NCLEX-RN clinical judgment practice questions, set 21
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 21
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
To accurately assess a patient's respiration rate, which of the following methods would be BEST?
A. Tell the patient, 'Please remain silent while I count your number of breaths.'
B. Count respirations at the same time you are counting the pulse rate
C. Count the pulse rate for one minute, then, while keeping your index fingers on the patient's radial artery, count the respirations for an additional minute.
D. Count the patient's respiration rate, then take the patient's temperature, and then take the pulse rate.
Show answer and rationale
Correct answer: B — Count respirations at the same time you are counting the pulse rate
The most accurate method to assess a patient's respiration rate is to count the breaths simultaneously while counting the pulse rate. This approach ensures that the patient is unaware of the specific focus on their breathing, preventing any conscious alteration in breathing patterns. Choice A is incorrect because informing the patient may lead to altered breathing as the patient may consciously change their breathing pattern. Choice C involves counting the pulse rate first, which is not necessary for assessing respiration rate. Choice D is incorrect as it includes unnecessary steps such as taking the patient's temperature before counting respiration rate, which adds no value to accurately assessing the respiration rate.
Question 2
An 85-year-old male has been losing mobility and gaining weight over the last two months. The patient also has the heater running in his house 24 hours a day, even on warm days. Which of the following tests is most likely to be performed?
A. CBC (complete blood count)
B. ECG (electrocardiogram)
C. Thyroid function tests
D. CT scan
Show answer and rationale
Correct answer: C — Thyroid function tests
The symptoms of weight gain and poor temperature tolerance in an elderly male suggest a potential thyroid dysfunction. Thyroid function tests are crucial in differentiating between hyperthyroidism, hypothyroidism, and a euthyroid state. These tests involve measuring the serum levels of thyroid hormones T3 and T4, also known as thyroxine, to evaluate thyroid function accurately. A complete blood count (Choice A) would not directly address the symptoms presented. An electrocardiogram (Choice B) assesses heart activity and would not be the primary test for these symptoms. A CT scan (Choice D) provides detailed images of internal organs and structures, which would not be the initial investigation for the described symptoms.
Question 3
As a nurse, you have been assigned to take over as charge nurse without any report after the previous charge nurse fell during her shift and was taken to the emergency room. At the end of the shift, you have made the assignments for the next shift's nurses and posted them. As the nurses come in, they begin to complain that the assignments make no sense based on patient acuity. One refuses to take her assignment and threatens to go home. What could you have done to prevent their dissatisfaction?
A. Reviewed the notes of the previous charge nurse
B. Tried to contact the previous charge nurse in the emergency room
C. Collaborated with the nurse manager
D. Collaborated with the other nurses on your shift
Show answer and rationale
Correct answer: D — Collaborated with the other nurses on your shift
Collaborating with the other nurses on your shift would have permitted them to provide the most updated information regarding patient status and acuity. Requesting their input into creating assignments would have provided shared governance and assurance that the unit staffing was arranged appropriately. Reviewing the notes of the previous charge nurse might not capture the real-time changes in patient conditions. Trying to contact the previous charge nurse in the emergency room may not be feasible or timely. Collaborating with the nurse manager could be helpful, but involving the nurses directly impacted by the assignments would have been more effective in addressing their concerns and ensuring appropriate patient care.
Question 4
The healthcare provider is preparing to perform a physical assessment. Which statement is true about the inspection phase of the physical assessment?
A. Usually yields little information
B. Takes time and reveals a surprising amount of information
C. May be somewhat uncomfortable for the expert practitioner
D. Requires a thorough examination of the patient's body before proceeding with palpation
Show answer and rationale
Correct answer: B — Takes time and reveals a surprising amount of information
During the inspection phase of a physical assessment, it is essential to take time as it can reveal a significant amount of information. Initially, it may feel uncomfortable for the examiner to focus solely on observing the patient without immediate action. Rushing through inspection is not recommended as it can lead to missing important cues. Train yourself to be thorough during inspection by observing carefully and taking the time needed to gather essential data. Choices A, C, and D are incorrect because inspection typically provides valuable information, may feel uncomfortable at first but is necessary for a comprehensive assessment, and does not involve a quick glance but requires a focused and detailed observation.
Question 5
Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain breakthrough for a morphine drip is not working?
A. The client complains of discomfort at the IV insertion site
B. The client states 'I just can't get relief from my pain.'
C. The level of the drug is 100 ml at 8 AM and is 80 ml at noon
D. The level of the drug is 100 ml at 8 AM and is 50 ml at noon
Show answer and rationale
Correct answer: C — The level of the drug is 100 ml at 8 AM and is 80 ml at noon
The correct answer is that the level of the drug is 100 ml at 8 AM and is 80 ml at noon. With a basal rate of 10 mL per hour, a total of 40 mL should have been infused by noon, leaving only 60 mL in the container. Any amount greater than 60 mL at noon indicates that the pump is not functioning properly. Therefore, the finding of 80 mL at noon suggests the pump is not delivering the expected medication volume. Choices A and B are related to the client's symptoms and may indicate the need for pain management assessment but do not specifically indicate pump malfunction. Choice D, where the level drops to 50 mL at noon, would actually indicate that the pump is working effectively, as the expected volume has been delivered.
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Question 6
An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen?
A. Arrange for a friend to administer the medication on schedule.
B. Give the patient written instructions about how to take the medications.
C. Teach the patient about the high risk for infecting others unless treatment is followed.
D. Arrange for a daily noon meal at a community center where the drug will be administered
Correct answer:
Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen for a homeless patient with active tuberculosis. By arranging a daily noon meal at a community center where the drug will be administered, the nurse ensures that the patient is available to receive the medication and can directly observe the patient taking it. This method helps address the challenges faced by homeless individuals, such as lack of a stable living situation. The other options, such as having a friend administer the medication, giving written instructions, or educating about infecting others, may not be as effective in ensuring adherence, especially in the case of a homeless individual with alcoholism.
What nursing intervention demonstrates that the nurse understands the priority nursing diagnosis when caring for oral cancer patients with extensive tumor involvement and/or a high amount of secretions?
A. The nurse uses a pen pad to communicate with the patient
B. The nurse provides oral care every 2 hours
C. The nurse listens for bowel sounds every 4 hours
D. The nurse suctions as needed and elevates the head of the bed
Correct answer:
The correct answer is to suction as needed and elevate the head of the bed. This intervention is crucial for managing Ineffective Airway Clearance, which is the priority nursing diagnosis in oral cancer patients with extensive tumor involvement and/or a high amount of secretions. Suctioning helps clear secretions that may obstruct the airway, while elevating the head of the bed promotes optimal respiratory function. Providing oral care every 2 hours may be important for overall oral health but is not directly related to addressing the priority diagnosis. Listening for bowel sounds every 4 hours is more relevant to gastrointestinal assessment and not specific to managing airway clearance issues in oral cancer patients.
The nurse practicing in a maternity setting recognizes that the postmature fetus is at risk due to:
A. Excessive fetal weight
B. Low blood sugar levels
C. Depletion of subcutaneous fat
D. Progressive placental insufficiency
Correct answer:
A postmature or postterm pregnancy occurs when a pregnancy exceeds the typical term of 38 to 42 weeks. In this situation, the fetus is at risk due to progressive placental insufficiency. This occurs because the placenta loses its ability to function effectively after 42 weeks. The accumulation of calcium deposits in the placenta reduces blood perfusion, oxygen supply, and nutrient delivery to the fetus, leading to potential growth problems. Choices A, B, and C are incorrect because excessive fetal weight, low blood sugar levels, and depletion of subcutaneous fat are not the primary risks associated with postmature fetuses. The main concern lies in the compromised placental function and its impact on fetal well-being.
The chain of infection includes the ________________.
A. germ, agent, reservoir, exit portal, mode of transmission, entry port, and susceptible host
B. active natural, active artificial, passive natural, and passive artificial
C. opportunism, weakness, immunity, and colonization
D. intrinsic, extrinsic, internal, and external transmission
Correct answer:
The chain, or cycle, of infection includes the germ (microorganism), agent, reservoir, exit portal, mode of transmission, entry port, and susceptible host. This sequence describes how infections are passed from one person to another. Choice B is incorrect because it refers to types of immunity, not components of the chain of infection. Choice C is also incorrect as it lists terms unrelated to the chain of infection. Choice D is incorrect as it describes transmission types, not components of the chain of infection. Understanding the chain of infection is crucial in preventing the spread of infections by breaking one or more links in the chain, such as interrupting the mode of transmission through proper hand hygiene.
A client has volunteered to take part in a research study. After participating for two months, he decides that he can no longer tolerate the study and decides to leave. What are the client's rights in this situation?
A. The client has a right to be released from the study but must reimburse the researchers for charges incurred
B. The client has a right to be released from the study without any liability
C. The client has a right to be released from the study but is prohibited from participating in any future studies
D. The client does not have the right to be released from the study; he must finish his participation
Correct answer:
When a client voluntarily participates in a research study and later decides to withdraw, they have the right to be released from the study without any liability. It is unethical to force a participant to continue in a study against their will as this violates their autonomy and personal rights. Choice A is incorrect as it suggests that the client must reimburse the researchers for charges incurred, which is not typically the case unless agreed upon beforehand. Choice C is incorrect as there is no standard practice prohibiting a participant from future studies just because they withdrew from a current one. Choice D is incorrect because participants always have the right to withdraw from a research study at any time.
A 1-month-old infant has a head measurement of 34 cm and a chest circumference of 32 cm. Based on the interpretation of these findings, what action would the nurse take?
A. Refer the infant to a physician for further evaluation.
B. Consider these findings normal for a 1-month-old infant.
C. Expect the chest circumference to be greater than the head circumference.
D. Ask the parent to return in 2 weeks to re-evaluate the head and chest circumferences.
Correct answer:
In infants, a normal head measurement is approximately 32 to 38 cm, and it is usually around 2 cm larger than the chest circumference. These measurements vary with age; between 6 months and 2 years, both measurements are approximately the same, and after age 2 years, the chest circumference becomes greater than the head circumference. Given that the 1-month-old infant's head measurement is within the typical range and slightly larger than the chest circumference, the nurse should consider these findings normal. There is no indication to refer the infant for further evaluation or to have the parent return for re-evaluation in 2 weeks, as these measurements fall within the expected parameters for a 1-month-old infant.
You are taking care of 5 patients today. One of your patients wants water; another needs help walking to the bathroom; another just stated that they have chest pain; and another is crying because his daughter did not visit him today. Which patient care problem must you deal with first?
A. The water
B. Help to the bathroom
C. The chest pain
D. The crying person
Correct answer:
The chest pain must be addressed immediately as it could indicate a serious condition like a heart attack. Treating chest pain is a top priority in healthcare settings due to the potential life-threatening nature of the symptom. Providing immediate attention to chest pain ensures prompt assessment, diagnosis, and intervention, which are crucial for patient safety and well-being. Addressing the other needs, such as providing water, assisting with bathroom needs, or emotional support, can follow once the urgent issue of chest pain has been managed. While the other patient concerns are important, the critical nature of chest pain requires immediate action to rule out severe cardiac events and provide appropriate care.
After Brandon is stabilized following his second myocardial infarction due to cocaine use, what collaborative process should begin to connect him with additional resources?
A. Law enforcement for further prevention
B. Social services for rehab
C. Narcotics Anonymous
D. Financial counselor to apply for assistance
Correct answer:
Following stabilization, it is essential to connect Brandon with additional resources to address his addiction. Social services are a crucial collaborative partner in this situation because they have access to community resources that can support Brandon's rehabilitation needs. While law enforcement may be involved in certain situations, their primary role is not to provide rehabilitation services. Narcotics Anonymous is a valuable support group but does not offer the comprehensive services that social services for rehab can provide. A financial counselor may be beneficial for addressing financial concerns, but the priority at this stage is to address Brandon's addiction through appropriate rehabilitation services.
A 27-year-old writer is admitted for the second time accompanied by his wife. He is demanding, arrogant, talks fast, and is hyperactive. Initially the nurse should plan this for a manic client:
A. Set realistic limits to the client's behavior
B. Repeat verbal instructions as often as needed
C. Allow the client to express feelings to relieve tension
D. Assign staff to be with the client at all times to help maintain control
Correct answer:
For a manic client who is hyperactive and may engage in injurious activities, setting realistic limits to the client's behavior is crucial to ensure safety. A quiet environment with firm and consistent limits helps in managing the client's behavior effectively. While repeating verbal instructions can be helpful due to the client's distractibility, it is not the priority compared to setting limits for safety concerns. Allowing the client to express feelings is important, but it should be done through non-destructive methods. Assigning staff to be with the client at all times is not realistic or feasible in the clinical setting and does not address the core issue of managing the client's behavior and ensuring safety.
To detect possible complications in a patient with severe cirrhosis who has bleeding esophageal varices, it is most important for the nurse to monitor
A. bilirubin levels.
B. ammonia levels.
C. potassium levels.
D. prothrombin time.
Correct answer:
In a patient with severe cirrhosis and bleeding esophageal varices, monitoring ammonia levels is crucial. Severe liver dysfunction impairs the metabolism of protein in the GI tract, leading to increased ammonia levels. Elevated ammonia levels can result in hepatic encephalopathy, a serious complication. Monitoring bilirubin levels is important for assessing liver function and jaundice but may not directly reflect the risk of complications from bleeding esophageal varices. Potassium levels are important but not the most critical in this scenario. Prothrombin time is essential for evaluating coagulation status but does not directly relate to the risk of complications from bleeding esophageal varices in this patient.
NCLEX-RN clinical judgment practice questions, set 21 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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