NCLEX-RN clinical judgment practice questions, set 17
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 17
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 of the following is an example of a breach of a client's right to privacy?
A. A nurse who is not caring for the client reads the client's personal information in the chart
B. A client is not allowed to keep a copy of their original medical record
C. A nurse files an incident report about a client that is reviewed with all staff at a meeting
D. A client's photograph is used without permission for the hospital newsletter
Show answer and rationale
Correct answer: D — A client's photograph is used without permission for the hospital newsletter
A breach of a client's right to privacy can occur when their personal information is used or disclosed without their consent. In this scenario, using a client's photograph without permission for the hospital newsletter violates their privacy rights. It is important to respect a client's confidentiality and seek their consent before using their personal information. Choices A, B, and C do not directly relate to breaching a client's right to privacy. Reading a client's personal information in their chart, not allowing a client to keep a copy of their medical record, and filing an incident report about a client do not necessarily violate their privacy rights as long as the information is handled appropriately and within legal and ethical boundaries.
Question 2
A nurse walks into a client's room to find the nursing assistant yelling, 'Sit back down or I won't help you eat, and then you will starve!' This type of behavior is known as:
A. Psychological abuse
B. Abandonment
C. Material exploitation
D. Physical abuse
Show answer and rationale
Correct answer: A — Psychological abuse
The correct answer is A: Psychological abuse. This behavior is classified as psychological abuse, which harms another person through words or threats. The nursing assistant's actions of yelling, making threats, and using food as a form of control fall under psychological abuse. Abandonment (choice B) refers to deserting or leaving a client without care, which is not the case in the scenario. Material exploitation (choice C) involves taking advantage of a person's assets or resources for personal gain, which is not evident here. Physical abuse (choice D) involves causing physical harm, which is not the primary issue in this situation. Therefore, the most appropriate classification for the behavior described in the scenario is psychological abuse.
Question 3
When developing a plan of care for a 6-year-old child diagnosed with acute glomerulonephritis, which intervention should the nurse prioritize?
A. Encourage limited activity and provide safety measures.
B. Catheterize the child to monitor intake and output strictly.
C. Encourage the child to talk about feelings related to illness.
D. Encourage classmates to visit and keep the child informed of school events.
Show answer and rationale
Correct answer: A — Encourage limited activity and provide safety measures.
The priority intervention for a 6-year-old child diagnosed with acute glomerulonephritis should be to encourage limited activity and provide safety measures. In glomerulonephritis, children tend to restrict their activities voluntarily due to fatigue during the active phase of the disease. Catheterization for intake and output monitoring may predispose the child to infection and is not the primary intervention. Encouraging the child to talk about feelings related to the illness may not be developmentally appropriate for a 6-year-old; instead, children can express feelings through play. It is important to limit visitors to allow the child to rest and recover rather than encouraging classmates to visit and keep the child informed of school events.
Question 4
Mr. W has orders for a physical therapy consult. The nurse contacts the appropriate department but 12 hours later, no one has come to see the client. Which is the most appropriate action of the nurse?
A. Call the supervisor and file a complaint against the physical therapy department
B. Contact the physician to notify him that the orders were not carried out
C. Assess the client's activity level by assisting with ambulation using a gait belt
D. Contact the physical therapy department again and repeat the order
Show answer and rationale
Correct answer: D — Contact the physical therapy department again and repeat the order
In this situation, the most appropriate action for the nurse to take is to contact the physical therapy department again and repeat the order. It is crucial to ensure that the client receives the necessary care as prescribed. Following up with the department reinforces the importance of the order and increases the likelihood of prompt action. Option A is incorrect because escalating the situation to filing a complaint should be a last resort after all other communication attempts have failed. Option B is not the best course of action as the first step should be to ensure proper communication within the healthcare team. Option C is not the priority in this scenario, as the immediate concern is to address the delay in the physical therapy consult.
Question 5
Which of the following is an example of a positive effect of exercise on a client?
A. Decreased basal metabolic rate
B. Decreased venous return
C. Decreased work of breathing
D. Decreased gastric motility
Show answer and rationale
Correct answer: C — Decreased work of breathing
The correct answer is 'Decreased work of breathing.' Exercise has numerous positive effects on clients, such as increasing metabolic rate, improving gastric motility, and enhancing venous return. When a client exercises regularly, their work of breathing decreases, meaning that everyday activities require less exertion. This is beneficial as it indicates improved cardiovascular and respiratory efficiency. Choices A, B, and D are incorrect because a decreased basal metabolic rate, decreased venous return, and decreased gastric motility are not typically considered positive effects of exercise. Instead, an increased basal metabolic rate, improved venous return, and optimal gastric motility are desired outcomes associated with physical activity.
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Question 6
A patient with a cast on the right leg is being cared for by a nurse. Which of the following assessment findings would be most concerning for the nurse?
A. The capillary refill time is 2 seconds
B. The patient complains of itching and discomfort
C. The cast has a foul-smelling odor
D. The patient is on antibiotics
Correct answer:
A foul-smelling odor emanating from the cast is a concerning finding as it indicates the possibility of infection or the presence of a pressure ulcer. These conditions can lead to serious complications if not promptly addressed. It is crucial for the nurse to investigate further and take appropriate actions to prevent potential harm to the patient. The other options do not directly indicate a risk of infection or complications associated with the cast. Itching and discomfort are common complaints due to wearing a cast, and the patient being on antibiotics may be part of their treatment plan for an unrelated condition. Capillary refill time of 2 seconds is within the normal range and would not be a cause for immediate concern in this scenario.
When a nurse is asked by a physician to speak to a colleague about their unprofessional behavior in front of a client but chooses not to confront the colleague and avoids the physician the next day, what type of conflict resolution is the nurse exhibiting?
A. Accommodation
B. Competition
C. Avoidance
D. Negotiation
Correct answer:
The nurse is exhibiting the conflict resolution strategy of avoidance. Avoidance involves ignoring the problem in the hope that it will go away on its own. In this scenario, the nurse avoids confronting the colleague and stays away from the physician, which does not address the issue directly. While avoidance may provide time for others to gain insight into the situation, it typically does not lead to a resolution of the underlying problems. Accommodation (A) involves yielding to the wishes of others, competition (B) entails pursuing one's own concerns at the expense of others, and negotiation (D) involves seeking a mutually agreeable solution through communication and compromise, none of which are demonstrated by the nurse in this situation.
Jack is a 2-month-old with a diagnosis of spinal muscular atrophy (SMA) type I. He has been admitted to the hospital for progressive respiratory difficulty. His parents have been informed that if he is not placed on ventilatory support, he will continue to decompensate and die of respiratory failure. Jack's physician discusses the poor prognosis of Jack's condition, and tells the parents that he will not be able to be removed from ventilatory support once it is initiated, due to his progressive neurological disease. After much discussion, the parents have decided to decline ventilatory support, agree to a do not resuscitate (DNR) order, and request hospice care for Jack. Another parent heard them discussing Jack's situation in the waiting room and says she could never do that to her baby. What is the most appropriate response to this parent?
A. You never know what you'll do until you're in that situation.
B. I can't discuss another patient's situation.
C. They have been through too much already.
D. You can contact administration with your concerns.
Correct answer:
In healthcare settings, privacy regulations prevent professionals from discussing patient situations with individuals not involved in that patient's care. Maintaining patient confidentiality is crucial to protect sensitive information. In this scenario, sharing details about Jack's situation with the parent who overheard the conversation would breach confidentiality. It is important to handle such situations delicately, especially in emotional environments like intensive care unit waiting rooms. While empathy and support are essential, it is equally crucial to respect patient privacy and confidentiality. Therefore, responding with 'I can't discuss another patient's situation' is the most appropriate and professional response in this context.
The depressed client verbalizes feelings of low self-esteem and self-worth, typified by statements such as "I'm such a failure"? I can't do anything right!"? The best nursing response would be:
A. To tell the client this is not true; that we all have a purpose in life.
B. To remain with the client and sit in silence; this will encourage the client to verbalize feelings.
C. To reassure the client that you know how the client is feeling and that things will get better.
D. To identify recent behaviors or accomplishments that demonstrate skill ability.
Correct answer:
The correct response in this situation is to reassure the client that you understand how they are feeling and provide hope for improvement. While acknowledging the client's feelings, it is essential to offer support and encouragement. Choice A is not the best response as it dismisses the client's feelings and offers a generalized statement. Choice B, remaining silent, may lead the client to feel unheard or unsupported. Choice D, identifying recent behaviors or accomplishments, may not be as effective in addressing the immediate emotional distress and negative self-talk expressed by the client. Therefore, choice C is the most appropriate response in this scenario, offering empathy and optimism to help the client feel understood and supported.
Which of the following interventions is most appropriate for a client with a diagnosis of Risk for Activity Intolerance?
A. Perform nursing activities throughout the entire shift
B. Assess for signs of increased muscle tone
C. Minimize environmental noise
D. Teach clients to perform the Valsalva maneuver
Correct answer:
The most appropriate intervention for a client diagnosed with Risk for Activity Intolerance is to minimize environmental noise. Environmental noise can increase the energy demand on the client as they try to manage their responses to stimuli. By reducing excess noise, the nurse helps promote rest and conserves the client's energy, which is crucial in managing activity intolerance. Choice A is incorrect because increasing nursing activities may exacerbate the client's intolerance to activity. Choice B is incorrect as assessing for signs of increased muscle tone does not directly address the issue of activity intolerance. Choice D is incorrect as teaching the Valsalva maneuver is not relevant to managing activity intolerance in this scenario.
During the examination, it is often appropriate to offer some brief teaching about the patient's body or the examiner's findings. Which one of these statements by the nurse is most appropriate?
A. "Your atrial dysrhythmias are under control."?
B. "You have pitting edema and mild varicosities."?
C. "Your pulse is 80 beats per minute, which is within the normal range."?
D. "I'm using my stethoscope to listen for any crackles, wheezes, or rubs in your lungs."?
Correct answer:
During an examination, providing brief educational information to the patient can enhance rapport, as long as the patient can comprehend the terminology. The most appropriate statement from the nurse is "Your pulse is 80 beats per minute, which is within the normal range." This statement conveys a vital sign in a way that is likely understandable to the patient. Choices A, B, and D use terminology that may be unfamiliar or confusing to the patient. Option A mentions 'atrial dysrhythmias,' which might not be clear to the patient. Option B involves terms like 'pitting edema' and 'varicosities,' which could be unfamiliar to the patient. Option D references 'crackles,' 'wheezes,' and 'rubs,' which might not be easily understood by the patient.
Which of the following abides by the Americans with Disabilities Act of 1990?
A. A nurse manager cannot cancel an interview with a potential employee because he has left-sided paralysis
B. A nurse is allowed to have a leave of absence to recover after a back injury
C. A nurse is mandated to receive 12 weeks off of work after having a baby
D. A nurse manager must hire a nurse who uses a walker for mobility
Correct answer:
The Americans with Disabilities Act of 1990 prohibits discrimination against individuals with disabilities in employment practices, ensuring equal opportunities for qualified individuals. Therefore, a nurse manager cannot cancel an interview with a potential employee simply because the individual has left-sided paralysis. Doing so would be considered discriminatory under the ADA. Choices B, C, and D do not directly align with ADA requirements. Choice B involves medical leave, which can be covered under a different law; choice C refers to maternity leave, which is protected under other regulations; and choice D involves a hiring decision based on a mobility aid, not the individual's qualifications, which does not fall under ADA guidelines.
The nurse is planning discharge instructions for the mother of a child following orchiopexy, which was performed on an outpatient basis. Which is a priority in the plan of care?
A. Wound care
B. Pain control measures
C. Measurement of intake
D. Cold and heat applications
Correct answer:
Following orchiopexy, the priority in the plan of care for the child's mother is wound care. The most common complications associated with orchiopexy are bleeding and infection. Discharge instructions should focus on demonstrating wound cleansing and dressing, and teaching parents to recognize signs of infection like redness, warmth, swelling, or discharge. It is crucial to prevent movement of the testicles and avoid contamination of the suture line. While analgesics may be prescribed, pain control measures are not the priority among the options presented. Measurement of intake is not essential as the child is likely to resume normal eating habits. Cold and heat applications are not typical prescribed treatments for post-orchiopexy care.
Application - The nurse is caring for a patient who has the following labs: Creatinine 2.5mg/dL, WBC 11,000 cells/mL, and Hemoglobin of 12 g/dL. Based on this information, which of these orders would the nurse question?
A. Administer 30 Units of Lantus Daily
B. CT of the spine with contrast
C. X-ray of the abdomen and chest
D. Administer heparin subcutaneously 5,000 Units every 12 hours
Correct answer:
The correct answer is to question the order for a CT of the spine with contrast. The patient's elevated creatinine level of 2.5mg/dL indicates impaired kidney function. Contrast agents are nephrotoxic and can further compromise kidney function in patients with existing nephropathy. Therefore, it is crucial to avoid contrast-enhanced imaging studies in patients with impaired renal function.
Choice A: Administering 30 Units of Lantus Daily is not contraindicated based on the provided lab values.
Choice C: Ordering an X-ray of the abdomen and chest is not contraindicated based on the provided lab values.
Choice D: Administering heparin subcutaneously at 5,000 Units every 12 hours is not contraindicated based on the provided lab values.
Mary T. was admitted to a nursing home on May 1st. On July 4th, she was diagnosed with a skin infection. This infection is considered a ________________ infection.
A. nosocomial
B. systemic
C. resident flora
D. resident aura
Correct answer:
The correct answer is 'nosocomial.' A nosocomial infection is defined as one that is not present upon admission to a healthcare facility but instead occurs during the patient's stay. In this case, since Mary was diagnosed with a skin infection after being admitted to the nursing home, it is considered a nosocomial infection. Nosocomial infections are a significant concern in healthcare settings, and infection control measures are in place to prevent their spread. Choices B, C, and D are incorrect. 'Systemic' refers to a condition affecting the entire body, not specific to a healthcare setting. 'Resident flora' and 'resident aura' are not commonly used terms in healthcare and do not relate to infections acquired in healthcare facilities.
NCLEX-RN clinical judgment practice questions, set 17 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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