NCLEX-RN clinical judgment practice questions, set 22
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 22
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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 patient diagnosed with epilepsy is receiving discharge education from a nurse. Which of the following teachings should be emphasized the most?
A. Avoid consuming alcohol and drugs
B. Adhere to follow-up appointments with the neurologist, physician, or other healthcare provider as directed
C. Continue taking anticonvulsants, even if seizures have ceased
D. Wear a medical alert bracelet or carry an ID card indicating epilepsy
Show answer and rationale
Correct answer: C — Continue taking anticonvulsants, even if seizures have ceased
The most critical teaching that the nurse should stress to a patient with epilepsy is to continue taking anticonvulsants even if seizures have stopped. Suddenly stopping antiepileptic drugs can lead to seizures and an increased risk of status epilepticus, a life-threatening condition. Choice A, advising to avoid alcohol and drugs, is important but not as crucial as maintaining anticonvulsant therapy. Choice B, emphasizing follow-up appointments, is essential but ensuring medication compliance is more critical to prevent seizure recurrence. Choice D, wearing a medical alert bracelet, is important for emergency identification but does not directly impact the patient's immediate safety like medication adherence does.
Question 2
A healthcare provider calls a physician with the concern that a patient has developed a pulmonary embolism. Which of the following symptoms has the healthcare provider most likely observed?
A. The patient is somnolent with decreased response to stimuli.
B. The patient suddenly complains of chest pain and shortness of breath.
C. The patient has developed a wet cough and the healthcare provider hears crackles on auscultation of the lungs.
D. The patient has a fever, chills, and loss of appetite.
Show answer and rationale
Correct answer: B — The patient suddenly complains of chest pain and shortness of breath.
The correct answer is 'The patient suddenly complains of chest pain and shortness of breath.' Typical symptoms of pulmonary embolism include chest pain, shortness of breath, and severe anxiety. The physician should be notified immediately. Clinical signs and symptoms for pulmonary embolism are nonspecific; therefore, patients suspected of having pulmonary embolism"?because of unexplained dyspnea, tachypnea, or chest pain or the presence of risk factors for pulmonary embolism"?must undergo diagnostic tests until the diagnosis is ascertained or eliminated or an alternative diagnosis is confirmed. Choices A, C, and D describe symptoms that are not typically associated with a pulmonary embolism, making them incorrect.
Question 3
According to HIPAA, which of the following is considered an individual right for privacy of a client's protected health information?
A. The right to receive a copy of the organization's privacy practices
B. The right to receive medical bills for care received
C. The right to change personal health information
D. An understanding that protected health information will only be used in regards to client treatments
Show answer and rationale
Correct answer: A — The right to receive a copy of the organization's privacy practices
According to HIPAA, individuals receiving care at healthcare facilities have rights surrounding their protected health information. One of these rights is to receive a copy of the organization's privacy practices, which outlines how their health information will be used and protected. This ensures transparency and allows individuals to understand how their information is handled. The other choices are incorrect because while individuals have the right to access their health information, receive explanations of how it is used, and ensure its confidentiality, receiving medical bills or changing personal health information are not specifically outlined as rights related to the privacy of protected health information.
Question 4
A physician has written an order for '2.0 mg MS q 2-4 hr prn pain.' What is the nurse's appropriate response to this order?
A. Give 2 mg of morphine sulfate to the client
B. Give 20 mg of morphine sulfate to the client
C. Contact the pharmacy to clarify the order
D. Contact the physician to rewrite the order
Show answer and rationale
Correct answer: D — Contact the physician to rewrite the order
The physician's order contains several errors that could lead to potential harm to the client if not addressed. The use of '2.0' involves a trailing decimal point, which may lead to confusion regarding the intended dose of the drug. Additionally, the abbreviation 'MS' is considered a Do Not Use abbreviation by the Joint Commission, as it could refer to morphine sulfate or magnesium sulfate, leading to medication errors. While the order indicates the drug should be used for pain, the nurse should contact the physician to clarify the exact dose and specific drug to be administered, ensuring safe and accurate medication administration. Therefore, the correct response is to contact the physician to rewrite the order.
Question 5
Upon admission to the stroke care unit of a rehabilitation center, what is the primary action of the nurse?
A. Collect and organize documents for the client's medical record
B. Prepare the client's identification bracelet
C. Identify pertinent health history data and current needs and limitations
D. Gather the client's valuables and secure them in a locked container
Show answer and rationale
Correct answer: C — Identify pertinent health history data and current needs and limitations
When a client is admitted to a stroke care unit in a rehabilitation center, the nurse's initial priority is to assess the client. This assessment includes identifying relevant health history data that may impact the client's care. By recognizing the client's current needs and limitations, the nurse can develop a comprehensive understanding of the client's condition. This information is crucial for generating a nursing diagnosis and establishing appropriate care outcomes. While collecting and organizing documents for the medical record, preparing identification bracelets, and securing valuables are important tasks, they are not the primary actions that directly influence the client's immediate care upon admission.
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Question 6
Claudication is a well-known effect of peripheral vascular disease. Which of the following facts about claudication is correct? Select the one that doesn't apply:
A. It results when oxygen demand is greater than oxygen supply.
B. It is characterized by pain that often occurs during rest.
C. It is a result of tissue hypoxia.
D. It is characterized by cramping and weakness.
Correct answer:
Claudication is a symptom of peripheral vascular disease where there is an inadequate supply of oxygen to the muscles due to reduced blood flow. This mismatch between oxygen demand and supply leads to tissue hypoxia, resulting in cramping, weakness, and discomfort. Option D correctly states that claudication is characterized by cramping and weakness, making it the correct answer. Options A, B, and C are incorrect. Claudication occurs when oxygen demand exceeds supply, not the other way around as stated in Option A. Pain in claudication typically occurs with activity, not at rest as mentioned in Option B. While tissue hypoxia is a consequence of claudication, it is not the primary cause, making Option C incorrect.
A teacher brings a 5-year-old child to the school nurse because of a bruise under her eye. When asked about the bruise, the child responds, 'my daddy did it.' What is the nurse's initial action in this situation?
A. Allow the child to return to class and monitor for future events that are suggestive of abuse
B. Call the parent and request an explanation for the bruises
C. Call the police and ask for a warrant for the parent's arrest
D. Notify the school administrator
Correct answer:
In cases of suspected child abuse, the priority for the school nurse is to notify the school administrator immediately. The school administrator can then collaborate with the nurse to follow established protocols for reporting suspected abuse to the appropriate authorities. All suspicions or allegations of child abuse must be handled with sensitivity and in compliance with state laws and school policies. All other options, such as allowing the child to return to class without further action, directly contacting the parent, or involving the police without proper investigation, could potentially compromise the safety and well-being of the child and may not adhere to legal requirements for reporting suspected abuse.
Claudication is a well-known effect of peripheral vascular disease. Which of the following facts about claudication is correct? Select the one that doesn't apply:
A. It results when oxygen demand is greater than oxygen supply.
B. It is characterized by pain that often occurs during rest.
C. It is a result of tissue hypoxia.
D. It is characterized by cramping and weakness.
Correct answer:
Claudication is a symptom of peripheral vascular disease where there is an inadequate supply of oxygen to the muscles due to reduced blood flow. This mismatch between oxygen demand and supply leads to tissue hypoxia, resulting in cramping, weakness, and discomfort. Option D correctly states that claudication is characterized by cramping and weakness, making it the correct answer. Options A, B, and C are incorrect. Claudication occurs when oxygen demand exceeds supply, not the other way around as stated in Option A. Pain in claudication typically occurs with activity, not at rest as mentioned in Option B. While tissue hypoxia is a consequence of claudication, it is not the primary cause, making Option C incorrect.
For a 6-year-old child hospitalized with moderate edema and mild hypertension associated with acute glomerulonephritis (AGN), which one of the following nursing interventions would be appropriate?
A. Institute seizure precautions
B. Weigh the child twice per shift
C. Encourage the child to eat protein-rich foods
D. Relieve boredom through physical activity
Correct answer:
Institute seizure precautions. The severity of the acute phase of AGN is variable and unpredictable; therefore, a child with edema, hypertension, and gross hematuria may be subject to complications, and anticipatory preparation such as seizure precautions is needed. Weighing the child twice per shift may be necessary for monitoring fluid balance but is not specifically related to the complications of AGN. Encouraging the child to eat protein-rich foods is important for overall nutrition but does not directly address the potential complications of AGN. Relieving boredom through physical activity is beneficial for overall well-being but is not the priority in this situation where seizure precautions are essential.
The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse's response?
A. Electrical energy fields
B. Spinal column manipulation
C. Mind-body balance
D. Exercise of joints
Correct answer:
The focus of the nurse's response should be on spinal column manipulation when discussing chiropractic treatment for illnesses. Chiropractic theory emphasizes that misalignment of the vertebrae can interfere with the transmission of mental impulses between the brain and body organs, leading to diseases. Manipulation is aimed at reducing such misalignments, known as subluxations. While mind-body balance and exercise of joints are important aspects of holistic health, in the context of chiropractic treatment, the key intervention is spinal column manipulation to address vertebral misalignments. Therefore, choices A, C, and D are incorrect as they do not directly address the primary focus of chiropractic treatment.
A 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 a staff member to be with the client at all times to help maintain control
Correct answer:
For a manic client who is demanding, arrogant, talks fast, and is hyperactive, setting realistic limits to the client's behavior is essential to ensure safety as manic clients may engage in injurious activities. A quiet environment and consistent, firm limits help to maintain control. While repeating verbal instructions may be necessary due to distractibility, it is not the priority compared to setting limits for safety. Allowing the client to express feelings is important, but only non-destructive methods of expression should be permitted. Assigning a staff member to be with the client at all times is not a realistic approach as it may not always be feasible or necessary for managing manic behavior effectively.
When teaching a client with coronary artery disease about nutrition, what should the nurse emphasize?
A. Eating three balanced meals a day
B. Adding complex carbohydrates
C. Avoiding very heavy meals
D. Limiting sodium intake to 7 g per day
Correct answer:
The correct answer is to emphasize avoiding very heavy meals. Eating large, heavy meals can divert blood away from the heart for digestion, potentially endangering clients with coronary artery disease. This practice may lead to an increased risk of plaque accumulation in the arteries, potentially obstructing the delivery of blood and oxygen to vital organs. Choices A, B, and D are incorrect. While eating three balanced meals a day, adding complex carbohydrates, and limiting sodium intake are generally good dietary practices, they are not the primary focus when teaching a client with coronary artery disease about nutrition. The emphasis should be on avoiding heavy meals that can strain the cardiovascular system.
A 49-year-old female patient with cirrhosis and esophageal varices has a new prescription for propranolol (Inderal). Which finding is the best indicator that the medication has been effective?
A. The patient reports no chest pain.
B. Blood pressure is 140/90 mm Hg
C. Stools test negative for occult blood.
D. The apical pulse rate is 68 beats/minute.
Correct answer:
The best indicator that propranolol has been effective in a patient with cirrhosis and esophageal varices is when the stools test negative for occult blood. Propranolol is prescribed to decrease the risk of bleeding from esophageal varices. This medication's effectiveness is primarily assessed by the absence of blood in the stools, indicating a reduction in the risk of bleeding from the varices. Monitoring for chest pain, blood pressure control, and a decrease in heart rate are important parameters in other conditions treated with propranolol, such as hypertension, angina, and tachycardia, but in this particular case, the absence of occult blood in the stools is the most relevant indicator of treatment success.
Which of the following is an example of the intervention phase of the individualized nursing care plan for a client who receives a colostomy after a bowel resection?
A. Taking a health history and performing a physical exam prior to the procedure
B. Instructing the client about how to care for his colostomy stoma
C. Developing goals that state the client will ambulate three times a day
D. Determining that the client may need more support at home after dismissal
Correct answer:
The intervention stage of the individualized nursing care plan is where the nurse provides care, treatments, or education to help the client meet the devised outcomes. Instructing the client about how to care for his colostomy stoma is the correct example of an intervention as it directly involves providing education and guidance to the client on post-operative care. This intervention supports the process of helping the client meet the outcomes designed for this case, which is to enable the client to properly care for his colostomy after a bowel resection. The other options do not directly involve interventions aimed at assisting the client in meeting the specific care needs related to the colostomy procedure.
Based on Mr. C's assessment, which of the following nursing interventions is most appropriate?
A. Elevate the lower extremities to 45 degrees to promote venous return
B. Place Mr. C in the Trendelenburg position
C. Administer total parenteral nutrition
D. Monitor urine output
Correct answer:
In the context of Mr. C's assessment, the most appropriate nursing intervention is to monitor urine output. A client in hypovolemic shock may experience decreased urine output due to poor kidney perfusion. By monitoring urine output, the nurse can assess renal function and fluid status. Administering total parenteral nutrition (Choice C) is not indicated based on the information provided, as the priority is to stabilize the client's condition. Elevating the lower extremities (Choice A) may be helpful in some cases but is not the priority in this situation. Placing Mr. C in the Trendelenburg position (Choice B) is contraindicated in hypovolemic shock as it can worsen venous return and compromise cardiac output.
NCLEX-RN clinical judgment practice questions, set 22 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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