NCLEX-PN clinical judgment practice questions, set 60
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 60
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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 child with seizure disorder is being treated with Dilantin (phenytoin). Which of the following statements by the patient's mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy?
A. "She is very irritable lately."?
B. "She sleeps quite a bit of the time."?
C. "Her gums look too big for her teeth."?
D. "She has gained about 10 pounds in the last 6 months."?
Show answer and rationale
Correct answer: C — "Her gums look too big for her teeth."?
The correct answer is '"Her gums look too big for her teeth."?' Hyperplasia of the gums is a known side effect associated with Dilantin therapy. Option A, '"She is very irritable lately,"?' is not a typical side effect of Dilantin. Option B, '"She sleeps quite a bit of the time,"?' is a common side effect of Dilantin but not specific to gum hyperplasia. Option D, '"She has gained about 10 pounds in the last 6 months,"?' is not typically associated with Dilantin therapy and is unrelated to the question.
Question 2
When teaching about preventable diseases, the importance of getting the following vaccines should be emphasized:
A. human papillomavirus, genital herpes, measles.
B. pneumonia, HIV, mumps.
C. syphilis, gonorrhea, pneumonia.
D. polio, pertussis, measles
Show answer and rationale
Correct answer: D — polio, pertussis, measles
Vaccines are crucial in preventing communicable diseases. Smallpox has been eradicated globally, so its vaccine is no longer used. Polio, pertussis, and measles are diseases that are controlled by routine childhood immunization. While smallpox has been eradicated, these diseases still exist, making it essential for children to be vaccinated against them. Choices A, B, and C include diseases that are not prevented by vaccination or are not related to routine immunizations, making them incorrect choices.
Question 3
A nursing student is assigned to care for a client who requires a total bed bath. When the student explains to the client that she is going to gather supplies to administer the bath, the client states, 'I don't want a bath. I've been up all night, and I'm clean enough.' The student reports the client's refusal to the nurse. Which action by the nurse is appropriate?
A. Telling the nursing student to persuade the client to have a bath so that the evening shift staff will not have to do it
B. Telling the nursing student to allow the client to rest
C. Telling the client that the refusal of care will be informed to the health care provider
D. Telling the nursing student to give the client the bath anyway
Show answer and rationale
Correct answer: B — Telling the nursing student to allow the client to rest
The client has the right to refuse a treatment or procedure, and if the client does refuse, the nurse must respect the client's decision. Therefore, the nurse would allow the client to rest. Persuading the client to have a bath and giving the bath anyway are both inappropriate as they violate the client's rights. Informing the health care provider of the refusal of care can be discussed with the client if needed, but the immediate action should be to respect the client's wishes and allow them to rest.
Question 4
While the client is receiving total parenteral nutrition (TPN), which lab test should be evaluated?
A. Hemoglobin
B. Creatinine
C. Blood glucose
D. White blood cell count
Show answer and rationale
Correct answer: C — Blood glucose
When a client is receiving total parenteral nutrition (TPN), monitoring blood glucose levels is crucial as TPN solutions contain high amounts of glucose. This monitoring helps prevent hyperglycemia or hypoglycemia. Evaluating hemoglobin (choice A) is not directly related to TPN administration. Creatinine (choice B) is more relevant for assessing kidney function. White blood cell count (choice D) is important for evaluating immune function and infection, but not specifically tied to TPN administration.
Question 5
Which client should the nurse see first?
A. Recurring crushing chest pain
B. Needing an IV for surgery in 5 minutes
C. Needing PCA morphine for pain control post-hysterectomy
D. Waiting to get back to bed after sitting in a chair for 30 minutes
Show answer and rationale
Correct answer: A — Recurring crushing chest pain
The client presenting with recurring crushing chest pain should be seen first as this symptom could indicate a myocardial infarction (MI), which is a life-threatening condition requiring immediate attention. Assessing and managing potential cardiac issues take priority over other concerns like needing an IV for surgery, pain control post-hysterectomy, or assistance with mobility. While all clients require care, addressing the chest pain promptly is crucial to ensure the client's safety and well-being.
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Question 6
A homeless person has been admitted to the medical unit and placed on airborne precautions for suspected active TB infection. The nurse will assess for these signs and symptoms (Select one that doesn't apply).
A. Weight gain
B. Fatigue
C. Bloody sputum
D. Diaphoresis during sleep
Correct answer:
The correct answer is 'Weight gain.' When assessing for signs and symptoms of active TB infection, weight loss is typically observed rather than weight gain. Other common signs and symptoms include fatigue, bloody sputum, and diaphoresis during sleep. Fatigue, bloody sputum, and diaphoresis during sleep are all associated with active TB infection. Weight gain is not typically seen in active TB; instead, patients usually experience weight loss due to the impact of the infection on their overall health.
Health promotion activities are designed to help clients:
A. reduce the risk of illness
B. maintain maximal function
C. promote healthy habits related to healthcare
D. all of the above
Correct answer:
Health promotion activities encompass a broad range of interventions aimed at enhancing overall well-being. These activities not only focus on reducing the risk of illness but also on maintaining maximal function and promoting healthy habits related to healthcare. Therefore, the correct answer is 'all of the above.' Choices A, B, and C are all integral components of health promotion strategies, emphasizing the multidimensional approach required to support clients in achieving optimal health outcomes.
When planning care for a client taking Heparin, which nursing diagnosis should the nurse address first?
A. Ineffective tissue perfusion related to the presence of a thrombus obstructing blood flow
B. Risk for injury related to active loss of blood from the vascular space
C. Deficient knowledge related to the client's lack of understanding of the disease process
D. Impaired skin integrity related to the development of bruises and/or hematoma
Correct answer:
The correct answer is 'Risk for injury related to active loss of blood from the vascular space.' When a client is taking Heparin, the primary concern is the risk of bleeding due to its anticoagulant properties. Monitoring for signs of active blood loss is crucial to prevent complications like hemorrhage. While ineffective tissue perfusion, deficient knowledge, and impaired skin integrity are important, they are secondary to the immediate risk of bleeding in clients taking anticoagulants like Heparin.
Laboratory tests reveal the following electrolyte values for Mr. Smith: Na 135 mEq/L, Ca 8.5 mg/dL, Cl 102 mEq/L, and K 2.0 mEq/L. Which of the following values should the nurse report to the physician because of its potential risk to the client?
A. Ca
B. K
C. Na
D. Cl
Correct answer:
The correct answer is 'K.' Normal serum potassium levels range between 3.5 and 5.5 mEq/L. Mr. Smith's potassium level of 2.0 mEq/L is significantly below the normal range, indicating hypokalemia, which can lead to serious risks such as cardiac arrhythmias. The levels of sodium (Na), calcium (Ca), and chloride (Cl) are within normal ranges, so they do not pose an immediate risk to the client's health. Therefore, the nurse should report the low potassium level to the physician for prompt intervention.
Which of the following is not typically considered one of the main mechanisms of Type II Diabetes treatment?
A. Medications
B. Nutrition
C. Increased activity
D. Continuous Insulin
Correct answer:
Continuous Insulin is not typically considered one of the main mechanisms for treating Type II Diabetes. While medications, nutrition, and increased activity play crucial roles in managing Type II Diabetes, continuous insulin therapy is more common in Type I Diabetes or in specific cases of Type II Diabetes where other treatments are ineffective. Therefore, the correct answer is Continuous Insulin. Choices A, B, and C are mainstays in the treatment of Type II Diabetes, making them incorrect answers.
A nurse is assisting with data collection regarding skin and peripheral vascular findings on a client in later adulthood. Which observation would the nurse expect to note as an age-related finding?
A. Thin, ridged toenails
B. Thick skin on the lower legs
C. Loss of hair on the lower legs
D. Bounding dorsalis pedis pulse
Correct answer:
In later adulthood, age-related findings include trophic changes associated with arterial insufficiency, such as thin, shiny skin; thin, ridged toenails; and loss of hair on the lower legs. These changes occur normally with aging. Thick skin on the lower legs would not be an expected age-related finding as it typically indicates chronic venous insufficiency. A bounding dorsalis pedis pulse is not typical in later adulthood and may indicate arterial insufficiency, which is not an age-related finding.
A 22-year-old patient in a mental health lock-down unit under suicide watch appears happy about being discharged. Which of the following is probably happening?
A. The patient is excited about being around family again.
B. The patient's suicide plan has probably progressed.
C. The patient's plans for the future have been clarified.
D. The patient's mood is improving.
Correct answer:
In this scenario, it is concerning that a patient under suicide watch is happy about being discharged as it may indicate that the patient's suicide plan has advanced. This change in behavior should be taken seriously as it can signal an increased risk of self-harm. Choices A, C, and D are less likely as the patient's happiness about discharge in this context is more indicative of a worsening situation rather than positive outcomes like being around family, clarifying future plans, or improving mood.
Which of the following foods should be avoided by clients who are prone to developing heartburn as a result of gastroesophageal reflux disease (GERD)?
A. lettuce
B. eggs
C. chocolate
D. butterscotch
Correct answer:
The correct answer is chocolate. Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure, leading to reflux and clinical symptoms of GERD. Lettuce and eggs do not significantly affect LES pressure, making them less likely to trigger GERD symptoms. Butterscotch, like lettuce and eggs, does not have a notable effect on LES pressure, so it is not as likely to worsen GERD symptoms as chocolate. Therefore, chocolate is the food to be avoided by clients prone to heartburn due to GERD.
What should be the primary action for a client who has just vomited 300 cc of bright red blood?
A. Document the vomiting.
B. Increase IV fluids.
C. Get a complete blood count.
D. Check the blood pressure.
Correct answer:
The correct first action for a client who has just vomited 300 cc of bright red blood is to check the blood pressure. This assessment is crucial to evaluate for hypotension, which could indicate significant blood loss and the need for immediate intervention. Documenting the vomiting is important for the client's medical record but not the initial priority. Increasing IV fluids and getting a complete blood count are necessary steps but should follow the assessment of the client's hemodynamic status.
When a client is having a seizure and their blood oxygen saturation drops from 92% to 82%, what should the nurse do first?
A. Open the airway.
B. Administer oxygen.
C. Suction the client.
D. Check for breathing.
Correct answer:
When a client is experiencing a seizure and their blood oxygen saturation drops, the priority action for the nurse is to open the airway. Ensuring a clear airway is essential to maintain oxygenation during a seizure episode. Administering oxygen may be necessary but is secondary to ensuring a patent airway. Suctioning the client should only be done if there is an airway obstruction. Checking for breathing is important, but opening the airway takes precedence to support ventilation and oxygenation.
NCLEX-PN clinical judgment practice questions, set 60 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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