NCLEX-RN clinical judgment practice questions, set 15
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 15
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
When assessing a 75-year-old patient who has asthma, the nurse notes that the patient assumes a tripod position, leaning forward with arms braced on the chair. How would the nurse interpret these findings?
A. Interpret that the patient is eager and interested in participating in the interview.
B. Evaluate the patient for abdominal pain, which may be exacerbated in the sitting position.
C. Interpret that the patient is having difficulty breathing and assist them to a supine position.
D. Recognize that a tripod position is often used when a patient is having respiratory difficulties.
Show answer and rationale
Correct answer: D — Recognize that a tripod position is often used when a patient is having respiratory difficulties.
Assuming a tripod position"?leaning forward with arms braced on chair arms"?occurs with chronic pulmonary diseases like asthma. This position helps improve breathing by allowing better use of respiratory muscles. Option A is incorrect because assuming the tripod position is not related to being eager or interested in participating in an interview. Option B is incorrect as abdominal pain is not typically associated with the tripod position in this context. Option C is incorrect as assisting the patient to a supine position would not address the underlying respiratory difficulty indicated by the tripod position. Therefore, the correct interpretation is to recognize that the patient is likely experiencing respiratory difficulties when assuming the tripod position.
Question 2
Which of the following statements made by a client during an individual therapy session would the nurse most identify as reflecting schizoaffective disorder?
A. ''I just want to stab myself with this pen.''
B. ''What's the point in life anyways?''
C. ''My thoughts are racing because of the conspiracies against me.''
D. ''I hear voices every day and sometimes see old friends that don't exist.''
Show answer and rationale
Correct answer: C — ''My thoughts are racing because of the conspiracies against me.''
The correct answer is, ''My thoughts are racing because of the conspiracies against me.'' Schizoaffective disorder combines the symptoms of bipolar disorder (mania and depression) with those of schizophrenia (delusions and disturbed thought processes). Racing thoughts are a characteristic symptom of a manic episode, while beliefs in conspiracies indicate paranoia, which are common in schizoaffective disorder. Choices A, B, and D do not specifically align with the symptoms of schizoaffective disorder. Choice A suggests self-harm, which may be seen in various mental health conditions; choice B reflects existential questioning or depression; and choice D describes hallucinations, which are more characteristic of schizophrenia rather than schizoaffective disorder.
Question 3
You have noticed that the last several patients you have cared for have had questionable blood pressure readings from their arterial lines. When checked against cuff pressures, a discrepancy has been noted, and further investigation has revealed faulty transducers. This is not the first product issue with this company. What positive step could you take to help resolve this situation?
A. Use the old stock from a previous company
B. Verify the cuff pressures every hour to ensure accuracy
C. Notify the risk manager
D. Form a peer workgroup to evaluate new products
Show answer and rationale
Correct answer: D — Form a peer workgroup to evaluate new products
Forming a peer workgroup to evaluate new products would be an excellent opportunity for collaboration among peers, management, and the purchasing department. When clinicians are engaged to work toward solutions that address patient care issues, they experience more empowerment and control over their work environments.
Choice A is incorrect because using old stock from a previous company does not address the root cause of the faulty transducers from the current company. Choice B is incorrect as verifying cuff pressures every hour does not directly address the issue of faulty transducers. Choice C is less effective than forming a peer workgroup as it involves only notifying the risk manager without involving a collaborative effort to resolve the product issue.
Question 4
The nurse is discussing the term subculture with a student nurse. Which statement by the nurse would best describe subculture?
A. "Fitting as many people as possible into the majority culture."?
B. "Identifying small groups of people who do not want to be identified with the larger culture."?
C. "Singling out groups of people who suffer differential and unequal treatment as a result of cultural variations."?
D. "Recognizing groups of people within a culture with shared characteristics that are not common to all members of the culture."?
Show answer and rationale
Correct answer: D — "Recognizing groups of people within a culture with shared characteristics that are not common to all members of the culture."?
A subculture refers to a group of people within a larger culture who share distinct beliefs, values, or attitudes that are not universal among all members of the larger culture. Subcultures can emerge based on factors such as ethnicity, religion, education, occupation, age, and gender. The correct answer describes the concept of a subculture accurately. Choices A, B, and C are incorrect because they do not capture the essence of a subculture. Fitting people into the majority culture, identifying small groups who distance themselves from the larger culture, or singling out individuals facing differential treatment do not define subculture. Subcultures represent specific groups with shared characteristics that differentiate them from the broader cultural norms.
Question 5
A 4-year-old child with acute glomerulonephritis is admitted to the hospital. The nurse identifies which client problem in the plan of care as the priority?
A. Infection related to hypertension
B. Injury related to loss of blood in urine
C. Excessive fluid volume related to decreased plasma filtration
D. Retarded growth and development related to a chronic disease
Show answer and rationale
Correct answer: C — Excessive fluid volume related to decreased plasma filtration
In acute glomerulonephritis, the child experiences excessive accumulation of water and retention of sodium, leading to circulatory congestion and edema. Excessive fluid volume is a primary concern due to the disease process. Hypertension and infection are not directly related to acute glomerulonephritis; therefore, they are not the priority client problems. While hematuria (blood in urine) may occur, it typically does not lead to significant injury that takes precedence over excessive fluid volume. Acute glomerulonephritis is an acute condition, not chronic; therefore, retarded growth and development related to a chronic disease is not the priority issue. With proper management, most children recover completely without long-term growth and development issues.
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Question 6
The patient with chronic pancreatitis will be taught to take the prescribed pancrelipase (Viokase)
A. at bedtime.
B. in the morning.
C. with each meal.
D. for abdominal pain.
Correct answer:
The correct answer is to take pancrelipase (Viokase) with each meal. Pancrelipase is a pancreatic enzyme replacement medication that helps with the digestion of nutrients. Patients with chronic pancreatitis often have difficulty digesting food properly due to insufficient pancreatic enzyme production. Taking pancrelipase with each meal assists in the breakdown of fats, proteins, and carbohydrates consumed during the meal. Option A ('at bedtime') is incorrect because enzymes should be taken with meals to aid in digestion. Option B ('in the morning') is not ideal as it does not ensure optimal enzyme activity during meals. Option D ('for abdominal pain') is incorrect as pancrelipase is not meant to be taken solely for pain relief but rather to aid in digestion.
A patient's nursing diagnosis is Insomnia. The desired outcome is: 'Patient will sleep for a minimum of 5 hours nightly by October 31.' On November 1, a review of the sleep data shows the patient sleeps an average of 4 hours nightly and takes a 2-hour afternoon nap. Which evaluation should be documented?
A. Consistently demonstrated
B. Often demonstrated
C. Sometimes demonstrated
D. Never demonstrated
Correct answer:
The correct answer is 'Never demonstrated.' Despite the patient sleeping a total of 6 hours daily, it is not achieved in one uninterrupted session at night as per the desired outcome. The patient's habit of taking a 2-hour afternoon nap also affects the evaluation. Therefore, the outcome should be evaluated as 'Never demonstrated.'
Choice A, 'Consistently demonstrated,' is incorrect because the desired outcome of sleeping for a minimum of 5 hours nightly in one session is not met.
Choice B, 'Often demonstrated,' is incorrect as the patient's sleep pattern does not consistently align with the desired outcome.
Choice C, 'Sometimes demonstrated,' is also incorrect as the patient's sleep pattern does not meet the specific criteria set in the desired outcome.
The nurse admits a patient who has a diagnosis of an acute asthma attack. Which statement indicates that the patient may need teaching regarding medication use?
A. I have not had any acute asthma attacks during the last year.
B. I became short of breath an hour before coming to the hospital.
C. I've been taking Tylenol 650 mg every 6 hours for chest-wall pain.
D. I've been using my albuterol inhaler more frequently over the last 4 days.
Correct answer:
The correct answer is 'I've been using my albuterol inhaler more frequently over the last 4 days.' This statement indicates that the patient may need teaching regarding medication use because an increased need for a rapid-acting bronchodilator suggests an exacerbation of asthma. The patient should be educated on recognizing worsening symptoms and the appropriate actions to take. Choices A, B, and C do not directly relate to asthma exacerbation or the need for medication teaching, making them incorrect. Choice A reflects a lack of recent acute asthma attacks, while choice B describes shortness of breath unrelated to medication use. Choice C mentions Tylenol use for chest-wall pain, which is not indicative of asthma exacerbation or medication teaching needs.
Why is it important to genotype HCV before initiating drug therapy?
A. Side effects of nucleotide analogs
B. Measures for improving the appetite
C. Ways to increase activity and exercise
D. Administering alpha-interferon (Intron A)
Correct answer:
Genotyping of HCV plays a crucial role in managing treatment as it helps determine the most effective therapy for the specific viral strain. It allows healthcare providers to personalize treatment regimens and predict response rates. The statement about acute HCV infection converting to chronic state is accurate, highlighting the need for appropriate management. Immune globulin and vaccines are not available for HCV, and Ribavirin is commonly used for chronic HCV infection. Improving appetite is essential in liver health as adequate nutritional intake supports hepatocyte regeneration. Choices A, C, and D are incorrect as they do not address the specific importance of genotyping in HCV treatment or the significance of appetite improvement in liver function.
On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse's initial response should be to:
A. Give the client orientation materials and review the unit rules and regulations.
B. Introduce him/her and accompany the client to the client's room.
C. Take the client to the day room and introduce him/her to the other clients.
D. Ask the nursing assistant to get the client's vital signs and complete the admission search.
Correct answer:
Anxiety is triggered by change that threatens the individual's sense of security. In response to anxiety in clients, the nurse should remain calm, minimize stimuli, and move the client to a calmer, more secure/safe setting. The correct initial response is to introduce the client and accompany them to their room. This approach helps the client feel oriented, safe, and supported. Giving orientation materials or reviewing rules and regulations may overwhelm the client further. Taking the client to the day room and introducing them to other clients could increase anxiety by exposing them to unfamiliar faces. Asking the nursing assistant to get vital signs and complete admission tasks can wait until the client feels more settled and secure in their environment.
What would be an appropriate evaluation statement for the nurse to write based on the client's ability to state only two signs of impaired circulation out of three as expected?
A. Client understands the signs of impaired circulation
B. Goal met: Client cited numbness and tingling as a sign of impaired circulation
C. Goal not met: Client able to name only two signs of impaired circulation
D. Goal not met: Client unable to describe signs of impaired circulation
Correct answer:
The appropriate evaluation statement for the nurse to write would be 'Goal not met: Client able to name only two signs of impaired circulation.' In this scenario, the client has only identified two out of the three signs of impaired circulation specified in the desired outcome. Therefore, the goal has not been fully achieved. It is essential in nursing practice to assess and document client progress accurately. While the client has shown some understanding by correctly identifying numbness and tingling as signs of impaired circulation, the inability to state the third sign indicates an incomplete achievement of the goal. This evaluation helps guide further interventions or educational strategies to help the client meet the desired outcome in the care plan.
All of the following are essential components of supervision EXCEPT:
A. All tasks to be delegated or supervised are within the nurse's scope of practice
B. The necessary tasks require repeated assessments
C. The nurse has adequate time to develop staff assignments
D. Policies have been developed that govern nursing practice
Correct answer:
Supervision in nursing requires key components to ensure effective management. Tasks to be delegated or supervised must align with the nurse's scope of practice to maintain safety and quality care. Adequate time for staff assignment development is essential for efficient workflow. Policies governing nursing practice provide a framework for safe and standardized care. However, the statement 'The necessary tasks require repeated assessments' is not an essential component of supervision. Tasks should be clear, achievable, and not necessitate repeated assessments, as this would impede delegation and efficient completion. Repeated assessments may indicate unclear task delegation or inadequate initial assessment, which should be avoided in effective supervision.
A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient?
A. Ask the patient to lie down to complete a full physical assessment.
B. Briefly ask specific questions about this episode of respiratory distress.
C. Complete the admission database to check for allergies before treatment.
D. Delay the physical assessment to first complete pulmonary function tests.
Correct answer:
When a patient presents with acute shortness of breath, the initial assessment should focus on gathering specific information relevant to the current episode of respiratory distress. A comprehensive health history or full physical examination can be deferred until the acute distress has been addressed. Asking specific questions helps determine the cause of the distress and guides appropriate treatment. While checking for allergies is important, completing the entire admission database is not a priority during the initial assessment. Likewise, delaying the physical assessment for pulmonary function tests is not recommended as the immediate focus should be on addressing the acute respiratory distress before ordering further diagnostic tests or interventions.
A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient?
A. Ask the patient to lie down to complete a full physical assessment.
B. Briefly ask specific questions about this episode of respiratory distress.
C. Complete the admission database to check for allergies before treatment.
D. Delay the physical assessment to first complete pulmonary function tests.
Correct answer:
When a patient presents with acute shortness of breath, the initial assessment should focus on gathering specific information relevant to the current episode of respiratory distress. A comprehensive health history or full physical examination can be deferred until the acute distress has been addressed. Asking specific questions helps determine the cause of the distress and guides appropriate treatment. While checking for allergies is important, completing the entire admission database is not a priority during the initial assessment. Likewise, delaying the physical assessment for pulmonary function tests is not recommended as the immediate focus should be on addressing the acute respiratory distress before ordering further diagnostic tests or interventions.
The client is receiving discharge teaching seven (7) days post myocardial infarction and inquires why he must wait six (6) weeks before engaging in sexual intercourse. What is the best response by the nurse to this question?
A. "You need to regain your strength before attempting such exertion."?
B. "When you can climb 2 flights of stairs without problems, it is generally safe."?
C. "Have a glass of wine to relax you, then you can try to have sex."?
D. "If you can maintain an active walking program, you will have less risk."?
Correct answer:
Following a myocardial infarction, there is a risk of cardiac rupture at the site of the infarction for approximately six (6) weeks until scar tissue forms. The advice to wait until the client can climb two flights of stairs without issues is common among healthcare providers as it indicates an adequate level of physical exertion tolerance and suggests a lower risk of complications during sexual activity. Choice A is not specific to the recovery timeline related to sexual activity post-myocardial infarction. Choice C is inappropriate as alcohol consumption should not be recommended before sexual activity. Choice D, though promoting an active lifestyle, does not directly address the safety concerns related to sexual intercourse post-myocardial infarction.
NCLEX-RN clinical judgment practice questions, set 15 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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