NCLEX-PN clinical judgment practice questions, set 61
NCLEX-PN · clinical judgment
NCLEX-PN clinical judgment practice questionsset 61
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
While receiving an infusion of cefazolin sodium, the client complained of itchy skin. The nurse observed warm, flushed skin with a red rash on the arms, chest, and back. The health care provider was promptly notified.
A. The client is apparently allergic to cefazolin sodium, as indicated by warm, flushed skin and a rash on the arms, chest, and back.
B. The client had an allergy to cefazolin sodium.
C. The health care provider was notified because a rash developed while the client was receiving cefazolin sodium.
D. During an infusion of cefazolin sodium, the client complained that his skin was itchy. The client's skin was warm and flushed, with a red rash on the arms, chest, and back. The health care provider was notified.
Show answer and rationale
Correct answer: D — During an infusion of cefazolin sodium, the client complained that his skin was itchy. The client's skin was warm and flushed, with a red rash on the arms, chest, and back. The health care provider was notified.
Accurate and objective documentation is essential during an incident report. Choice A makes an assumption of allergy based on subjective interpretation, which is not appropriate. Choice B states a conclusion without proper documentation. Choice C is incomplete as it fails to provide a detailed account of the observed symptoms. Choice D offers a precise description of the client's symptoms, actions taken, and notification of the healthcare provider, making it the most suitable documentation choice.
Question 2
What is one characteristic of human immunodeficiency virus (HIV)?
A. The presence of circulating antibodies that neutralize HIV is evidence of exposure to HIV.
B. HIV replication occurs intracellularly.
C. HIV integrates its genetic material into the host cell's DNA.
D. DNA replication is irrelevant to HIV.
Show answer and rationale
Correct answer: C — HIV integrates its genetic material into the host cell's DNA.
The correct answer is C. HIV integrates its genetic material into the host cell's DNA. The virus uses the enzyme reverse transcriptase to make a DNA copy of its RNA, which is then inserted into the genetic material of the infected cell. Choice A is incorrect because the presence of antibodies does not indicate immunity to HIV but rather exposure to the virus. Choice B is incorrect as HIV replication occurs intracellularly, inside the host cell. Choice D is irrelevant to the characteristics of HIV.
Question 3
A patient has suffered a left CVA and developed severe hemiparesis resulting in a loss of mobility. The nurse notices on assessment that an area over the patient's left elbow appears as non-blanchable erythema, and the skin is intact. The nurse should score the patient as having which of the following?
A. Stage I pressure ulcer
B. Stage II pressure ulcer
C. Stage III pressure ulcer
D. Stage IV pressure ulcer
Show answer and rationale
Correct answer: A — Stage I pressure ulcer
Erythema with the skin intact is characteristic of a Stage I pressure ulcer. At this stage, the skin is not broken, but there is localized redness that does not blanch when pressed. Stage II pressure ulcers involve partial-thickness skin loss, Stage III pressure ulcers have full-thickness skin loss, and Stage IV pressure ulcers extend to deeper tissues, including muscle and bone. In this case, the non-blanchable erythema with intact skin aligns with the characteristics of a Stage I pressure ulcer.
Question 4
In a disaster situation, the nurse assessing a diabetic client on insulin assesses for all of the following except:
A. diabetic signs and symptoms.
B. nutritional status.
C. bleeding problems.
D. availability of insulin.
Show answer and rationale
Correct answer: C — bleeding problems.
In a disaster situation, when assessing a diabetic client on insulin, the nurse should assess for diabetic signs and symptoms to monitor the client's condition, nutritional status to ensure proper dietary management, and availability of insulin to maintain the client's medication regimen. Bleeding problems are not directly related to diabetes or insulin use, making it the exception in this assessment scenario. Therefore, bleeding problems would not be a typical focus of assessment in this context.
Question 5
In conducting a health screening for 12-month-old children, the nurse expects them to have been immunized against which of the following diseases?
A. measles, polio, pertussis, hepatitis B
B. diphtheria, pertussis, polio, tetanus
C. rubella, polio, pertussis, hepatitis A
D. measles, mumps, rubella, polio
Show answer and rationale
Correct answer: B — diphtheria, pertussis, polio, tetanus
By 12 months of age, children should have received vaccines for diphtheria, pertussis, polio, and tetanus (DTaP and IPV). The correct answer is B as it includes these vaccines that are typically administered in the first year of life. Measles, mumps, and rubella (MMR) vaccination usually begins at 12 months of age but is not expected to be completed by this time. Choices A and C are incorrect as they include diseases that are not part of the routine immunization schedule for a 12-month-old child.
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Question 6
Which of the following medications is not classified as a neuromuscular blocker?
A. Anectine
B. Pavulon
C. Pitressin
D. Mivacron
Correct answer:
The correct answer is Pitressin. Pitressin is a hormone replacement medication and is not classified as a neuromuscular blocker. Choices A, B, and D (Anectine, Pavulon, Mivacron) are neuromuscular blockers used during anesthesia to induce muscle relaxation for various procedures. Anectine is also known as succinylcholine, Pavulon is rocuronium, and Mivacron is mivacurium. These medications act on the neuromuscular junction to block the transmission of nerve impulses, leading to muscle relaxation.
A 20-year-old obese female client is preparing to have gastric bypass surgery for weight loss. She says to the nurse, 'I need this surgery because nothing else I have done has helped me to lose weight.' Which response by the nurse is most appropriate?
A. "If you eat less, you can save some money."?
B. "Exercise is a healthier way to lose weight."?
C. "You should try the Atkins diet first."?
D. "I respect your decision to choose surgery."?
Correct answer:
The most appropriate response by the nurse is to show respect and empathy towards the client's decision. Choosing surgery for weight loss is a significant decision, and acknowledging and respecting this choice is crucial in providing patient-centered care. Option D is the correct answer as it validates the client's decision and shows support. Options A, B, and C are all inappropriate as they do not address the client's feelings, lack empathy, and can be considered insensitive and unprofessional.
When a client describes their family as having multiple wives, all of whom are sisters, married to one man, the nurse documents the family structure as?
A. polyandry
B. sororal
C. nonsororal
D. soronal
Correct answer:
The correct answer is 'soronal.' The practice of polygamy refers to having multiple wives or husbands. When there are multiple wives who are sisters, the polygamy is designated as sororal. Polyandry refers to multiple husbands, which is rare. Nonsororal polygamy is when the wives are not sisters. Sororate polygamy specifies that a husband must marry his wife’s sister if she dies. Therefore, in this scenario, the family structure described by the client fits the definition of soronal polygamy.
The LPN has been given assignments by the RN. Which assignment should the LPN question as being beyond the scope of the LPN?
A. The LPN is assigned to care for a client with diabetes mellitus who needs instructions reinforced on how to self-administer insulin.
B. The LPN is assigned to reinforce discharge teaching about dressing changes and medications to a 35-year-old man.
C. The LPN is assigned to care for a 75-year-old woman, hospitalized for dehydration, who is being discharged home today with no medications.
D. The LPN is assigned to care for a woman with newly diagnosed leukemia who will be receiving her initial dose of chemotherapy.
Correct answer:
The LPN should be able to recognize when an assignment is beyond their scope of practice. Administering chemotherapy for leukemia is not within the scope of practice for the LPN, and this assignment should be questioned. Choices A, B, and C are within the scope of practice for an LPN. Reinforcing teaching on self-administration of insulin, assisting with discharge instructions on dressing changes, and caring for a client being discharged with no medications are all appropriate tasks for an LPN.
In a client with asthma who develops respiratory acidosis, what should the nurse expect the client's serum potassium level to be?
A. normal
B. elevated
C. low
D. unrelated to the pH
Correct answer:
In respiratory acidosis, the serum potassium level is expected to be elevated. This occurs because potassium shifts from cells into the bloodstream as a compensatory mechanism to maintain acid-base balance. Choices A, C, and D are incorrect. A normal potassium level is not expected in respiratory acidosis. A low potassium level is more commonly associated with alkalosis, not acidosis. The potassium level is indeed related to pH changes in respiratory acidosis, leading to the expected elevation.
A 21-year-old college student has just learned that she contracted genital herpes from her sexual partner. After completing the initial history and assessment, the nurse has data concerning areas pertinent to the disease. The data is likely to include all but which of the following?
A. voiding patterns
B. characteristics of lesions
C. vaginal discharge
D. prior history of varicella
Correct answer:
The correct answer is 'prior history of varicella.' When assessing a client with genital herpes, it is important to gather data on voiding patterns, characteristics of lesions, and vaginal discharge as these are pertinent to the disease. However, the prior history of varicella is not directly related to the current diagnosis of genital herpes. Varicella, which refers to chickenpox, is caused by the varicella-zoster virus, a different virus from the herpes simplex virus causing genital herpes.
An advance directive is written and notarized according to law in the state of Colorado. This document is legal and binding:
A. internationally.
B. in the state of Colorado only.
C. in the continental United States.
D. in the county of origination only.
Correct answer:
The correct answer is 'in the state of Colorado only.' Advance directive protocols and documents are specific to each state's laws and regulations. Choice A is incorrect as advance directives are not universally recognized internationally. Choice C is incorrect as the legal validity of an advance directive is limited to the state in which it was created. Choice D is incorrect as the legal reach of an advance directive typically extends throughout the state of origination, not just the county.
A new nursing graduate indicates in charting entries that he is a licensed practical nurse, although he has not yet received the results of the licensing exam. The graduate's action can result in what type of charge?
A. Fraud
B. Tort
C. Malpractice
D. Negligence
Correct answer:
The correct answer is 'Fraud.' Identifying oneself as a nurse without a license defrauds the public and can lead to prosecution. A tort is a wrongful act in breach of a legal duty imposed by law; malpractice is the failure to act appropriately as a nurse or acting in a way that harm comes to the client; and negligence is failing to perform care. In this scenario, the key issue is the misrepresentation of licensure status, which constitutes fraud. Therefore, choices B, C, and D are incorrect.
A client is admitted with Ewing's sarcoma. Which symptoms would be expected due to this tumor's location?
A. Hemiplegia
B. Aphasia
C. Nausea
D. Bone pain
Correct answer:
Ewing's sarcoma is a type of bone cancer that primarily affects the bones. Therefore, bone pain would be an expected symptom due to this tumor's location. Hemiplegia, which refers to paralysis on one side of the body, Aphasia, a language disorder, and Nausea are not typical symptoms of Ewing's sarcoma. While Nausea is a common symptom in various conditions, it is not specific to bone cancer like Ewing's sarcoma. Therefore, Bone pain is the most likely symptom associated with Ewing's sarcoma.
What is the primary sign of displacement following a total hip replacement?
A. pain on movement and weight bearing
B. hemorrhage
C. affected leg appearing 1-2 inches longer
D. edema in the area of the incision
Correct answer:
The correct answer is pain on movement and weight bearing. This pain is the primary sign of prosthesis displacement after a total hip replacement, indicating pressure on nerves or muscles due to dislocation. Hemorrhage is not typically associated with prosthesis displacement. While the affected leg may appear longer, this is not the primary sign of displacement; it might actually be shorter due to muscle spasm. Edema in the incision area is not a primary indicator of prosthesis displacement.
NCLEX-PN clinical judgment practice questions, set 61 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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