NCLEX-PN clinical judgment practice questions, set 52
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 52
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 microorganisms are considered normal body flora?
A. staphylococcus on the skin
B. streptococcus in the nares
C. candida albicans in the vagina
D. pseudomonas in the blood
Show answer and rationale
Correct answer: A — staphylococcus on the skin
Staphylococcus is considered normal body flora as it is commonly found on the skin, being a part of the normal microbiota. While streptococcus in the nares can be part of the normal flora of the upper respiratory tract, it is not as common or as widespread as staphylococcus on the skin. Candida albicans in the vagina is not considered normal flora; it is a common opportunistic pathogen in the vagina. Pseudomonas in the blood is also not considered normal body flora; pseudomonas is not typically found in the blood as part of the normal microbiota.
Question 2
A 57-year-old woman is recently widowed. She states, 'I will never be able to learn how to manage the finances. My husband did all of that.' Select the nurse's response that could help raise the client's self-esteem.
A. "You feel inadequate because you have never learned to balance a checkbook."?
B. "You should have insisted your husband teach you about the finances."?
C. "You are strong and will learn how to manage your finances after a while."?
D. "Why don't you take a class in basic finance from the local college?"?
Show answer and rationale
Correct answer: C — "You are strong and will learn how to manage your finances after a while."?
The nurse can raise the client's self-esteem by acknowledging the client's feelings and providing positive reinforcement. Choice C shows empathy and support by recognizing the client's strength and potential to learn. This response encourages the client to believe in her abilities and instills confidence. Choices A and B may come across as judgmental or critical, which can further lower the client's self-esteem. Choice D, while offering a solution, does not address the client's emotional needs or provide direct reassurance about her capabilities.
Question 3
A client with a history of peptic ulcer disease arrives in the emergency department complaining of weakness and states that he vomited 'a lot of dark coffee-looking stomach contents.' The client is cool and moist to the touch. BP 90/50, HR 110, RR 20, T 98. Of the following physician orders, which will the nurse perform first?
A. Initiate oxygen at 2 liters/nasal cannula.
B. Start an IV of NS at 150 ml/hr
C. Insert NG tube to low suction
D. Attach the client to the ECG monitor
Show answer and rationale
Correct answer: A — Initiate oxygen at 2 liters/nasal cannula.
The correct answer is to initiate oxygen at 2 liters/nasal cannula. The client is presenting signs of shock with hypotension, tachycardia, and cool, moist skin, which indicate poor tissue perfusion. Oxygen should be administered first to improve tissue oxygenation. While all interventions are important, oxygenation takes priority in the ABCs of emergency care. Starting an IV of NS, inserting an NG tube, and attaching the client to the ECG monitor are necessary interventions but should follow the priority of oxygen administration in this scenario.
Question 4
The client is undergoing progressive ambulation on the third day after a myocardial infarction. Which clinical manifestation would indicate that the client should not be advanced to the next level?
A. Facial flushing
B. A complaint of chest heaviness
C. Heart rate increase of 10 beats/min
D. Systolic blood pressure increase of 10 mm Hg
Show answer and rationale
Correct answer: B — A complaint of chest heaviness
The correct answer is a complaint of chest heaviness. Onset of chest pain indicates myocardial ischemia, which can be life-threatening. Chest pain in a client post-myocardial infarction should be promptly evaluated, and the activity level should not be advanced. Choices A, C, and D are not the best options because facial flushing, a heart rate increase of 10 beats/min, and a systolic blood pressure increase of 10 mm Hg are not typical indicators of myocardial ischemia or necessarily contraindications for advancing activity levels in this context.
Question 5
A nurse is preparing a female client for a rectal examination. Into which position does the nurse assist the client?
A. Supine
B. Standing
C. Lithotomy
D. Left lateral
Show answer and rationale
Correct answer: D — Left lateral
For a rectal examination in a female client, the nurse should assist the client into the left lateral position. This position allows easier access to the rectal area, facilitating the examination. The lithotomy position is used for examining the genitalia and rectum in females, not solely for a rectal examination. The standing position is not appropriate for a rectal examination as it does not provide the necessary access. The supine position would hinder the effectiveness of a rectal examination as it does not optimize access to the rectal area.
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Question 6
What are the major electrolytes in the extracellular fluid?
A. potassium and chloride
B. potassium and phosphate
C. sodium and chloride
D. sodium and phosphate
Correct answer:
The correct answer is sodium and chloride. These two electrolytes are the major components of extracellular fluid. Potassium and phosphate (Choice B) are not the major electrolytes in the extracellular fluid. Potassium is primarily an intracellular ion, and phosphate is more abundant in the intracellular fluid and bones. Sodium and phosphate (Choice D) are also not the major electrolytes in the extracellular fluid. Chloride plays a crucial role in maintaining electrolyte balance and is predominantly found in extracellular fluid alongside sodium.
The new mother asks why her baby has lost weight since he was born. The best explanation of the weight loss is:
A. The baby is dehydrated due to polyuria.
B. The baby is hypoglycemic due to lack of glucose.
C. The baby is allergic to the formula the mother is giving him.
D. The baby can lose up to 10% of weight due to meconium stool, loss of extracellular fluid, and initiation of breastfeeding.
Correct answer:
After birth, newborns can lose weight due to meconium stool, loss of extracellular fluid, and the initiation of breastfeeding. This weight loss is a normal and expected physiological process, and infants can lose up to 10% of their birth weight during this period. There is no indication of dehydration (polyuria), hypoglycemia (lack of glucose), or allergy to the formula as reasons for weight loss in newborns. Therefore, answers A, B, and C are incorrect. Answer D provides the most accurate explanation for the observed weight loss in the newborn.
How many feet should separate the nurse and the source when extinguishing a small, wastebasket fire with an appropriate extinguisher?
A. 1 foot
B. 2 feet
C. 4 feet
D. 6 feet
Correct answer:
The nurse should stand about 6 feet from the source of the fire. Getting closer might put the nurse in danger. Choice A, 1 foot, is incorrect because it is too close to the fire and can expose the nurse to unnecessary risk. Choice B, 2 feet, is also too close to the fire and may lead to potential harm. Similarly, choice C, 4 feet, is not the ideal distance as it is still within the range of potential danger. The correct answer is D, 6 feet, which is a safe distance for the nurse to extinguish the fire effectively without risking personal safety.
A man reports his wife is constantly cleaning, which interferes with family life. Friends avoid visiting due to feeling uncomfortable. The husband finds her cleaning even at night. The nurse should consult and recommend the husband help with therapy by:
A. telling his wife to stop cleaning whenever he notices her actions.
B. making a baseline record of the time the wife spends cleaning.
C. decreasing the stimuli in the home.
D. helping his wife with the cleaning.
Correct answer:
The correct answer is to decrease the stimuli in the home. The wife's behavior suggests obsessive-compulsive disorder, an anxiety disorder. By reducing stimuli in the environment, such as clutter or triggers that prompt cleaning, it helps in managing the condition and promoting a calmer atmosphere. Option A is incorrect as directly telling the wife to stop can escalate her anxiety. Option B is not the priority initially, as addressing the root cause is more crucial. Option D may reinforce the behavior rather than addressing the underlying issue.
Which reported symptom would indicate a client with Addison's disease has received too much fludrocortisone (Florinef) replacement?
A. Oily skin and hair
B. Weight gain of 6 pounds in one week
C. Loss of muscle mass in arms and legs
D. Increased blood glucose level
Correct answer:
Fludrocortisone (Florinef) replacement in Addison's disease involves mimicking aldosterone to retain sodium and water. This retention can lead to weight gain due to increased fluid retention. Rapid weight gain, such as 6 pounds in one week, is a concerning sign of excessive fluid retention, indicating a potential overdose of fludrocortisone. Choices A, C, and D are incorrect because oily skin and hair, loss of muscle mass, and increased blood glucose levels are not specific symptoms of excessive fludrocortisone replacement in Addison's disease.
When assessing a client in the Emergency Department whose membranes have ruptured, the nurse notes that the fluid is a greenish color. What is the cause of this greenish coloration?
A. blood
B. meconium
C. hydramnios
D. caput
Correct answer:
The correct answer is B: meconium. Greenish amniotic fluid passed when the fetus is in a cephalic (head) presentation might indicate fetal distress. A fetus in the breech presentation passes meconium due to compression on the intestinal tract. Choice A, blood, is incorrect as blood in the amniotic fluid would present as a different color. Choice C, hydramnios, refers to an excess of amniotic fluid and would not cause the greenish coloration. Choice D, caput, is swelling of a newborn's scalp and is not related to the color of the amniotic fluid.
Because of the possible nervous system side-effects that occur with isoniazid (Nydrazid) therapy, which supplementary nutritional agent would the nurse teach the client to take as a prophylaxis?
A. Alpha tocopherol (vitamin E)
B. Ascorbic acid (vitamin C)
C. Calcitriol (vitamin D)
D. Pyridoxine (vitamin B6)
Correct answer:
Pyridoxine is the correct choice in this scenario because it is used as a prophylaxis to prevent neuritis, a possible nervous system side-effect of isoniazid therapy. Neuritis is a condition that involves inflammation of the nerves and can be a side effect of isoniazid. Pyridoxine, also known as vitamin B6, helps prevent this side effect. Vitamin E (Alpha tocopherol), vitamin C (Ascorbic acid), and vitamin D (Calcitriol) do not specifically address the nervous system side-effects associated with isoniazid therapy, making them incorrect choices.
Which client can best be assigned to the newly licensed practical nurse?
A. The client receiving chemotherapy
B. The client post-coronary bypass
C. The client with a TURP
D. The client with diverticulitis
Correct answer:
The best client to assign to the newly licensed nurse is the most stable client. In this case, the client with diverticulitis is the most stable among the options provided. Clients receiving chemotherapy and those post-coronary bypass require specialized care and attention, making them unsuitable for a newly licensed nurse. The client with a TURP may be at risk of bleeding, needing a nurse experienced in managing such complications. Therefore, the client with diverticulitis is the most appropriate choice for the newly licensed practical nurse.
A 15-year-old high school wrestler has been taking diuretics to lose weight to compete in a lower weight class. Which of the following medical tests is most likely to be given?
A. Lab values of Potassium and Sodium
B. Lab values of Glucose and Hemoglobin
C. ECG
D. CT scan
Correct answer:
Diuretics can disrupt the sodium and potassium balance, potentially leading to cardiac complications. Monitoring the lab values of potassium and sodium is crucial to assess electrolyte imbalances due to diuretic use. Testing glucose and hemoglobin levels is not directly related to diuretic use in this context. An ECG would be indicated if there were signs or symptoms of cardiac abnormalities, but it is not the primary test to monitor the effects of diuretics. A CT scan is not typically used to assess electrolyte imbalances caused by diuretics.
As part of the teaching plan for a client with type I diabetes mellitus, the nurse should include that carbohydrate needs might increase when:
A. an infection is present.
B. there is an emotional upset.
C. a large meal is eaten.
D. active exercise is performed.
Correct answer:
During active exercise, insulin sensitivity increases, leading to lower blood glucose levels. To balance the effect of increased insulin sensitivity, additional carbohydrates might be needed. The other choices are incorrect because: A) an infection typically raises blood glucose levels rather than increasing the need for carbohydrates; B) emotional upset can impact blood glucose but does not directly affect carbohydrate needs; C) while a large meal can raise blood glucose levels, it does not necessarily mean an increase in carbohydrate needs.
NCLEX-PN clinical judgment practice questions, set 52 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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