NCLEX-PN clinical judgment practice questions, set 51
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 51
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 of the following indicates a hazard for a client on oxygen therapy?
A. A 'No Smoking' sign is on the door.
B. The client is wearing a synthetic gown.
C. Electrical equipment is grounded.
D. Matches are removed.
Show answer and rationale
Correct answer: B — The client is wearing a synthetic gown.
The correct answer is that the client is wearing a synthetic gown. A synthetic gown might generate sparks of static electricity, which can be a fire hazard, especially in the presence of oxygen. Clients on oxygen therapy should wear cotton gowns to minimize the risk of fire. The other options are not hazards for a client on oxygen therapy: having a 'No Smoking' sign on the door promotes safety by preventing smoking, ensuring electrical equipment is grounded reduces the risk of electrical hazards, and removing matches decreases the risk of fire hazards.
Question 2
What should be the first action upon the discovery of an electrical fire?
A. Disconnect the electrical power if it can be done safely
B. Smother the source with an object like a blanket
C. Saturate the source with water or another liquid
D. Immediately activate the fire alarm
Show answer and rationale
Correct answer: A — Disconnect the electrical power if it can be done safely
The correct initial action upon discovering an electrical fire is to disconnect the electrical power if it can be done safely. This helps prevent the fire from spreading through the electrical system. Smothering the fire with a blanket is not recommended for electrical fires as it can fuel the fire. Saturating the source with water or other liquids is also not advised as it can lead to electric shock or spread the fire. Activating the fire alarm is important, but it should be done after disconnecting the power to prevent further escalation of the fire.
Question 3
A nurse assesses an 83-year-old female's venous ulcer for the second time that is located near the right medial malleolus. The wound is exhibiting purulent drainage, and the patient has limited mobility in her home. Which of the following is the best course of action?
A. Encourage warm water soaks to the right foot.
B. Notify the case manager of the purulent drainage.
C. Determine the patient's pulse in the right ankle.
D. Recommend increased activity to reduce the purulent drainage.
Show answer and rationale
Correct answer: A — Encourage warm water soaks to the right foot.
The correct course of action is to encourage warm water soaks to the right foot. This can help promote wound healing and alleviate discomfort. Before recommending increased activity or notifying additional team members, it is crucial to assess arterial blood flow by determining the patient's pulse in the right ankle. Poor arterial blood flow could worsen the condition, making increased activity inappropriate. While notifying the case manager of purulent drainage is important, addressing the wound care directly should be the primary focus at this stage.
Question 4
Which of the following is an appropriate nursing goal for a client at risk for nutritional problems?
A. provide oxygen
B. promote healthy nutritional practices
C. treat complications of malnutrition
D. increase weight
Show answer and rationale
Correct answer: B — promote healthy nutritional practices
The correct answer is to promote healthy nutritional practices. This goal focuses on preventive measures to address the client's nutritional risk. Providing oxygen (Choice A) is not directly related to addressing nutritional problems. Treating complications of malnutrition (Choice C) involves addressing the consequences rather than preventing or managing the nutritional problems. Increasing weight (Choice D) would only be appropriate if the client is underweight; it does not address the broader aspect of promoting overall healthy nutritional practices.
Question 5
A woman seeks assistance because she recently remembered childhood sexual abuse. The nurse should include which of the following goals for this client?
A. prosecuting the perpetrator
B. managing symptoms of anxiety and fear
C. determining if the memories are real
D. collaborating with the client's story
Show answer and rationale
Correct answer: B — managing symptoms of anxiety and fear
The correct answer is 'managing symptoms of anxiety and fear.' When a client remembers childhood sexual abuse, the nurse's primary goal should be to help the client cope with the emotional distress and symptoms such as anxiety and fear. Prosecuting the perpetrator is not within the nurse's scope of practice and is a legal matter. Determining if the memories are real is not the nurse's role; the focus should be on providing support and care. Collaborating with the client's story is vague and does not address the immediate emotional needs of the client.
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Question 6
The newborn nursery is filled to capacity. Which newborn should the nurse assess first?
A. A three-hour-old just waking up after a period of sleep
B. A two-day-old crying loudly
C. A three-day-old two hours after circumcision
D. A one-hour-old sucking his fist
Correct answer:
The most critical time for assessment in a newborn is during the second period of reactivity, which occurs approximately 3-5 hours after delivery. During this phase, newborns are more likely to gag on mucus and aspirate, making it crucial for the nurse to assess their respiratory status first. Choice A indicates a newborn in this critical phase, requiring immediate assessment for potential airway compromise or respiratory distress. Choices B, C, and D do not present an immediate need for assessment related to airway compromise or respiratory distress.
Following a classic cholecystectomy resection for multiple stones, the PACU nurse observes serosanguinous drainage on the dressing. The most appropriate intervention is to:
A. notify the physician of the drainage.
B. change the dressing.
C. reinforce the dressing.
D. apply an abdominal binder
Correct answer:
Serosanguinous drainage is expected after a classic cholecystectomy resection. The appropriate intervention is to reinforce the dressing to maintain pressure and promote clot formation. Changing the dressing prematurely increases the risk of infection as it disturbs the wound. Applying an abdominal binder is not indicated as it can interfere with visualizing the dressing and assessing for any signs of bleeding or infection. Notifying the physician is not necessary at this point unless there are signs of excessive bleeding or other concerning symptoms.
Which is the proper hand position for performing chest vibration?
A. cup the hands
B. use the side of the hands
C. flatten the hands
D. spread the fingers of both hands
Correct answer:
The correct hand position for performing chest vibration is to flatten the hands. By flattening the hands over the area of the body where chest percussion is applied, vibrations can be conducted effectively to the chest to help loosen secretions. Cupping the hands may dampen vibrations, using the side of the hands reduces the surface area in contact with the chest, and spreading the fingers can lead to uneven pressure distribution. Therefore, flattening the hands provides the necessary contact and surface area to perform chest vibration efficiently.
While assessing a patient in the ICU, a nurse observes signs of a weak pulse, quick respiration, acetone breath, and nausea. Which of the following conditions is most likely occurring?
A. Hypoglycemic patient
B. Hyperglycemic patient
C. Cardiac arrest
D. End-stage renal failure
Correct answer:
The correct answer is a hyperglycemic patient. The signs described - weak pulse, quick respiration, acetone breath, and nausea - are indicative of hyperglycemia. A hypoglycemic patient would typically present with different signs such as pale skin, sweating, and confusion. Cardiac arrest would manifest with sudden loss of heart function and consciousness, not the signs described. End-stage renal failure would present with symptoms related to kidney dysfunction like edema, fatigue, and changes in urine output, which are not mentioned in the scenario.
During a screening on a patient with a recent cast on the left lower extremity, which of the following statements should the nurse be most concerned about?
A. The patient reports, "I didn't keep my extremity elevated as the doctor asked me to."?
B. The patient reports, "I have been having pain in my left calf."?
C. The patient reports, "My left leg has really been itching."?
D. The patient reports, "The arthritis in my wrists is flaring up when I put weight on my crutches."?
Correct answer:
The correct answer is B because pain in the left calf could indicate a potential neurovascular complication related to the casted extremity. It could suggest issues such as compartment syndrome or impaired circulation. Option A is not as concerning since not elevating the extremity may lead to swelling but is not an immediate concern. Option C indicates itching, which is common with casts and not as concerning as potential neurovascular issues. Option D, regarding arthritis in the wrists, is unrelated to the lower extremity issue being screened for.
A patient has recently been prescribed Zidovudine (Retrovir). The patient has AIDS. Which of the following side effects should the patient specifically watch out for?
A. Weakness and SOB
B. Fever and anemia
C. Hypertension and SOB
D. Fever and hypertension
Correct answer:
The correct answer is 'Fever and anemia.' Zidovudine (Retrovir) is known to cause anemia as a side effect due to its impact on the bone marrow. Fever is also a common side effect associated with Zidovudine use. Therefore, the patient should watch out for these specific side effects. Choice A (Weakness and SOB) is incorrect as shortness of breath (SOB) is not a commonly reported side effect of Zidovudine. Choice C (Hypertension and SOB) and Choice D (Fever and hypertension) are unrelated to the known side effects of Zidovudine, making them incorrect.
The doctor orders 2% nitroglycerin ointment in a 1-inch dose every 12 hours. Proper application of nitroglycerin ointment includes:
A. Rotating application sites
B. Limiting applications to the chest
C. Rubbing it into the skin
D. Covering it with a thin paper dressing
Correct answer:
Proper application of nitroglycerin ointment involves rotating application sites to prevent skin irritation. It should be applied to the back and upper arms, not restricted to the chest, making option B incorrect. Rubbing it into the skin, as indicated in option C, is not recommended for nitroglycerin ointment as it can lead to faster absorption and potential side effects. The correct way is to cover it with a thin paper dressing, not gauze as mentioned in option D, to ensure proper absorption and prevent the medication from evaporating too quickly.
A 60-year-old widower is hospitalized after complaining of difficulty sleeping, extreme apprehension, shortness of breath, and a sense of impending doom. What is the best response by the nurse?
A. "You have nothing to worry about. You are in a safe place. Try to relax."?
B. "Has anything happened recently or in the past that might have triggered these feelings?"?
C. "We have given you a medication that helps to decrease feelings of anxiety."?
D. "Take some deep breaths and try to calm down."?
Correct answer:
Choice B is the best response as it shows empathy, acknowledges the patient's feelings, and opens the door for discussion about potential triggers for anxiety. This approach helps the patient explore the root cause of his anxiety and provides an opportunity for therapeutic communication. Choice A dismisses the patient's feelings and offers false reassurance, which may not address the underlying issue. Choices C and D do not encourage the patient to express his emotions or delve into the reasons behind his anxiety, hindering the therapeutic process.
The nurse notes the patient care assistant looking through the personal items of the client with cancer. Which action should be taken by the registered nurse?
A. Notify the police department for investigation
B. Report this behavior to the charge nurse
C. Monitor the situation and document any suspicious activities
D. Confront the patient care assistant immediately
Correct answer:
The appropriate action for the registered nurse in this scenario is to report the behavior to the charge nurse. This allows for proper investigation and intervention. Inappropriate actions include notifying the police directly without following the chain of command (Choice A), monitoring without immediate action (Choice C), and confronting the assistant without involving a superior (Choice D). By reporting to the charge nurse, the situation is escalated appropriately within the healthcare setting, ensuring the well-being and safety of the client.
A 25-year-old male is brought to the emergency room with a piece of metal in his eye. Which action by the nurse is correct?
A. Use a magnet to remove the object.
B. Rinse the eye thoroughly with saline.
C. Cover both eyes with paper cups.
D. Administer eye drops immediately.
Correct answer:
Covering both eyes with paper cups is the correct action as it helps prevent consensual movement of the affected eye. Attempting to remove the object with a magnet might cause trauma, making choice A incorrect. While rinsing the eye with saline may be necessary, it should be ordered by a doctor and is not the initial action for the nurse, making choice B incorrect. Administering eye drops immediately, as in choice D, is not appropriate in this scenario and does not address the primary concern of preventing further damage by limiting eye movement.
NCLEX-PN clinical judgment practice questions, set 51 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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