolic alkalosis (choice C) is defined by high pH and high bicarbonate levels, which are not seen in this scenario.
A client is admitted to the critical care unit after suffering from a massive cerebral vascular accident. The client's vital signs include BP 160/110, HR 42, Cheyne-Stokes respirations. Based on this assessment, the nurse anticipates the client to be in which acid-base balance?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
Correct answer:
In this scenario, the client is exhibiting Cheyne-Stokes respirations, which are characterized by periods of deep breathing alternating with apnea. This pattern indicates respiratory insufficiency, resulting in an accumulation of carbon dioxide in the blood. The elevated BP and slow heart rate further support the respiratory insufficiency, leading to respiratory acidosis. Therefore, the correct answer is Respiratory acidosis.
Choices B, C, and D are incorrect. Respiratory alkalosis is characterized by decreased carbon dioxide levels in the blood, which is not indicated by the client's presentation. Metabolic acidosis results from conditions such as renal failure or diabetic ketoacidosis and is not the primary imbalance in this case. Metabolic alkalosis is characterized by elevated pH and bicarbonate levels, which are not present in the client's vital signs.
NCLEX-PN clinical judgment practice questions, set 5 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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