NCLEX-PN clinical judgment practice questions, set 6
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 6
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 mother has just given birth to a baby who died soon after. The mother has been crying and states, "I can't believe this has happened to me. I did everything right during this pregnancy."? How should the nurse respond to this mother?
A. Tell her she did nothing wrong; it was God's will.
B. Tell her she can have another baby.
C. Tell her that her behavior is not going to solve anything.
D. Tell her nothing and let her mourn this loss in the manner she chooses.
Show answer and rationale
Correct answer: D — Tell her nothing and let her mourn this loss in the manner she chooses.
Perinatal loss is a significant tragedy for parents, and it is crucial to provide sensitive and compassionate care. When a mother expresses her disbelief and feelings of doing everything right during the pregnancy, it is important for the nurse to acknowledge her pain and allow her to grieve in her way. Telling her that she did nothing wrong and it was God's will (Choice A) may not be comforting and can come across as dismissive of her feelings. Suggesting she can have another baby (Choice B) is insensitive and overlooks the grief she is experiencing for the current loss. Telling her that her behavior is not going to solve anything (Choice C) is invalidating her emotions and not supportive in this situation. Therefore, the best approach is to support her in her mourning process by respecting her feelings and allowing her to express her grief as she sees fit.
Question 2
A client with a left arm fracture complains of severe diffuse pain that is unrelieved by pain medication. On further assessment, the nurse notes that the client experiences increased pain during passive motion compared with active motion of the left arm. Based on these assessment findings, which action should the nurse take first?
A. Contacting the health care provider
B. Checking if it is time for more pain medication
C. Encouraging the client to continue active range of motion exercises of the left arm
D. Repositioning the client for comfort
Show answer and rationale
Correct answer: A — Contacting the health care provider
The correct answer is to contact the health care provider. The client with early acute compartment syndrome typically complains of severe diffuse pain that is unrelieved by pain medication. Additionally, the affected client experiences greater pain during passive motion compared to active motion. In this situation, it is crucial to notify the health care provider immediately for further evaluation and intervention. Contacting the health care provider is essential to ensure timely diagnosis and appropriate management of the condition. Checking for more pain medication, encouraging active range of motion exercises, or repositioning the client may not address the underlying issue of acute compartment syndrome and could delay necessary interventions. Therefore, the priority action should be to involve the healthcare provider for prompt assessment and treatment.
Question 3
A nurse, assigned to care for a hospitalized child who is 8 years old, assists with planning care, taking into account Erik Erikson's theory of psychosocial development. According to Erikson's theory, which task represents the primary developmental task of this child?
A. Developing a sense of control over self and body functions
B. Mastering useful skills and tools
C. Gaining independence from parents
D. Developing a sense of trust in the world
Show answer and rationale
Correct answer: B — Mastering useful skills and tools
According to Erikson's theory of psychosocial development, the primary task for an 8-year-old child aligns with the stage of industry versus inferiority. This stage focuses on mastering useful skills and tools of the culture, emphasizing competence in various areas. Option A, 'Developing a sense of control over self and body functions,' is more characteristic of the toddler stage, emphasizing autonomy and self-regulation. Option C, 'Gaining independence from parents,' is more relevant to the adolescent stage, where identity development and autonomy become crucial. Option D, 'Developing a sense of trust in the world,' pertains to the infant stage, highlighting the importance of forming secure attachments. Therefore, the correct answer is B as it directly corresponds to the developmental tasks associated with an 8-year-old child according to Erikson's theory.
Question 4
A nurse is assisting a new nursing graduate with organizational skills in delivering client care. The nurse determines that the new nursing graduate needs assistance with time management if the new graduate takes which action?
A. Gathers supplies before beginning a task
B. Allows time for unexpected tasks
C. Prioritizes client needs and daily tasks
D. Documents task completion and client information at the end of the day
Show answer and rationale
Correct answer: A — Gathers supplies before beginning a task
The correct answer is 'Gathers supplies before beginning a task.' This action indicates a lack of effective time management because gathering supplies before starting a task can lead to inefficiency and time wastage. Effective time management involves organizing tasks efficiently, which includes having all necessary supplies ready before initiating a task. Allowing time for unexpected tasks, prioritizing client needs and daily tasks, and documenting task completion and client information at the end of the day are all essential components of good time management practices. Therefore, the new nursing graduate should focus on improving the timing of supply gathering to enhance time management skills. The other choices are not indicative of poor time management; instead, they demonstrate important aspects of effective time management in client care delivery.
Question 5
A newborn baby exhibits a reflex that includes hand opening, abducted, and extended extremities following a jarring motion. Which of the following correctly identifies the reflex?
A. ATNR reflex
B. Startle reflex
C. Grasping reflex
D. Moro reflex
Show answer and rationale
Correct answer: D — Moro reflex
The Moro reflex, also known as the startle reflex, is the correct answer. This reflex is characterized by the baby's response to a sudden head movement or loud noise, causing them to open their hands, extend their arms, and then bring them back towards their body. The characteristics mentioned in the question - hand opening, abducted, and extended extremities following a jarring motion - align with the Moro reflex. The asymmetrical tonic neck reflex (ATNR) involves the head turning to one side with extension of the same side's arm and leg, not the described characteristics. The grasping reflex involves the baby's response to touch on the palm, causing them to grasp an object. While the Moro reflex is often referred to as the startle reflex due to its response to sudden stimuli, the specific characteristics described in the question match the Moro reflex.
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Question 6
In the Emergency Department (ED), which client should the nurse see first?
A. COPD client with a non-productive cough
B. Diabetic client who has an infected sore on the foot
C. Client with adrenal insufficiency who feels weak
D. Client with a fracture of the forearm in an air splint
Correct answer:
In the Emergency Department, the priority is to assess and manage clients based on the urgency of their conditions. A client with adrenal insufficiency presenting with weakness should be seen first as this could indicate a state of shock, which requires immediate attention to stabilize the client's condition. Weakness in adrenal insufficiency can progress rapidly to a life-threatening adrenal crisis. Choice A, a COPD client with a non-productive cough, may need treatment but is not immediately life-threatening. Choice B, a diabetic client with an infected sore on the foot, requires timely care to prevent complications but can generally wait for evaluation compared to the potential urgency of adrenal insufficiency. Choice D, a client with a fracture of the forearm in an air splint, is important but not as time-sensitive as a client potentially in shock.
A graduate nurse hired to work in a medical unit of a hospital is attending an orientation session. The nurse educator, discussing care maps, asks the graduate nurse whether she understands how a care map is used. Which response indicates understanding?
A. The care map outlines the day-to-day expected outcomes of care and the outcomes anticipated at discharge
B. The care map is a plan that is used only by the nurse to provide client care
C. The care map is a standard plan, rather than an individualized one, that is developed strictly by a nurse and used for a client with a particular diagnosis
D. The care map is developed by a nurse and identifies nursing diagnoses
Correct answer:
The correct answer is A. A care map, also known as a critical pathway, outlines the day-to-day expected outcomes of care and the outcomes anticipated at discharge or the end of a treatment phase. It includes clinical assessments, treatments, dietary interventions, activity therapies, client education, and discharge planning. While it may identify nursing diagnoses, a care map is developed by all disciplines caring for the client type and is used by the interdisciplinary team, not just the nurse alone. Choice B is incorrect because a care map is not solely for the nurse but for the entire interdisciplinary team. Choice C is incorrect as care maps are individualized plans developed by the interdisciplinary team, not just by a nurse. Choice D is incorrect as a care map is not solely about nursing diagnoses but encompasses a comprehensive plan of care.
When a 17-year-old client arrives at the clinic suspecting a sexually transmitted infection, what information does the nurse provide concerning informed consent?
A. She will need to sign an informed consent form.
B. Her mother or father will need to be contacted for permission to treat her.
C. A consent form is not needed if the problem is a sexually transmitted infection.
D. Anyone over the age of 18 years may sign a consent form for her treatment.
Correct answer:
Informed consent is a person's agreement to allow something, such as a treatment, to be performed. A consent form is required even if the problem is a sexually transmitted infection. If the client is a minor, the minor may sign the informed consent form in specific situations, including seeking treatment for a sexually transmitted infection. In this case, the 17-year-old client is seeking examination and treatment for a sexually transmitted infection, so she will need to sign the informed consent form. Contacting her parents for permission is not required in this situation. Choice C is incorrect because a consent form is necessary regardless of the medical issue. Choice D is incorrect because the individual's age is not the determining factor; rather, it is the nature of the medical service being sought that dictates the need for informed consent.
The manic client has just interrupted the group session with the counselor for the 4th time, explaining that she already knows this information on 'dealing with others when you are down' and constantly gets up and goes to the front. What should the nurse do at this time?
A. Engage the client to walk with you to make another pot of coffee
B. Ask the client to reflect on their behavior to determine if it is appropriate
C. Ask the group to tell the client how they feel when she interrupts
D. Instruct the client to perform jumping jacks and count aloud to get rid of some energy
Correct answer:
In this situation, it is important to redirect the client's energy and focus. Engaging the client in a purposeful activity like making another pot of coffee can help distract them from disruptive behavior and provide an outlet for their excess energy. This choice also helps in maintaining a therapeutic environment by involving the client in a constructive task. Asking the client to reflect on their behavior (Choice B) might not be effective during a manic episode as the client may not be in a state to critically analyze their actions. Asking the group to tell the client how they feel (Choice C) can escalate the situation and may not be appropriate in this context. Instructing the client to perform jumping jacks and count aloud (Choice D) may not address the underlying issue of disruptive behavior and may not be suitable for the current situation.
What are major competencies for the nurse giving end-of-life care?
A. demonstrating respect and compassion, and applying knowledge and skills in the care of the family and the client.
B. assessing and intervening to support total management of the family and client.
C. setting goals, expectations, and dynamic changes to care for the client.
D. keeping all sad news away from the family and client.
Correct answer:
Major competencies for nurses providing end-of-life care involve a combination of skills and qualities. Demonstrating respect and compassion towards the family and the client is essential in end-of-life care. Additionally, applying knowledge and skills in caring for both the family and the client is crucial to ensure comprehensive and compassionate care. Option A is the correct choice as it accurately reflects these key competencies. Option B, which focuses on assessing and intervening for total management, is important but does not fully address the holistic approach necessary for end-of-life care. Option C, about setting goals and expectations, is relevant but not as critical as the core competencies mentioned in option A. Option D is incorrect as withholding sad news goes against the principles of honesty and transparency in end-of-life care.
Central venous access devices (CVADs) are frequently utilized to administer chemotherapy. What is an advantage of using CVADs for chemotherapeutic agent administration?
A. CVADs are more expensive than a peripheral IV.
B. Weekly administration is possible.
C. Chemotherapeutic agents can be caustic to smaller veins.
D. The client or family can administer the drug at home.
Correct answer:
The correct advantage of using CVADs for chemotherapeutic agent administration is that chemotherapeutic agents can be caustic to smaller veins. Many chemotherapeutic drugs are vesicants, which can cause tissue damage even in low concentrations. Using a CVAD to administer these agents into a large vein is optimal as it reduces the risk of damage. Choice A is incorrect as CVADs are actually more expensive than a peripheral IV, making it a disadvantage. Choice B is incorrect because the frequency of administration depends on the specific drug being administered, not on the access device, so it does not represent a universal advantage. Choice D is incorrect because IV chemotherapeutic agents are typically not self-administered at home; they are usually given in a hospital, outpatient, or clinic setting, making it an invalid advantage of using CVADs.
The nurse is preparing task assignments for the day. Which task should the nurse assign to a nursing assistant?
A. Monitoring for bleeding for a client who has just undergone cardiac catheterization
B. Assisting a client who is getting up to ambulate for the first time after surgery
C. Providing oral care to an unconscious client who requires oral care
D. Completing the preoperative checklist for a client scheduled for a liver biopsy
Correct answer:
When delegating tasks, the nurse must consider the state nursing practice act guidelines and job descriptions. Providing oral care to an unconscious client is a task suitable for delegation to a nursing assistant. The nurse should give clear instructions on adapting the procedure for the client's needs and the signs of complications to watch for. Monitoring for bleeding after cardiac catheterization necessitates immediate nursing assessment, which requires critical thinking and intervention that exceeds a nursing assistant's scope of practice. Assisting a client with ambulation post-surgery carries the risk of orthostatic hypotension and should be performed by a licensed nurse. Completing a preoperative checklist for a client scheduled for a liver biopsy involves critical assessment and preparation that are within the nurse's scope of practice.
Which of the following statements is true about syphilis?
A. The cause and mode of transmission are well understood.
B. There is no known cure for the disease.
C. When the primary lesion heals, the disease is cured.
D. Syphilis can be cured with a course of antibiotic therapy.
Correct answer:
The correct statement about syphilis is that it can be cured with a course of antibiotic therapy. Syphilis is a treponemal disease that can be effectively treated with antibiotics, particularly long-acting penicillin G. The primary lesion of syphilis, known as a chancre, typically appears about three weeks after exposure and can involute even without specific treatment. If left untreated, secondary manifestations may occur, followed by latent periods. Specific treatment with antibiotics is crucial to prevent progression and transmission of the disease. Therefore, option D is correct. Option A is incorrect because the cause and mode of transmission of syphilis are well understood. Option B is incorrect as there is a known cure for syphilis. Option C is incorrect because the healing of the primary lesion does not indicate a cure for the disease.
Why might the physician order antibiotics to be given through the central venous access device (CVAD) rather than through a peripheral IV line if the CVAD becomes infected?
A. To prevent infiltration of the peripheral line
B. To reduce the pain and discomfort associated with antibiotic administration in a small vein
C. To lessen the chance of an allergic reaction to the antibiotic
D. To attempt to eliminate microorganisms in the catheter and prevent having to remove it
Correct answer:
When a patient's central venous access device (CVAD) becomes infected, administering antibiotics through the line is essential to attempt to eliminate microorganisms within the catheter. The goal is to prevent the necessity of removing the catheter, which might be required if the infection persists. Choice A, 'To prevent infiltration of the peripheral line,' is incorrect as the priority is addressing the catheter infection, not preventing issues with a peripheral line. Choice B, 'To reduce the pain and discomfort associated with antibiotic administration in a small vein,' is not relevant to the rationale for choosing the CVAD for antibiotic administration. Choice C, 'To lessen the chance of an allergic reaction to the antibiotic,' is also incorrect as the main focus is managing the catheter-associated infection rather than allergy prevention.
An RN on your unit has had an argument with the family of a client regarding the way in which the RN has changed the client's dressing. The family is adamant that the dressing change was performed incorrectly. The RN insists that sterile technique was observed. As an RN manager, what is the best response?
A. Meet with the family member and the RN to discuss the disagreement regarding the dressing change.
B. Talk to the family member and assure them that the nurse followed the hospital procedure.
C. Discuss the dressing change procedure with the RN and compare it to a current textbook.
D. Change the RN's assignment the next day to another client.
Correct answer:
When conflict occurs, it is best to meet with both parties together to discuss the problem. This approach allows each party to hear what the other is saying and prevents the RN manager from being caught in the middle. By facilitating a discussion between the family member and the RN, they can work together to find a resolution or the manager can mediate. This promotes open communication, understanding, and collaboration. Option A is the correct choice because it emphasizes addressing the conflict directly and seeking a mutual understanding. Option B is incorrect because just assuring the family member may not address the underlying issues. Option C is incorrect as it does not involve the family member in the resolution process. Option D is inappropriate as it doesn't address the conflict but rather avoids it by changing the RN's assignment.
NCLEX-PN clinical judgment practice questions, set 6 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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