NCLEX-PN clinical judgment practice questions, set 50
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 50
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 on the night shift is making client rounds. When the nurse checks a client who is 97 years old and has successfully been treated for heart failure, he notes that the client is not breathing. If the client does not have a do-not-resuscitate (DNR) order, the nurse should take which action?
A. Administer cardiopulmonary resuscitation (CPR)
B. Call the client's health care provider
C. Administer oxygen to the client and call the health care provider
D. Contact the nursing supervisor for directions
Show answer and rationale
Correct answer: A — Administer cardiopulmonary resuscitation (CPR)
Administering cardiopulmonary resuscitation (CPR) is the appropriate action when a client is not breathing and does not have a do-not-resuscitate (DNR) order. CPR is considered an emergency treatment that can be provided without client consent in life-threatening situations. Calling the health care provider or nursing supervisor for directions, as well as administering oxygen without addressing the lack of breathing, would delay critical life-saving interventions. Therefore, administering CPR is the most urgent and necessary action to perform in this scenario.
Question 2
An Asian family has an elderly member with the latest stage of Alzheimer's disease. The physician has recommended placement in a long-term care facility, but the family refuses. Which of the following is an appropriate response by the nurse?
A. "You really need to listen to what the physician says."?
B. "You will get too tired to take care of him at home."?
C. "What can I do to assist you to care for him at home?"?
D. "You are too busy to be taking care of an elderly person."?
Show answer and rationale
Correct answer: C — "What can I do to assist you to care for him at home?"?
The correct answer is, "What can I do to assist you to care for him at home?"? This response shows cultural sensitivity and respect for the family's values. In many Asian cultures, there is a strong tradition of caring for elders at home rather than in a long-term care facility. By offering assistance to the family in caring for their elderly member at home, the nurse shows understanding and support. Choices A, B, and D are incorrect because they do not acknowledge or respect the family's cultural beliefs and values regarding caring for elderly family members.
Question 3
Nursing care for a client undergoing chemotherapy includes assessment for signs of bone marrow depression. Which finding accounts for some of the symptoms related to bone marrow depression?
A. erythrocytosis
B. leukocytosis
C. polycythemia
D. thrombocytopenia
Show answer and rationale
Correct answer: D — thrombocytopenia
Thrombocytopenia is an abnormal decrease in the number of platelets, which results in bleeding tendencies. During chemotherapy, bone marrow depression can lead to a reduction in platelet production, causing thrombocytopenia. Erythrocytosis is an abnormal increase in red blood cells, leukocytosis is an increase in white blood cells, and polycythemia is an excess of red blood cells, which is synonymous with erythrocytosis. In the context of chemotherapy, the focus is on the decrease in red and white blood cells, making thrombocytopenia the most relevant finding.
Question 4
During the health screening of an adolescent, which finding by the nurse requires further teaching?
A. The client started her first menses 2 years ago.
B. The client states she is currently taking birth control pills.
C. The client states she recently lost 5 pounds.
D. The client states she is experiencing growing pains.
Show answer and rationale
Correct answer: B — The client states she is currently taking birth control pills.
The correct answer is 'The client states she is currently taking birth control pills.' This finding requires further teaching because being on birth control pills does not protect against sexually transmitted diseases (STDs), and the adolescent should be educated on the importance of using barrier methods (e.g., condoms) for STD prevention. Choices A, C, and D are not concerning. Choice A is a normal developmental milestone in adolescence. Choice C could indicate a positive lifestyle change, and choice D is a common complaint during this stage of development.
Question 5
A young boy is recently diagnosed with a seizure disorder. Which of the following statements by the boy's mother indicates a need for further teaching by the nurse?
A. "I should make sure he gets plenty of rest."?
B. "I should get him a medical alert bracelet."?
C. "I should lay him on his back during a seizure."?
D. "I should loosen his clothing during a seizure."?
Show answer and rationale
Correct answer: C — "I should lay him on his back during a seizure."?
The correct answer is "I should lay him on his back during a seizure."? This statement indicates a need for further teaching because a client having a seizure should be turned to the side to prevent aspiration of secretions. Choices A, B, and D are correct. Getting plenty of rest helps in managing seizures, having a medical alert bracelet informs others about the condition in case of emergency, and loosening clothing during a seizure ensures better air circulation and prevents injury. These actions demonstrate adequate understanding of the teaching provided.
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Question 6
The nurse is caring for a preschool child who is being treated in the hospital for respiratory syncytial virus (RSV). In planning the client's care, the nurse should recognize that the child is likely to view this illness as?
A. Punishment.
B. Disturbance to body image.
C. Rejection from parents.
D. Change in routine with friends.
Correct answer:
The correct answer is A: Punishment. Preschool children often see illness as a form of punishment, especially when they are unable to understand the cause of their sickness. This perception is rooted in their limited cognitive abilities and understanding of health concepts. Choices B, C, and D are incorrect because preschool children are less likely to associate illness with disturbance to body image, rejection from parents, or changes in routine with friends. These options are not developmentally appropriate for how preschoolers typically interpret illness.
Quality is defined as a combination of all of the following except:
A. conforming to standards.
B. performing at the minimally acceptable level.
C. meeting or exceeding customer requirements.
D. exceeding customer expectations.
Correct answer:
Quality in any context is about meeting or exceeding customer requirements and exceeding customer expectations. It also involves conforming to standards to ensure consistency and reliability. Merely performing at the minimally acceptable level does not encompass the essence of quality, as it sets the bar at the lowest level of acceptability rather than aiming for excellence or customer satisfaction. Therefore, the correct answer is 'performing at the minimally acceptable level,' as this choice falls short in capturing the comprehensive definition of quality.
What is the best nursing diagnosis for a client with newly diagnosed Diabetes Mellitus?
A. Impaired Skin Integrity
B. Knowledge Deficit: New Diabetes Diagnosis
C. Alteration in Nutrition: More than Body Requirements
D. Fluid Volume Deficit
Correct answer:
The correct answer is 'Knowledge Deficit: New Diabetes Diagnosis.' Newly diagnosed diabetics require education on their disease, medications, glucose testing, insulin injections, foot care, and sick-day plans. Choices A and D aim to prevent issues that do not currently exist for the client. Choice C, 'Alteration in Nutrition: More than Body Requirements,' is not the priority diagnosis for a newly diagnosed diabetic. While nutritional adjustments may be required for type I or type II diabetes, providing knowledge and education takes precedence at this stage.
A. The terminally ill client is referred to hospice and dies 3 months later.
B. A client receives an unordered mammogram which reveals a small cyst.
C. A client with a laceration to the knee requiring 4 sutures falls when getting up unassisted after being instructed to remain in bed.
D. A client scheduled for knee replacement surgery had an above-the-knee amputation performed.
Correct answer:
Yes! A sentinel event is an unexpected occurrence causing death or serious injury. In this case, a client who was scheduled for knee replacement surgery but had an above-the-knee amputation performed instead represents a sentinel event as it resulted in serious harm that was not intended. The other choices do not meet the criteria for a sentinel event. Choice A describes a natural progression for a terminally ill client, choice B shows an incidental finding from a test, and choice C involves a preventable fall leading to an injury but not a sentinel event.
Nail and foot care are essential in meeting the basic hygiene needs of clients. Important assessments by the nurse in this area include:
A. a full-body assessment is not specific to nail and foot care.
B. the essential lab work of the client is not related to nail and foot assessments.
C. the nail beds and the tissue surrounding the nails.
D. foot corns and calluses only neglect other important aspects of nail and foot care.
Correct answer:
The correct answer is to assess the nail beds and the tissue surrounding the nails. This assessment is crucial to identify abnormal discoloration, lesions, paronychia, dryness, breaks in the skin, pressure areas, or any other unusual appearances. Choice A is incorrect as a full-body assessment is broader and not specific to nail and foot care. Choice B is incorrect as lab work is not directly related to nail and foot assessments. Choice D is incorrect as it focuses only on foot corns and calluses, neglecting other important aspects of nail and foot care.
A healthcare professional is reviewing a patient's medical record. The record indicates the patient has limited shoulder flexion on the left. Which plane of movement is limited?
A. Horizontal
B. Sagittal
C. Frontal
D. Vertical
Correct answer:
The correct answer is 'Sagittal.' The sagittal plane divides the body into left and right halves, and movements in this plane involve flexion and extension. In this case, limited shoulder flexion on the left indicates a restriction in the forward and backward movement of the arm, which occurs in the sagittal plane. Choice A, 'Horizontal,' is incorrect as it refers to movements parallel to the ground. Choice C, 'Frontal,' is incorrect as it involves side-to-side movements. Choice D, 'Vertical,' is incorrect as it typically refers to up and down movements.
A healthcare professional is reviewing a patient's ECG report. The patient exhibits a flat T wave, depressed ST segment, and short QT interval. Which of the following medications can cause all of the above effects?
A. Morphine
B. Atropine
C. Procardia
D. Digitalis
Correct answer:
The correct answer is Digitalis. Digitalis is known to cause a flat T wave, depressed ST segment, and a short QT interval on an ECG report. These ECG changes are characteristic of digitalis toxicity. Morphine is not typically associated with these ECG changes. Atropine is more commonly linked to increasing heart rate rather than causing these specific ECG abnormalities. Procardia is a calcium channel blocker that does not typically produce the described ECG findings. Therefore, Digitalis is the most likely medication causing these effects in the patient.
When treating anemia in clients with renal failure, erythropoietin should be given in conjunction with:
A. iron, folic acid, and B12.
B. an increase in protein in the diet.
C. vitamins A and C.
D. an increase in calcium in the diet.
Correct answer:
Erythropoietin is used to stimulate red blood cell production in clients with renal failure. To effectively increase red blood cell production, adequate levels of iron, folic acid, and B12 are necessary. These nutrients play crucial roles in erythropoiesis. Choices B, an increase in protein in the diet, is not directly related to enhanced erythropoiesis and can potentially worsen uremia. Choices C and D, vitamins A and C, and an increase in calcium in the diet, are not directly involved in red blood cell production and are not essential in this context.
A client, age 28, was recently diagnosed with Hodgkin's disease. After staging, therapy is planned to include combination radiation therapy and systemic chemotherapy with MOPP"?nitrogen mustard, vincristine (Onconvin), prednisone, and procarbazine. In planning care for this client, the nurse should anticipate which of the following side effects to contribute to a sense of altered body image?
A. Cushingoid appearance
B. Alopecia
C. Temporary or permanent sterility
D. Pathologic fractures
Correct answer:
The correct answer is B: Alopecia. Chemotherapy drugs like vincristine can cause alopecia, which is hair loss. This side effect can significantly impact a patient's body image. While Cushingoid appearance (A) can be a side effect of long-term steroid use, temporary or permanent sterility (C) may affect a patient's future fertility but not necessarily alter body image. Pathologic fractures (D) are not common side effects of Hodgkin's disease or its treatment and do not directly contribute to a sense of altered body image in the same way as alopecia does.
The healthcare provider should utilize data about which of the following to provide information about the nutritional status of a client being evaluated for malnutrition?
A. triceps skinfold measurement
B. fasting blood glucose level
C. hemoglobin A1c level
D. serum lipid profile results
Correct answer:
Objective anthropometric measurements such as triceps skinfold and mid-arm circumference (MAC), along with weight, are usually used to diagnose malnutrition. Triceps skinfold measurement specifically helps assess body fat and muscle mass, providing valuable information about the client's nutritional status. Fasting blood glucose level, hemoglobin A1c level, and serum lipid profile results are important tests in assessing different aspects of health such as diabetes management and cardiovascular risk, but they are not specific indicators of malnutrition.
NCLEX-PN clinical judgment practice questions, set 50 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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