NCLEX-RN clinical judgment practice questions, set 11
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 11
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-RN exam guide or more NCLEX-RN 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 client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the healthcare provider ordering:
A. Pulmonary embolectomy
B. Vena caval interruption
C. Increasing the coumadin therapy to achieve an INR of 3-4
D. Thrombolytic therapy
Show answer and rationale
Correct answer: B — Vena caval interruption
In the case of a client with a history of recurrent pulmonary embolism or contraindications to heparin, vena caval interruption may be necessary. Vena caval interruption involves placing a filter device in the inferior vena cava to prevent clots from traveling to the pulmonary circulation. Pulmonary embolectomy is a surgical procedure to remove a clot from the pulmonary artery, which is usually considered in severe or life-threatening cases. Increasing coumadin therapy to achieve a higher INR may be an option but vena caval interruption would be more appropriate in this scenario. Thrombolytic therapy is used in acute cases of pulmonary embolism to dissolve the clot rapidly, but in a recurrent case with contraindications to anticoagulants, vena caval interruption would be a preferred intervention.
Question 2
You are caring for a Hispanic patient who is scheduled for surgery in the morning. A member of the surgery staff is in a hurry when she visits the patient to obtain surgical consent. You know that the patient speaks limited English and can see that he does not really understand what's being said. What is the most appropriate next action?
A. Call a family member to interpret
B. Consult the hospital translator to assist
C. Allow the consent to be signed
D. Ask the staff member to come back later
Show answer and rationale
Correct answer: B — Consult the hospital translator to assist
Consulting the hospital translator is the most reliable means of ensuring accuracy in the information that the patient is receiving. Family members can be helpful, but they may have difficulty understanding the medical procedures well enough to explain them accurately and may misinterpret the message. Relying on family members could lead to misunderstandings or miscommunication. Allowing the consent to be signed without ensuring the patient's full understanding could pose risks to the patient's well-being. Asking the staff member to come back later delays the essential communication process needed before surgery. Therefore, consulting the hospital translator is the best course of action to ensure clear and accurate communication, especially in critical healthcare decisions like surgical consent.
Question 3
Which of the following is an example of effective time management?
A. Always agreeing to others' requests for help
B. Arranging long meetings to discuss important data
C. Using multiple forms of technology to communicate or educate others
D. Working in a secluded area to minimize interruptions
Show answer and rationale
Correct answer: D — Working in a secluded area to minimize interruptions
Effective time management involves strategies that help individuals focus and complete tasks efficiently. Working in a secluded area to minimize interruptions is an example of effective time management as it allows for concentration and productivity without distractions. Choices A, B, and C are not examples of effective time management. Always agreeing to others' requests for help can lead to overcommitment and time mismanagement. Arranging long meetings can be counterproductive as they consume time that could be used for actual work. Using multiple forms of technology, though helpful, can lead to information overload and inefficiency if not managed properly. Therefore, the most effective choice for optimal time management in this scenario is working in a secluded area to minimize interruptions.
Question 4
An examiner is using an ophthalmoscope to examine a patient's eyes. The patient has astigmatism and is nearsighted. Which of these techniques by the examiner would indicate that the examination is being correctly performed?
A. Rotating the lens selector dial to bring the object into focus
B. Using the large full circle of light when assessing pupils that are not dilated
C. Rotating the lens selector dial to the black numbers to compensate for astigmatism
D. Using the grid on the lens aperture dial to visualize the external structures of the eye
Show answer and rationale
Correct answer: A — Rotating the lens selector dial to bring the object into focus
To correctly perform an eye examination using an ophthalmoscope on a patient with astigmatism and nearsightedness, the examiner should rotate the lens selector dial to bring the object into focus. This adjustment helps compensate for nearsightedness or farsightedness but does not correct astigmatism. Rotating the lens selector dial to the black numbers is not an appropriate technique for compensating for astigmatism. Using the grid on the lens aperture dial is primarily for visualizing external structures of the eye, not for addressing refractive errors. The large full circle of light is typically used when assessing dilated pupils, not for examining patients with astigmatism and nearsightedness. Therefore, the correct technique is rotating the lens selector dial to bring the object into focus.
Question 5
A nurse is caring for a 2-year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to
A. A cerebral vascular accident
B. Postoperative meningitis
C. Medication reaction
D. Metabolic alkalosis
Show answer and rationale
Correct answer: A — A cerebral vascular accident
The correct answer is a cerebral vascular accident. Polycythemia occurs as a physiological reaction to chronic hypoxemia, which commonly occurs in clients with Tetralogy of Fallot. Polycythemia and the resultant increased viscosity of the blood increase the risk of thromboembolic events, including cerebrovascular accidents. Signs and symptoms of a cerebral vascular accident include sudden paralysis, altered speech, extreme irritability or fatigue, and seizures. Postoperative meningitis (choice B) is less likely in this scenario as the sudden onset of seizing is more indicative of a vascular event rather than an infection. Medication reaction (choice C) is not the most probable cause given the history provided. Metabolic alkalosis (choice D) is not associated with sudden seizing in this context.
Keep going past these 15 questions
Missed-question review, longer banks, and the rest of 20,000+ nursing practice questions open when you start studying.
Stems and choices stay public so you can still reason. Correct answers and full rationales unlock with the rest of the bank.
Question 6
A thirty-five-year-old male has been an insulin-dependent diabetic for five years and now is unable to urinate. Which of the following would you most likely suspect?
A. Atherosclerosis
B. Diabetic nephropathy
C. Autonomic neuropathy
D. Somatic neuropathy
Correct answer:
In this case, the correct answer is autonomic neuropathy. Autonomic neuropathy affects the autonomic nerves, which control various bodily functions including the bladder. In diabetes, it can lead to bladder paralysis, resulting in symptoms like urgency to urinate and difficulty initiating urination. Atherosclerosis (choice A) is a condition involving the hardening and narrowing of arteries, not directly related to the inability to urinate in this context. Diabetic nephropathy (choice B) primarily affects the kidneys, leading to kidney damage, but does not typically cause urinary retention. Somatic neuropathy (choice D) involves damage to sensory nerves, not the autonomic nerves responsible for bladder control, making it less likely to be the cause of the urinary issue described in the question.
The key to the prevention of a pandemic influenza is:
A. Early detection
B. Early antibiotic treatment
C. Vaccination of at-risk populations
D. Isolation of suspected cases
Correct answer:
The key to preventing a pandemic influenza is early detection. Detecting influenza cases early allows for timely public health responses to limit the spread of the virus. Early detection helps in implementing measures such as isolation, treatment, and vaccination to prevent the development of a full-blown pandemic. Antibiotics are not effective against influenza viruses, so early antibiotic treatment is not the key to prevention. While vaccination of at-risk populations is important in controlling the spread of influenza, early detection is crucial as it allows for timely implementation of vaccination strategies. Isolation of suspected cases is a containment measure rather than a prevention strategy; the key to prevention lies in early detection to stop the spread before it becomes a pandemic.
A nurse is preparing to insert a small-bore nasogastric feeding tube for a client's enteral feedings. In which method does the nurse measure the correct length of the tube?
A. From the tip of the nose to the xiphoid process
B. From the tip of the nose to the earlobe to the xiphoid process
C. From the earlobe to the xiphoid process
D. From the tip of the nose to the earlobe to the umbilicus
Correct answer:
When preparing to insert a nasogastric tube, the nurse must measure the correct length to ensure that the end of the tube will be in the correct position in the stomach. The accurate method to measure the length is from the tip of the nose to the earlobe to the xiphoid process. This length ensures that the end of the tube reaches the stomach, avoiding placement in the small intestine or esophagus. Choice A is incorrect as it does not include the earlobe, which is essential for accurate measurement. Choice C is incorrect because measuring from the earlobe alone does not provide the correct length for positioning in the stomach. Choice D is incorrect as it includes the umbilicus, which is not the appropriate landmark for measuring the length of a nasogastric tube intended for stomach placement.
The healthcare provider is reviewing the lab results of a patient who has presented in the Emergency Room. The lab results show that the BNP (B-type Natriuretic Peptide) value is 615 pg/ml. What would the healthcare provider take as the priority action?
A. Call for a cardiac evaluation and implement appropriate measures
B. Check the patient's oxygen saturation
C. Inform the physician about the elevated BNP level
D. Encourage the patient to limit physical activity
Correct answer:
An elevated BNP level is indicative of decreased cardiac output, suggesting potential heart failure. In this scenario, the priority action is to check the patient's oxygen saturation. Oxygen saturation assessment is crucial to ensure adequate oxygenation and respiratory function, which is essential in managing cardiac conditions. Calling for a cardiac evaluation and implementing appropriate measures may be necessary but is not the immediate priority without assessing oxygen saturation. Informing the physician about the elevated BNP level can be important for further management but is not the immediate action needed in this situation. Encouraging the patient to limit physical activity might be a consideration later but is not the priority action when dealing with a potential cardiac emergency.
The nurse is caring for a 36-year-old patient with pancreatic cancer. Which nursing action is the highest priority?
A. Offer psychological support for depression.
B. Offer high-calorie, high-protein dietary choices.
C. Administer prescribed opioids to relieve pain as needed.
D. Teach about the need to avoid scratching any pruritic areas.
Correct answer:
The correct answer is to administer prescribed opioids to relieve pain as needed. Pain management is the highest priority in this scenario as effective pain control is essential for the patient's overall well-being. Pain relief will not only improve the patient's comfort but also enhance their ability to eat, follow dietary recommendations, and be open to psychological support. Offering psychological support for depression (Choice A) is important but addressing pain takes precedence. While providing high-calorie, high-protein dietary choices (Choice B) is crucial, it is secondary to managing pain. Teaching about the need to avoid scratching pruritic areas (Choice D) is relevant but not the highest priority in this situation where pain management is critical for the patient's quality of life.
An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse should place the infant in which best position at this time?
A. Prone position
B. On the stomach
C. Left lateral position
D. Right lateral position
Correct answer:
After surgical repair of a cleft lip on the right side, the nurse should position the infant carefully to ensure comfort and prevent complications. Placing the infant in the prone position or on the stomach is not recommended as it may cause rubbing of the surgical site against the mattress. The optimal position for the infant is the left lateral position, away from the surgical repair site, to minimize the risk of trauma. Placing the infant on the right lateral position would be contraindicated as it is on the side of the repair. Additionally, positioning the infant upright on the back can help prevent airway obstruction by secretions, blood, or the tongue. Therefore, the correct choice is to place the infant in the left lateral position to promote safety and comfort post cleft lip surgery.
A 67-year-old male patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. Which information obtained by the nurse indicates that these therapies have been effective?
A. Bowel sounds are present.
B. Grey Turner sign resolves.
C. Electrolyte levels are normal.
D. Abdominal pain is decreased.
Correct answer:
The correct answer is 'Abdominal pain is decreased.' In a patient with acute pancreatitis, the goal of using an NG tube for suction and keeping the patient NPO is to decrease the release of pancreatic enzymes and alleviate pain. Therefore, a decrease in abdominal pain would indicate the effectiveness of these therapies. Bowel sounds being present do not necessarily indicate treatment effectiveness, as they can still be present even if the therapies are not fully effective. Normal electrolyte levels are important but do not directly reflect the efficacy of NG suction and NPO status. The resolution of Grey Turner sign, a bruising over the flanks associated with pancreatitis, is a late and non-specific finding and waiting for it to resolve is not a reliable indicator of treatment effectiveness.
A newborn infant in the nursery has developed vomiting, poor feeding, lethargy, and respiratory distress, and has been diagnosed with necrotizing enterocolitis. Which of the following nursing interventions is most appropriate for this infant?
A. Feed the infant 30 cc of sterile water
B. Position the infant on his back
C. Administer antibiotics as ordered
D. Allow the infant to breastfeed
Correct answer:
Necrotizing enterocolitis (NEC) is a serious condition characterized by ischemic bowel, leading to gastrointestinal symptoms, lethargy, poor feeding, and respiratory distress. In the management of NEC, it is crucial to stop oral feedings, insert a nasogastric tube for decompression, and administer antibiotics as prescribed by the physician. Therefore, the most appropriate nursing intervention for an infant with NEC is to administer antibiotics as ordered.
Choice A, feeding the infant sterile water, is incorrect because oral feedings should be stopped in NEC. Choice B, positioning the infant on his back, is not directly related to the treatment of NEC. Choice D, allowing the infant to breastfeed, is contraindicated in NEC as oral feedings should be ceased to prevent further complications.
The nurse is providing discharge instructions to the mother of a child who had a cleft palate repair. Which statement should the nurse make to the mother?
A. You should use an orthodontic nipple on the child's bottle.
B. You need to use a plastic spoon to feed the child.
C. You can allow the child to use a pacifier but only for 30 minutes at a time.
D. You need to monitor the child's temperature for signs of infection using an oral thermometer.
Correct answer:
After a cleft palate repair, it is crucial to use an orthodontic nipple on the child's bottle to feed them appropriately. The mother should be instructed to give the child baby food or baby food mixed with water. It is important to avoid introducing straws, pacifiers, spoons, or fingers into the child's mouth for 7 to 10 days post-surgery to prevent complications. The use of a pacifier should be avoided for at least 2 weeks following the surgical repair to promote proper healing. Additionally, taking oral temperatures should be avoided, and alternative temperature monitoring methods should be utilized to reduce the risk of infection. Therefore, options B, C, and D are incorrect because they could potentially lead to complications or hinder the child's recovery after cleft palate repair.
The family of a patient who is receiving therapeutic hypothermia states they do not understand why the patient is being kept so cold. What objective information can you provide to help address their concerns?
A. Let them talk to another patient who has had the same therapy
B. Provide research-based information about therapeutic hypothermia
C. Connect them with the nurse manager
D. Call the physician and ask him to talk to the family
Correct answer:
Providing research-based information about the benefits of therapeutic hypothermia for their loved one will provide evidence that this is an established therapy with generally positive outcomes. Families are certainly not expected to be familiar with critical care interventions, and their concerns should be addressed with evidence-based data whenever possible. Option A is not appropriate as sharing patient information violates privacy laws and does not address the family's concerns directly. Option C may not directly provide the detailed information the family needs to understand therapeutic hypothermia. Option D involves unnecessary escalation by immediately involving the physician, when providing education and information should be the initial step in addressing the family's concerns.
NCLEX-RN clinical judgment practice questions, set 11 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
No. Nursier is independent practice. Register through the official path named on the NCLEX-RN exam guide.
The first five questions already include the rationale. Start full practice to unlock the remaining keys, missed-question review, and the rest of the bank.
Keep going past these 15 questions
Missed-question review, longer banks, and the rest of 20,000+ nursing practice questions open when you start studying.
