NCLEX-RN clinical judgment practice questions, set 16
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 16
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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
A client is being seen for disrupted sleep patterns. The nurse encourages the client to verbalize feelings about sleep and inability to maintain adequate sleep habits. What is the rationale for this action?
A. The client most likely has a mental illness that should be treated before addressing sleep issues
B. The client may have unrecognized anxiety or fear that could be contributing to poor sleep habits
C. The client may become tired once they start talking
D. None of the above
Show answer and rationale
Correct answer: B — The client may have unrecognized anxiety or fear that could be contributing to poor sleep habits
Clients experiencing disrupted sleep patterns may have underlying anxiety or fear contributing to their poor sleep habits. Encouraging clients to verbalize their feelings about sleep allows them to address any negative emotions that may be impacting their ability to sleep well. By working through these issues, clients may experience increased peace and relaxation, which can help promote better sleep. Option A is incorrect because assuming a mental illness without evidence can lead to mismanagement of the client's care. Option C is incorrect as it does not address the underlying emotional factors affecting the client's sleep patterns. Option D is incorrect as there is a specific rationale for encouraging the client to verbalize their feelings about sleep.
Question 2
When preparing to perform a physical examination on an infant, what should the nurse do?
A. Have the parent remove all clothing except the diaper.
B. Instruct the parent not to feed the infant immediately before the examination.
C. Allow the infant to suck on a pacifier during abdominal auscultation.
D. Ensure the parent is present during the examination.
Show answer and rationale
Correct answer: A — Have the parent remove all clothing except the diaper.
For performing a physical examination on an infant, it is important to have the parent remove all clothing except the diaper to allow for a thorough examination while ensuring the infant remains comfortable. It is recommended not to feed the infant immediately before the examination but rather 1 to 2 hours after feeding when the baby is neither too drowsy nor too hungry. While a pacifier may be used during invasive assessments or if the infant is crying, it is not typically necessary during abdominal auscultation. Having the parent present during the examination is important for the infant's security and for the parent to understand the process; however, the clothing should still be removed except for the diaper to facilitate a comprehensive assessment.
Question 3
Which action will the nurse include in the plan of care for a patient who has been diagnosed with chronic hepatitis B?
A. Advise limiting alcohol intake to 1 drink daily
B. Schedule for liver cancer screening every 6 months
C. Initiate administration of the hepatitis C vaccine series
D. Monitor anti-hepatitis B surface antigen (anti-HBs) levels annually
Show answer and rationale
Correct answer: B — Schedule for liver cancer screening every 6 months
Patients diagnosed with chronic hepatitis B are at a higher risk for developing liver cancer. Therefore, it is essential to schedule them for liver cancer screening every 6 to 12 months to detect any potential malignancies at an early stage. Advising patients to limit alcohol intake is crucial as alcohol can exacerbate liver damage; thus, patients with chronic hepatitis B are advised to completely avoid alcohol. Administering the hepatitis C vaccine is irrelevant for a patient diagnosed with chronic hepatitis B since it is a different virus. Monitoring anti-hepatitis B surface antigen (anti-HBs) levels annually is not necessary as the presence of anti-HBs indicates a past hepatitis B infection or vaccination, and it does not require regular monitoring.
Question 4
A client who complains of nausea and seems anxious is admitted to the nursing unit. The nurse should take which of the following actions regarding completion of the admission interview?
A. Help the client to get settled and conduct the interview the next morning when the client is rested
B. Conduct the interview immediately, directing the majority of the questions to the client
C. Conduct the interview as soon as uninterrupted time is available to address the client's concerns
D. Ask the charge nurse to interview the client while the admitting nurse calls the doctor for anti-nausea and anti-anxiety medication
Show answer and rationale
Correct answer: C — Conduct the interview as soon as uninterrupted time is available to address the client's concerns
When dealing with a client who is experiencing nausea and anxiety, it is important to promptly conduct the admission interview to address their concerns. This allows for the collection of accurate data while attending to the client's immediate needs. Delaying the interview until the next morning (Choice A) may not be in the best interest of the client as timely assessment and intervention are essential. Directing questions to the client's spouse (Choice B) may not provide accurate information from the client themselves. Asking another nurse to conduct the interview while administering medications (Choice D) does not prioritize building a therapeutic relationship with the client, which is crucial in addressing their concerns and providing holistic care.
Question 5
The parents of an infant who underwent surgical repair of bladder exstrophy ask if the infant will be able to control their bladder as they get older. How should the nurse respond?
A. Your child will need catheterization until bladder control is gained.
B. Your child will be able to control their bladder like other children.
C. You should potty train your child at the same time you normally would.
D. Your child will not have a sphincter mechanism for the first 3 to 5 years, so urine will drain freely.
Show answer and rationale
Correct answer: D — Your child will not have a sphincter mechanism for the first 3 to 5 years, so urine will drain freely.
Bladder exstrophy is a congenital defect where the infant is born with the bladder located on the outside of the body. Surgical repair typically occurs within the first 1 to 2 days of life. In the following 3 to 5 years post-surgery, urine will drain freely from the urethra due to the absence of a sphincter mechanism. This period allows the bladder to develop capacity as the child grows. Subsequent surgical interventions will be required to establish a functioning sphincter mechanism. Therefore, the correct response is that the child will not have a sphincter mechanism for the first 3 to 5 years, leading to urine draining freely. Options A, B, and C are incorrect as they do not align with the physiological process and management of bladder exstrophy.
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Question 6
The parents of a 2-year-old child who had an orchiopexy to correct cryptorchidism are provided with discharge instructions by the nurse. Which statement by the parents indicates the need for further instruction?
A. I'll check his temperature.
B. I'll give him medication so he'll be comfortable.
C. I'll check his voiding to be sure there's no problem.
D. I'll let him decide when to return to his play activities.
Correct answer:
Cryptorchidism is a condition where one or both testes fail to descend into the scrotal sac. Orchiopexy, a surgical correction, may be required. After surgery, it is crucial to restrict vigorous activities for 2 weeks to promote healing and prevent injury. Allowing the child to decide when to return to play activities may lead to delayed healing and increased risk of injury, as 2-year-olds typically want to be active. Checking the child's temperature, administering analgesics as needed, and monitoring urine output are important postoperative care measures to ensure recovery and detect complications early. Therefore, the statement indicating the need for further instruction is the one related to letting the child decide when to resume play activities.
A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is most appropriate?
A. Document the presence of continuous bubbling.
B. Notify the surgeon of a possible pneumothorax.
C. Take no further action with the collection device.
D. Adjust the dial on the wall regulator to decrease suction.
Correct answer:
Continuous bubbling in the suction-control chamber of the chest tube collection device is an expected finding and indicates that the suction control chamber is connected to suction. It does not necessarily indicate a large air leak, which would be detected in the water-seal chamber. There is no evidence to suggest a pneumothorax based solely on continuous bubbling in the suction-control chamber. Adjusting the suction level by changing the wall regulator setting is not indicated in this situation, as the amount of suction applied is primarily regulated by the water level in the water-seal chamber and not by the vacuum source. Therefore, the most appropriate action in this scenario is for the nurse to take no further action with the collection device.
The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How would the nurse assess this child's respirations?
A. Respirations should be counted for 1 full minute.
B. Child's pulse and respirations should be simultaneously checked for 30 seconds and then multiplied by 2.
C. Child's respirations should be checked for a minimum of 5 minutes to identify any variations in his or her respiratory pattern.
D. Patient's respirations should be counted for 15 seconds and then multiplied by 4.
Correct answer:
To accurately assess a child's respiratory pattern, the nurse should count respirations for a full minute. This duration provides a comprehensive view of the child's breathing pattern, ensuring abnormalities are not missed. Counting for only 30 seconds may not capture irregularities effectively. Checking respirations for 5 minutes is excessive and unnecessary for a routine assessment. Counting for 15 seconds and multiplying by 4 is not as precise as a full-minute count. Pulse and respirations should not be checked simultaneously; instead, the nurse should count respirations unobtrusively while appearing to take the child's pulse. Therefore, the correct approach is to count the child's respirations for 1 full minute to obtain an accurate assessment.
The major difference between a grand mal and petit mal seizure is that a person with a grand mal seizure will have _______________ and the person with a petit mal seizure will not.
A. convulsive movements
B. sleep apnea
C. atonic movements
D. flaccidity
Correct answer:
The major difference between a grand mal and petit mal seizure is the presence or absence of convulsive movements. Grand mal seizures are characterized by convulsive movements, including jerking of limbs and loss of consciousness. In contrast, petit mal seizures, also known as absence seizures, typically involve brief episodes of staring or eye blinking without convulsive movements. Therefore, choice A, 'convulsive movements,' is the correct answer. Choices B, 'sleep apnea,' and D, 'flaccidity,' are incorrect as they are not associated with the characteristics of grand mal or petit mal seizures. Choice C, 'atonic movements,' is also incorrect as petit mal seizures do not involve atonic movements, but rather absence behaviors such as staring spells.
A client with myocardial infarction is receiving tissue plasminogen activator, alteplase (Activase, tPA). While on the therapy, the nurse plans to prioritize which of the following?
A. Observe for neurological changes
B. Monitor for any signs of renal failure
C. Check the food diary
D. Observe for signs of bleeding
Correct answer:
The priority concern for a client receiving thrombolytic medication, such as tissue plasminogen activator (alteplase), is to monitor for signs of bleeding. Thrombolytics work by converting plasminogen to plasmin, which degrades fibrin. This process can lead to the breakdown of both fibrin-bound plasminogen on thrombi surfaces and unbound plasminogen in the plasma. The resulting plasmin can degrade fibrin, fibrinogen, factor V, and factor VIII. Observing for signs of bleeding is crucial due to the increased risk of hemorrhage associated with thrombolytic therapy. Monitoring for neurological changes, signs of renal failure, or checking the food diary are not the immediate priorities compared to detecting and managing potential bleeding complications.
A toddler has recently been diagnosed with cerebral palsy. Which of the following information should the nurse provide to the parents? Select one that doesn't apply.
A. Regular developmental screening is important to avoid secondary developmental delays.
B. Cerebral palsy is caused by injury to the upper motor neurons and results in motor dysfunction, as well as possible ocular and speech difficulties.
C. Developmental milestones may be slightly delayed but usually will require no additional intervention.
D. Parent support groups are helpful for sharing strategies and managing health care issues.
Correct answer:
The correct answer is 'Developmental milestones may be slightly delayed but usually will require no additional intervention.' This statement is incorrect as delayed developmental milestones in a child with cerebral palsy require interventions and constant follow-ups. Developmental monitoring is essential to track a child's growth and development over time. If any concerns are raised during monitoring, a developmental screening test should be conducted promptly to address any developmental delays or issues. Regular interventions, therapies, and support are crucial to optimize the child's development and well-being. Therefore, it is important for parents to be aware that additional interventions may be necessary to support their child's development.
A teen patient is admitted to the hospital by his physician who suspects a diagnosis of acute glomerulonephritis. Which of the following findings is consistent with this diagnosis? Select one that doesn't apply.
A. Urine specific gravity of 1.040.
B. Urine output of 350 ml in 24 hours.
C. Brown ("tea-colored"?) urine.
D. Generalized edema.
Correct answer:
The correct answer is 'Generalized edema.' Acute glomerulonephritis typically presents with periorbital edema, not generalized edema. Findings in acute glomerulonephritis include dark, smoky, or tea-colored urine (hematuria) due to red blood cells in the urine, elevated blood pressure, and proteinuria. The urine specific gravity may be high due to decreased urine output, but a urine output of 350 ml in 24 hours is extremely low and suggestive of renal impairment. Generalized edema is more commonly associated with nephrotic syndrome, where there is significant proteinuria leading to hypoalbuminemia and subsequent fluid retention in tissues. In acute glomerulonephritis, the edema is usually limited to the face and lower extremities, not generalized.
A teen patient is admitted to the hospital by his physician who suspects a diagnosis of acute glomerulonephritis. Which of the following findings is consistent with this diagnosis? Select one that doesn't apply.
A. Urine specific gravity of 1.040.
B. Urine output of 350 ml in 24 hours.
C. Brown ("tea-colored"?) urine.
D. Generalized edema.
Correct answer:
The correct answer is 'Generalized edema.' Acute glomerulonephritis typically presents with periorbital edema, not generalized edema. Findings in acute glomerulonephritis include dark, smoky, or tea-colored urine (hematuria) due to red blood cells in the urine, elevated blood pressure, and proteinuria. The urine specific gravity may be high due to decreased urine output, but a urine output of 350 ml in 24 hours is extremely low and suggestive of renal impairment. Generalized edema is more commonly associated with nephrotic syndrome, where there is significant proteinuria leading to hypoalbuminemia and subsequent fluid retention in tissues. In acute glomerulonephritis, the edema is usually limited to the face and lower extremities, not generalized.
All hospitals and nursing homes are mandated to have the goal of a restraint-free environment. The best way to achieve this goal is to ________________.
A. ban the use of all restraints under all circumstances
B. limit restraints to only those situations when falls cannot be prevented
C. keep all bedside rails up for all patients during nighttime hours
D. use non-skid socks and sheets to prevent falls from chairs
Correct answer:
All hospitals and nursing homes are mandated by JCAHO and state departments of health to have the goal of a restraint-free environment. This does not mean that no restraints can ever be used under any circumstances. The goal is to minimize the use of restraints and prioritize other preventive measures. Restraining a patient should only be considered when all other preventive strategies have failed, and the patient is at risk of harm. Therefore, the best approach is to limit the use of restraints to situations where falls cannot be prevented, ensuring that restraints are used as a last resort to maintain patient safety. Choices C and D are not ideal solutions as they do not address the appropriate use of restraints in a restraint-free environment.
Which finding indicates to the nurse that a patient's transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective?
A. Increased serum albumin level
B. Decreased indirect bilirubin level
C. Improved alertness and orientation
D. Fewer episodes of bleeding varices
Correct answer:
The correct answer is 'Fewer episodes of bleeding varices.' A transjugular intrahepatic portosystemic shunt (TIPS) is used to reduce pressure in the portal venous system, thus decreasing the risk of bleeding from esophageal varices. This outcome would indicate the effectiveness of the TIPS procedure. The other choices are incorrect because: Increased serum albumin level and decreased indirect bilirubin level are not direct indicators of TIPS effectiveness. Improved alertness and orientation could be influenced by various factors and may not directly correlate with the effectiveness of the TIPS procedure. Additionally, TIPS can actually increase the risk of hepatic encephalopathy, which contradicts the choice of improved alertness and orientation.
NCLEX-RN clinical judgment practice questions, set 16 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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