NCLEX-RN clinical judgment practice questions, set 13
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 13
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
Which technique is correct when assessing the radial pulse of a patient?
A. Palpate for 1 minute if the rhythm is irregular.
B. Palpate for 15 seconds and multiply by 4 if the rhythm is regular.
C. Palpate for 2 full minutes to detect any variation in amplitude.
D. Palpate for 10 seconds and multiply by 6 if the rhythm is regular and the patient has no history of cardiac abnormalities.
Show answer and rationale
Correct answer: A — Palpate for 1 minute if the rhythm is irregular.
When assessing the radial pulse, if the rhythm is irregular, the pulse should be counted for a full minute to get an accurate representation of the pulse rate. In cases where the rhythm is regular, the recommended technique is to palpate for 15 seconds and then multiply by 4 to calculate the beats per minute. This method is more accurate and efficient for normal or rapid heart rates. Palpating for 30 seconds and multiplying by 2 is not as effective, as any error in counting results in a larger discrepancy in the calculated heart rate. Palpating for 2 full minutes is excessive and not necessary for routine pulse assessment. Palpating for 10 seconds and multiplying by 6 is not a standard technique and may lead to inaccuracies, especially in patients with cardiac abnormalities.
Question 2
Which desired outcome written by the nurse is correctly written and measurable?
A. Client will have a normal bowel pattern by April 2
B. The client will lose 4 lbs. within the next 2 weeks
C. The nurse will provide skin care at least 3 times each day
D. The client will breathe better after resting for 10 minutes
Show answer and rationale
Correct answer: B — The client will lose 4 lbs. within the next 2 weeks
An outcome statement must describe the observable client behavior that should occur in response to the nursing interventions. It consists of a subject, action verb, conditions under which the behavior is to be performed, and the level at which the client will perform the desired behavior. Option B is correctly written and measurable as it includes all the required elements: subject (client), action verb (lose), conditions (within the next 2 weeks), and the level at which the behavior should occur (4 lbs.). Option A lacks the conditions and a specific level, making it not measurable. Option C is a nursing intervention rather than a client goal. Option D does not provide a specific level at which the client should perform the desired behavior, making it not measurable as well.
Question 3
Which interventions should the nurse include when creating a care plan for a child with hepatitis? Select one that doesn't apply.
A. Providing a low-fat, well-balanced diet.
B. Teaching the child effective hand-washing techniques.
C. Notifying the primary health care provider (PHCP) if jaundice is present.
D. Instructing the parents to avoid administering medications unless prescribed.
Show answer and rationale
Correct answer: D — Instructing the parents to avoid administering medications unless prescribed.
The correct answer is instructing the parents to avoid administering medications unless prescribed. This choice is not directly related to the care of a child with hepatitis. It is essential for the nurse to educate the child and family about providing a low-fat, well-balanced diet to support the liver, teaching effective hand-washing techniques to prevent the spread of infection, and notifying the primary health care provider if jaundice is present to monitor the progression of the disease and adjust the treatment plan accordingly. Avoiding unnecessary medications is crucial, but it should be done under healthcare provider guidance, so the statement should be revised to reflect this aspect. Therefore, the other options are appropriate for the care of a child with hepatitis.
Question 4
When assessing a patient suspected to have Hepatitis, a nurse notes the patient's eyes are yellow-tinged. Which of the following diagnostic results would further assist in confirming this diagnosis?
A. Decreased serum Bilirubin
B. Elevated serum ALT levels
C. Low RBC and Hemoglobin with increased WBCs
D. Increased Blood Urea Nitrogen level
Show answer and rationale
Correct answer: B — Elevated serum ALT levels
Elevated serum ALT levels would further confirm the diagnosis of Hepatitis. ALT is a liver enzyme, and hepatitis is a liver disease. Elevated liver enzymes, such as ALT, often indicate liver damage. Choice A, 'Decreased serum Bilirubin,' is incorrect as elevated bilirubin levels are typically seen in hepatitis due to impaired bilirubin metabolism. Choices C and D are unrelated to confirming a diagnosis of hepatitis as they describe findings not specific to liver function or hepatitis. Low RBC and Hemoglobin with increased WBCs (Choice C) suggest a different condition like anemia or infection, not specific to liver disease. Increased Blood Urea Nitrogen level (Choice D) is more indicative of kidney function rather than liver function, thus not helpful in confirming hepatitis.
Question 5
What is a key principle of patient teaching that must take place to ensure patient safety?
A. Family members should be present
B. Teaching must be documented
C. Understanding must be confirmed
D. Teaching should be provided by multiple staff members
Show answer and rationale
Correct answer: C — Understanding must be confirmed
A key principle of patient teaching that ensures patient safety is the confirmation of understanding. To ensure patient safety, it is crucial to confirm that the patient comprehends the information provided. This confirmation can be achieved by having the patient repeat back the information or demonstrate understanding through return demonstration. Documenting the patient's understanding is essential to track the effectiveness of the teaching session and ensure that the patient is equipped with the necessary knowledge for their safety. Family members being present or having multiple staff members provide teaching may be beneficial in certain situations, but the primary focus should be on confirming the patient's understanding to enhance safety and promote effective learning.
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Question 6
During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute, and the client complains of periodic dizzy spells. The nurse instructs the client to:
A. Increase fluids that are high in protein
B. Restrict fluids
C. Force fluids and reassess blood pressure
D. Limit fluids to non-caffeine beverages
Correct answer:
In this scenario, the client with cardiomyopathy is exhibiting signs of orthostatic hypotension, which is characterized by a significant drop in systolic blood pressure (>15 mm Hg) and an increase in heart rate (>15%), along with dizziness. These symptoms suggest volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency. The appropriate nursing intervention in this case is to force fluids and reassess blood pressure to address the underlying issue of volume depletion and improve hemodynamic stability. Choices A, B, and D are incorrect because increasing fluids high in protein, restricting fluids, or limiting fluids to non-caffeine beverages are not appropriate actions for a client experiencing orthostatic hypotension and signs of volume depletion.
Assuming that an elderly patient will have a difficult time understanding the directions for how to take medication is an example of:
A. Prejudice
B. Stereotyping
C. Encoding
D. Rationalization
Correct answer:
Stereotyping is defined as providing a generalization about a person based on their culture or characteristics. In this scenario, assuming that an elderly patient will have difficulty understanding medication directions solely based on their age is an act of stereotyping. The healthcare provider is attributing a generalized trait to the patient without considering individual differences. Prejudice, on the other hand, involves forming a negative opinion about someone based on their heritage or culture, which is not evident in this situation. Encoding refers to the process of converting information into a form that can be stored in memory, and rationalization involves justifying one's behavior or decisions with logical reasons, neither of which are applicable in this context.
When caring for a patient with latex allergy, the healthcare provider creates a latex-safe environment by doing which of the following?
A. Carefully cleaning the wall-mounted blood pressure device before using it.
B. Donning latex gloves outside the room to limit powder dispersal.
C. Using a latex-free pharmacy protocol.
D. Placing the patient in a semi-private room.
Correct answer:
Creating a latex-safe environment for a patient with latex allergy is crucial to prevent allergic reactions. Using a latex-free pharmacy protocol is essential as it ensures that medications and supplies provided to the patient are free of latex components. Cleaning a wall-mounted blood pressure device may not be sufficient as the device itself may contain latex parts that can trigger an allergic reaction. Donning latex gloves, even outside the room, is not recommended as powder dispersal can cause issues; only non-latex gloves should be used in a latex-safe environment. Placing the patient in a semi-private room does not directly address the need to eliminate latex exposure from medical supplies and equipment, which is better achieved through a latex-free pharmacy protocol.
The nurse is teaching parents about the treatment plan for a 2-week-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report
A. Loss of consciousness
B. Feeding problems
C. Poor weight gain
D. Fatigue with crying
Correct answer:
The correct answer is 'Loss of consciousness.' While parents should report any concerning observations, they need to call the healthcare provider immediately if the infant experiences a loss of consciousness. This change in alertness may indicate anoxia, which can be life-threatening. Tetralogy of Fallot is a congenital heart defect characterized by four main features: pulmonic stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. Surgery for Tetralogy of Fallot may be delayed or done in stages. Reporting loss of consciousness is crucial due to the potential seriousness of the condition. Feeding problems, poor weight gain, and fatigue with crying are important issues but do not require immediate reporting like loss of consciousness does.
A client is admitted for a head injury. His body is lying in an abnormal position and the physician states he is exhibiting decorticate posturing. Based on this assessment, the nurse can expect to find the client with:
A. The legs extended and rotated internally; the elbow, wrists, and fingers flexed
B. The legs pulled toward the chest; the head bent back at a 30-degree angle
C. The back arched; the arms and legs extended and rigid
D. The legs extended and rotated externally; the head turned to the right or the left
Correct answer:
Decorticate posturing is indicative of an injury to the corticospinal tract, resulting in abnormal posturing. It may occur spontaneously or in response to stimulation. This posture involves the legs being extended and rotated internally, while the elbows, wrists, and fingers are flexed inward. Choice A is correct because it accurately describes the expected positioning associated with decorticate posturing. Choices B, C, and D are incorrect. Choice B describes a different type of posturing known as opisthotonos. Choice C describes an exaggerated arching of the back, which is not characteristic of decorticate posturing. Choice D describes a different type of posturing with external rotation of the legs and head turning to the side, not consistent with decorticate posturing.
A client has developed a vitamin C deficiency. Which of the following symptoms might the nurse most likely see with this condition?
A. Cracks at the corners of the mouth
B. Altered mental status
C. Bleeding gums and loose teeth
D. Anorexia and diarrhea
Correct answer:
A client with a severe vitamin C deficiency has a condition called scurvy. Scurvy is characterized by symptoms such as bleeding gums, loose teeth, poor wound healing, and easy bruising. The correct answer is 'Bleeding gums and loose teeth' because these are classic signs of scurvy due to vitamin C deficiency. Choice A ('Cracks at the corners of the mouth') is more indicative of a deficiency in B vitamins, specifically riboflavin. Choice B ('Altered mental status') is not typically associated with vitamin C deficiency but can occur with other conditions like vitamin B12 deficiency. Choice D ('Anorexia and diarrhea') are not common symptoms of vitamin C deficiency, as they are more commonly associated with other gastrointestinal issues or deficiencies in different nutrients.
A new nursing unit is opening in the hospital. In order to meet the staffing needs of the unit, nurses from other areas will be moved and required to work in the new area. When notifying the nurses chosen to staff this area, the nurse manager states, 'You will either move to work on this unit or you will no longer be employed at this hospital.' Which of the following strategies is this nurse manager using?
A. Manipulation
B. Facilitation
C. Co-optation
D. Coercion
Correct answer:
The nurse manager in this scenario is using a coercion tactic to influence the nurses' job changes. Coercion involves using power to force others to make a choice. In this case, the nurses are left with no option but to either work on the new unit or face termination. Choice A, 'Manipulation,' is incorrect as manipulation involves influencing others through deceit or dishonesty, which is not evident in this situation. Choice B, 'Facilitation,' is incorrect as it refers to the process of making something easier or more convenient, which is not applicable here. Choice C, 'Co-optation,' involves absorbing or integrating individuals into a group, which does not align with the scenario described. Therefore, the most suitable term for the nurse manager's strategy is 'Coercion.'
When auscultating the patient's lungs during a shift assessment on a patient admitted in the early phase of heart failure, which finding would the nurse most likely hear?
A. Continuous rumbling, snoring, or rattling sounds mainly on expiration
B. Continuous high-pitched musical sounds on inspiration and expiration
C. Discontinuous, high-pitched sounds of short duration heard on inspiration
D. A series of long-duration, discontinuous, low-pitched sounds during inspiration
Correct answer:
In the early phase of heart failure, fine crackles are likely to be heard upon auscultation of the lungs. Fine crackles are characterized as discontinuous, high-pitched sounds of short duration heard on inspiration. Rhonchi are continuous rumbling, snoring, or rattling sounds mainly on expiration, which are often associated with airway secretions. Coarse crackles are a series of long-duration, discontinuous, low-pitched sounds during inspiration, typically indicating fluid in the alveoli. Wheezes are continuous high-pitched musical sounds on inspiration and expiration, commonly heard in conditions like asthma or chronic obstructive pulmonary disease (COPD). Therefore, the correct choice is C, as it describes the expected lung sounds in a patient with early heart failure.
What procedure examines a portion of the large intestine with an endoscope?
A. Colposcopy
B. Sigmoidoscopy
C. Upper GI
D. Cardiac catheterization
Correct answer:
Sigmoidoscopy is the correct answer because it specifically examines the sigmoid colon located in the descending colon using an endoscope inserted through the rectum. This procedure captures video and images of the large intestine's lining, helping in the diagnosis of conditions like inflammatory bowel disease or colorectal cancer. Colposcopy, on the other hand, is a procedure for examining the cervix and vagina, not the large intestine. Upper GI involves capturing images of the esophagus and stomach, focusing on the upper gastrointestinal tract, not the large intestine. Cardiac catheterization is a procedure that involves threading a thin instrument through the femoral artery to the heart, used for cardiac interventions and not related to examining the large intestine.
A client is seen for testing to rule out Rocky Mountain Spotted Fever. Which of the following signs or symptoms is associated with this condition?
A. Fever and rash
B. Circumoral cyanosis
C. Elevated glucose levels
D. All of the above
Correct answer:
The correct answer is 'Fever and rash.' Rocky Mountain Spotted Fever (RMSP) is caused by the R. rickettsii pathogen, which damages blood vessels. Patients with RMSP typically present with fever, edema, and a rash that initially appears on the hands and feet before spreading across the body. The disease manifests following a tick bite. Choice A is correct as fever and rash are key indicators of RMSP. Circumoral cyanosis (choice B) is not typically associated with RMSP; it refers to a bluish discoloration around the mouth and is more indicative of oxygen deprivation. Elevated glucose levels (choice C) are not specific signs of RMSP. Therefore, choice D, 'All of the above,' is incorrect since only choice A, 'Fever and rash,' is associated with Rocky Mountain Spotted Fever.
NCLEX-RN clinical judgment practice questions, set 13 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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