NCLEX-PN clinical judgment practice questions, set 59
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 59
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
The client is admitted to the unit after a cholecystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because:
A. The client is at risk for evisceration.
B. The client will require frequent dressing changes.
C. The straps provide support for drains that are inserted in the incision.
D. No sutures or clips are used to secure the incision.
Show answer and rationale
Correct answer: B — The client will require frequent dressing changes.
Montgomery straps are used to secure dressings that require frequent changes due to the large amount of drainage usually present after a cholecystectomy. They are also beneficial for clients allergic to various types of tape. Answer A is incorrect as the client is not at higher risk of evisceration. Answer C is incorrect because Montgomery straps are not used to support drains. Answer D is incorrect as sutures or clips are typically used to secure the incision after gallbladder surgery, not Montgomery straps.
Question 2
Which of the following can certain foods like broccoli, oranges, dark greens, and dark yellow vegetables help improve?
A. Vitamin intake
B. Body functions
C. Defense mechanisms
D. Disease cure
Show answer and rationale
Correct answer: C — Defense mechanisms
Certain foods like broccoli, oranges, dark greens, and dark yellow vegetables can help improve defense mechanisms by enhancing the immune system and overall health. While these foods can boost defense mechanisms, they are not a cure for diseases, do not balance body functions, and are not intended to solely supplement vitamin intake, which may be necessary in some cases. Therefore, the correct answer is defense mechanisms as these foods strengthen the body's ability to fight off illnesses and maintain health.
Question 3
The nurse is caring for a client with cerebral palsy. The nurse should provide frequent rest periods because:
A. Grimacing and writhing movements decrease with relaxation and rest.
B. Hypoactive deep tendon reflexes become more active with rest.
C. Stretch reflexes are increased with rest.
D. Fine motor movements are improved.
Show answer and rationale
Correct answer: A — Grimacing and writhing movements decrease with relaxation and rest.
Frequent rest periods help to relax tense muscles and preserve energy in clients with cerebral palsy. This can lead to a decrease in grimacing and writhing movements, as relaxation and rest help to alleviate muscle tension. Choices B, C, and D are incorrect because they provide inaccurate information. Hypoactive deep tendon reflexes do not become more active with rest; stretch reflexes are not increased with rest in cerebral palsy patients, and fine motor movements are not necessarily improved solely by rest.
Question 4
Which statement best describes electrolytes in intracellular and extracellular fluid?
A. There is a greater concentration of sodium in extracellular fluid and potassium in intracellular fluid
B. There is an equal concentration of sodium and potassium in extracellular fluid
C. There is a greater concentration of potassium in extracellular fluid and sodium in intracellular fluid
D. There is an equal concentration of sodium and potassium between intracellular and extracellular fluid
Show answer and rationale
Correct answer: A — There is a greater concentration of sodium in extracellular fluid and potassium in intracellular fluid
Electrolytes are distributed unequally between intracellular and extracellular fluids. Sodium concentration is higher in extracellular fluid, while potassium concentration is higher in intracellular fluid. Therefore, the correct answer is 'There is a greater concentration of sodium in extracellular fluid and potassium in intracellular fluid.' Choices B, C, and D are incorrect because they do not accurately describe the typical distribution of sodium and potassium between intracellular and extracellular fluid.
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."?' When a client is having a seizure, it is crucial to turn them onto their side to prevent aspiration of secretions. Placing them on their back can lead to potential airway compromise. Choices A, B, and D are correct statements that indicate a good understanding of caring for a child with a seizure disorder: ensuring rest, getting a medical alert bracelet for identification, and loosening clothing to facilitate breathing during a seizure.
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Question 6
A nurse is preparing to assess the fetal heart rate (FHR) of a client who is 14 weeks pregnant. Which piece of equipment does the nurse use to assess the FHR?
A. Stethoscope
B. Doppler transducer
C. Fetoscope
D. Pulse oximetry on the client and a fetoscope
Correct answer:
To assess the fetal heart rate of a client who is 14 weeks pregnant, the nurse should use a Doppler transducer. Fetal heart sounds can be heard with a fetoscope by 20 weeks of gestation. The Doppler transducer amplifies fetal heart sounds so that they are audible by 10 to 12 weeks of gestation, making it the most appropriate choice for this scenario. Fetal heart sounds cannot be heard with a stethoscope. Pulse oximetry is not used to auscultate fetal heart sounds, so it is an incorrect choice in this context.
When giving an intramuscular injection to an infant, which of the following sites is preferred?
A. Ventrogluteal region
B. Deltoid
C. Vastus lateralis
D. Dorsogluteal region
Correct answer:
The correct answer is the Vastus lateralis when giving an intramuscular injection to an infant. The Vastus lateralis muscle, located in the thigh, is the preferred site for infants as it has a larger muscle mass and is well-developed, making it suitable for injections. The Ventrogluteal region and Dorsogluteal region are not recommended for infants due to their smaller muscle mass and potential risk of damaging nearby structures. The Deltoid muscle is typically used for older children and adults, not infants.
A nurse auscultating the fetal heart rate (FHR) of a pregnant client in the first trimester of pregnancy notes that the FHR is 160 beats/min. With this information, what should be the nurse's next action?
A. Notify the healthcare provider of the finding.
B. Document the findings.
C. Tell the client that the FHR is faster than normal but that it is nothing to be concerned about at this time.
D. Wait 15 minutes and then recheck the FHR.
Correct answer:
An FHR of 160 beats/min in the first trimester of pregnancy is within the normal range, which is generally 120 to 160 beats/min. The appropriate action for the nurse in this situation is to document the findings. There is no need to notify the healthcare provider as this is a normal finding. Informing the client that the FHR is faster than normal may cause unnecessary anxiety, as it falls within the expected range. Waiting to recheck the FHR is not necessary since the rate is already within the normal range.
Why might breast implants interfere with mammography?
A. They might cause additional discomfort.
B. They are contraindications to mammography.
C. They are likely to be dislodged.
D. They might prevent detection of masses.
Correct answer:
Breast implants can interfere with mammography by potentially preventing the detection of masses. The presence of implants can obscure a clear view of breast tissue, making it difficult to identify abnormalities such as masses that may indicate breast cancer. Choices A, B, and C are incorrect because discomfort, contraindications, and dislodgment are not primary reasons why breast implants interfere with mammography. The main concern is the impedance of detecting abnormalities accurately due to the implants.
To ensure safety while administering a nitroglycerine patch, what should the nurse do?
A. Wear gloves
B. Shave the area where the patch will be applied
C. Wash the area thoroughly with soap and rinse with hot water
D. Apply the patch to the buttocks
Correct answer:
To protect herself, the nurse should wear gloves when applying a nitroglycerine patch or cream. Answer B is incorrect because shaving the area where the patch will be applied might abrade the skin, increasing the risk of irritation. Answer C is incorrect because washing with hot water can vasodilate the skin, potentially increasing the absorption of nitroglycerine. Nitroglycerine patches should be applied to areas above the waist, making answer D incorrect as applying it to the buttocks is not recommended.
A client is complaining of difficulty walking secondary to a mass in the foot. The nurse should document this finding as:
A. Plantar fasciitis.
B. Hallux valgus.
C. Hammertoe.
D. Morton's neuroma.
Correct answer:
The correct answer is Morton's neuroma. Morton's neuroma is a small mass or tumor in a digital nerve of the foot, causing symptoms such as pain and difficulty walking. Hallux valgus is commonly known as a bunion and involves the deviation of the big toe towards the other toes. Hammertoe is a condition where one or more toes are bent in a claw-like position. Plantar fasciitis is characterized by pain and inflammation in the arch of the foot, not typically associated with a mass causing difficulty walking.
A healthcare professional is assessing a patient in the rehab unit during shift change. The patient has sustained a TBI 3 weeks ago. Which of the following is the most distinguishing characteristic of a neurological disturbance?
A. LOC (level of consciousness)
B. Short-term memory
C. Babinski sign
D. Clonus sign
Correct answer:
Level of consciousness (LOC) is the most crucial indicator of impaired neurological function. Changes in LOC can signify various neurological conditions, including traumatic brain injury. Short-term memory, while important, is not the most distinguishing characteristic of neurological disturbances. Babinski and Clonus signs are specific neurological tests that can provide information about upper motor neuron lesions but are not as generalizable as changes in LOC for assessing overall neurological status.
The client with diverticulosis is being assisted by the nurse in selecting appropriate foods. Which food should be avoided?
A. Bran
B. Fresh peaches
C. Cucumber salad
D. Yeast rolls
Correct answer:
The food that should be avoided for a client with diverticulosis is Cucumber salad. Foods with seeds should be avoided as they can aggravate diverticulosis by causing irritation and inflammation in the diverticula. Choices A, B, and D are allowed and even beneficial. Bran cereal and fruit like fresh peaches can help prevent constipation, which is beneficial for individuals with diverticulosis. Yeast rolls are also acceptable unless the client has specific dietary restrictions related to yeast or gluten.
The licensed practical nurse is observing a graduate nurse as she assesses the central venous pressure. Which observation would indicate that the graduate needs further teaching?
A. The graduate places the client in a supine position to read the manometer.
B. The graduate turns the stop-cock to the off position from the IV fluid to the client.
C. The graduate instructs the client to perform the Valsalva maneuver during the CVP reading.
D. The graduate notes the level at the top of the meniscus.
Correct answer:
The correct answer is C because the client should breathe normally during a central venous pressure monitor reading. Placing the client in a supine position (Choice A) is correct if the client can tolerate it. Turning the stop-cock off (Choice B) and noting the level at the top of the meniscus (Choice D) are also correct actions during CVP monitoring. Instructing the client to perform the Valsalva maneuver is incorrect as it can artificially alter the CVP reading, indicating a need for further teaching.
A nurse working in a surgical unit notices a patient experiencing SOB, calf pain, and warmth over the posterior calf. All of these symptoms may indicate which of the following medical conditions?
A. Patient may have a DVT.
B. Patient may be exhibiting signs of dermatitis.
C. Patient may be in the late stages of CHF.
D. Patient may be experiencing anxiety after surgery.
Correct answer:
The correct answer is that the patient may have a DVT (Deep Vein Thrombosis). SOB (Shortness of Breath), calf pain, and warmth over the posterior calf are classic signs and symptoms of DVT. DVT is a serious condition where a blood clot forms in a deep vein, commonly in the legs. Choices B, C, and D are incorrect because dermatitis does not typically present with these symptoms, late stages of CHF would manifest with other signs, and anxiety after surgery usually does not produce these specific symptoms.
NCLEX-PN clinical judgment practice questions, set 59 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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