NCLEX-RN clinical judgment practice questions, set 23
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 23
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
Why should a palpated pressure be performed before auscultating blood pressure?
A. To more clearly hear the Korotkoff sounds.
B. To detect the presence of an auscultatory gap.
C. To avoid missing a falsely elevated blood pressure.
D. To more readily identify phase IV of the Korotkoff sounds.
Show answer and rationale
Correct answer: B — To detect the presence of an auscultatory gap.
Performing a palpated pressure before auscultating blood pressure helps in detecting the presence of an auscultatory gap. An auscultatory gap is a period during blood pressure measurement when Korotkoff sounds temporarily disappear before reappearing. Inflation of the cuff 20 to 30 mm Hg beyond the point where a palpated pulse disappears helps in identifying this gap. This technique ensures accurate blood pressure measurement by preventing the underestimation of blood pressure values. The other options are incorrect because palpating the pressure is not primarily done to hear Korotkoff sounds more clearly, avoid missing falsely elevated blood pressure, or readily identify a specific phase of Korotkoff sounds.
Question 2
The client has a long leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommend:
A. Isometric
B. Range of motion
C. Aerobic
D. Isotonic
Show answer and rationale
Correct answer: D — Isotonic
The nurse should recommend isometric exercises for the muscles of the casted extremity. Isometric exercises involve contracting and relaxing muscles without moving the affected part. This type of exercise helps maintain muscle strength without moving the joint, which is important for clients with immobilized extremities. Range of motion exercises involve moving the joint through its full range of motion, which may not be suitable for a client with a long leg cast. Aerobic exercises focus on increasing cardiovascular endurance and may not be appropriate for a client with a casted extremity. Isotonic exercises involve muscle contractions with movement, which may not be safe for the affected extremity in a cast.
Question 3
An adolescent brings a physician's note to school stating that he is not to participate in sports due to a diagnosis of Osgood-Schlatter disease. Which of the following statements about the disease is correct?
A. The condition is not caused by the student's competitive swimming schedule.
B. The student will most likely not require surgical intervention.
C. The student experiences pain in the inferior aspect of the knee.
D. The student is not trying to avoid participation in physical education.
Show answer and rationale
Correct answer: C — The student experiences pain in the inferior aspect of the knee.
Osgood-Schlatter disease occurs in adolescents during the rapid growth phase when the infrapatellar ligament of the quadriceps muscle pulls on the tibial tubercle, causing pain and swelling in the inferior aspect of the knee. The condition is commonly caused by activities that require repeated use of the quadriceps, such as track and soccer. Choice A is incorrect because Osgood-Schlatter disease is not specifically linked to competitive swimming. Choice B is incorrect as surgical intervention is not usually necessary for this condition. Choice D is incorrect as the student is not trying to avoid physical education but is restricted from participating in sports due to the diagnosis of Osgood-Schlatter disease.
Question 4
You are caring for a group of elderly clients, many of whom are affected by multiple chronic disorders and are also, at times, affected by some acute disorders that require medical and nursing attention. As you are caring for these clients, some will need a new medication regimen for an acute disorder. You should consider the fact that the elderly population is at risk for more side effects, adverse drug reactions, and toxicity due to the elderly having a(n):
A. Increased creatinine clearance.
B. Impaired immune system.
C. Decreased hepatic metabolism.
D. Increased bodily fat
Show answer and rationale
Correct answer: C — Decreased hepatic metabolism.
The correct answer is 'Decreased hepatic metabolism.' The elderly population is at risk for more side effects, adverse drug reactions, and toxicity due to a decrease in hepatic metabolism. This is caused by changes in hepatic functioning in the elderly, including decreased hepatic blood flow and functioning. Choice A, 'Increased creatinine clearance,' is incorrect as aging typically results in decreased, not increased, creatinine clearance. Choice B, 'Impaired immune system,' is not directly related to the increased risk of adverse drug reactions in the elderly. Choice D, 'Increased bodily fat,' is not a primary factor contributing to the increased risk of medication-related issues in the elderly population.
Question 5
When performing a physical assessment, what technique should the nurse always perform first?
A. Palpation
B. Inspection
C. Percussion
D. Auscultation
Show answer and rationale
Correct answer: B — Inspection
During a physical assessment, the nurse should always begin with inspection. The sequence of techniques for physical examination is inspection, palpation, percussion, and auscultation. These skills are performed in a specific order, except for the abdominal assessment where auscultation precedes palpation and percussion. Inspection allows the nurse to observe and gather initial information without direct contact. It is a crucial step that provides valuable insights before proceeding to palpation, percussion, and auscultation. Therefore, choice B, 'Inspection,' is the correct answer. Choices A, C, and D are incorrect because they should follow inspection in the sequence of a comprehensive physical assessment.
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Question 6
What might be signaled when a client tells the nurse to 'pray for me' and entrusts her wedding ring to the nurse?
A. Anxiety
B. Suicidal ideation
C. Major depression
D. Hopelessness
Correct answer:
The client entrusting the wedding ring and asking the nurse to pray for them can be indicative of suicidal ideation. This behavior suggests a deep level of distress and hopelessness, potentially leading to suicidal thoughts or actions. While anxiety is a common emotion, the act of entrusting personal items and making requests like praying for them go beyond typical anxiety symptoms. Major depression can be associated with suicidal ideation, but the specific actions described in this scenario point more towards suicidal thoughts. Hopelessness, while related to suicidal ideation, is a broader concept that does not capture the specific cues given by the client in this scenario, making it a less accurate choice.
When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient?
A. Emergency pericardiocentesis
B. Stabilization of the chest wall with tape
C. Administration of an inhaled bronchodilator
D. Insertion of a chest tube with a chest drainage system
Correct answer:
The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. Emergency pericardiocentesis is not indicated as the patient's symptoms are not suggestive of cardiac tamponade. Stabilization of the chest wall with tape would not address the underlying issue of a potential pneumothorax or hemothorax. Administration of an inhaled bronchodilator is not appropriate in this scenario as the patient is not exhibiting signs of asthma or bronchoconstriction. Therefore, the correct intervention for this patient is the insertion of a chest tube with a chest drainage system to address the potential pneumothorax or hemothorax.
Which of the following signs or symptoms indicates a possible nutritional deficiency?
A. Subcutaneous fat at the waist and abdomen
B. Presence of papillae on the surface of the tongue
C. Straight arms and legs
D. Pale conjunctiva
Correct answer:
A client with poor nutritional intake may have pale mucous membranes surrounding the eye, or the conjunctiva. This area should normally be pink, indicating good circulation and a lack of irritation or dryness. Improper nutrition can manifest as numerous signs in the body, including bowed legs, pale mucous membranes, a smooth or beefy tongue, and poor muscle tone. Subcutaneous fat at the waist and abdomen is not a sign of nutritional deficiency but rather of excess fat deposition. The presence of papillae on the surface of the tongue is normal and not indicative of a nutritional deficiency. Straight arms and legs are also typical anatomical features and not specifically related to nutritional deficiencies.
A 23-year-old has been admitted with acute liver failure. Which assessment data are most important for the nurse to communicate to the healthcare provider?
A. Asterixis and lethargy
B. Jaundiced sclera and skin
C. Elevated total bilirubin level
D. Liver 3 cm below costal margin
Correct answer:
The most critical assessment data for the nurse to communicate to the healthcare provider in a patient with acute liver failure are asterixis and lethargy. These findings are indicative of grade 2 hepatic encephalopathy, which signals a rapid deterioration in the patient's condition, necessitating early transfer to a transplant center. Jaundiced sclera and skin, elevated total bilirubin level, and a liver 3 cm below the costal margin are all typical findings in hepatic failure but do not indicate an immediate need for a change in the therapeutic plan. Therefore, while these findings are relevant and should be reported, they are not as urgent as asterixis and lethargy in a patient with acute liver failure.
A client is about to have a TENS unit attached for pain relief. Which of the following actions is most appropriate in this situation?
A. Inform the client that he may experience tingling sensations.
B. Connect the TENS unit before the client goes to bed for the night.
C. Inform the client that the TENS unit may have pain-reducing effects for 10 to 15 days.
D. After treatment, inform the client that he may not use a TENS unit again for at least 2 weeks.
Correct answer:
When attaching a TENS unit for pain relief, it is essential to inform the client that he may experience tingling sensations. This is a common sensation experienced when using a TENS unit, but it should not cause muscle twitching. The therapeutic effects of a TENS unit usually last between 3 to 5 days. Choice B is incorrect because there is no specific recommendation to connect the TENS unit before bedtime. Choice C is incorrect as stating that the TENS unit may have pain-reducing effects for 10 to 15 days is inaccurate, as the effects typically last 3 to 5 days. Choice D is incorrect because there is no guideline suggesting that the client cannot use a TENS unit again for at least 2 weeks after treatment.
A 75-year-old client, hospitalized with a cerebral vascular accident (stroke), becomes disoriented at times and tries to get out of bed but is unable to ambulate without help. What is the most appropriate safety measure?
A. Restrain the client in bed
B. Ask a family member to stay with the client
C. Check the client every 15 minutes
D. Use a bed exit safety monitoring device
Correct answer:
Option D is the most appropriate safety measure in this scenario. Using a bed exit safety monitoring device allows the client to retain some independence while ensuring that the nursing staff is alerted when assistance is needed. This solution promotes client safety without compromising their autonomy. Option A, restraining the client in bed, can lead to increased agitation, confusion, and a loss of independence. Option B, asking a family member to stay with the client, shifts the responsibility away from the healthcare team. Option C, checking the client every 15 minutes, is not a sufficient safety measure as the client could attempt to get out of bed in the unobserved interval, risking falls and injury.
Rachel is a 48-year-old mother of three who has been admitted after a drug overdose in a failed suicide attempt. When she regains consciousness, she states that she is ashamed and embarrassed that she tried to take her own life. What is the most therapeutic response to Rachel's statement?
A. It's a relief your children weren't left without a mother.
B. What were you thinking?
C. We're here to help patients who value life.
D. I know life can be difficult. We're here to help you.
Correct answer:
The most therapeutic response to Rachel's statement is to provide non-judgmental support and hope. By acknowledging the patient's feelings of shame and embarrassment and offering help and understanding, the nurse can help Rachel maintain her self-esteem. Choice A is not therapeutic as it may unintentionally convey guilt or further shame. Choice B is judgmental and confrontational, which can create a barrier to open communication. Choice C is dismissive and does not address Rachel's emotional state. The correct response (Choice D) acknowledges the patient's struggle, offers support, and conveys empathy, aligning with the nurse's role to treat all patients with respect and dignity in challenging situations.
In which of the following ways can a healthcare provider promote the sense of taste for an older adult?
A. Mixing foods together on the dinner tray
B. Avoiding cologne, air fresheners, or room deodorizers
C. Encouraging the client to chew food thoroughly
D. Discouraging the use of salt or seasonings with prepared food
Correct answer:
As individuals age, their sense of taste may diminish, impacting the enjoyment of eating. One effective way for a healthcare provider to promote the sense of taste for an older adult is by encouraging them to chew food thoroughly. Thorough chewing increases the contact of food with the taste buds, enhancing the chances of experiencing the flavors. Mixing foods together on the dinner tray may not necessarily enhance taste perception. Avoiding strong scents like cologne, air fresheners, or room deodorizers is more related to olfactory senses rather than taste. Discouraging the use of salt or seasonings can further diminish the taste experience for older adults who may already have reduced taste sensitivity.
You are caring for a patient with newly diagnosed multiple sclerosis. Discharge instructions will likely include all of the following EXCEPT:
A. PT referral for development of a planned exercise program
B. Avoidance of prolonged sun exposure
C. Hot baths to promote muscle relaxation
D. Instructions to evaluate the home environment to ensure safety
Correct answer:
Discharge instructions for a patient with newly diagnosed multiple sclerosis should focus on promoting safety and minimizing exacerbations. Hot baths should be avoided as excessive heat can trigger acute symptoms. Therefore, instructions may include PT referral for an exercise program to maintain mobility, avoidance of prolonged sun exposure to prevent symptom exacerbation, and guidance to evaluate the home environment for safety as symptoms progress. Hot baths are not recommended due to the risk of exacerbating symptoms, making it the correct answer. Choices A, B, and D are appropriate for a patient with multiple sclerosis, as they address mobility, symptom management, and safety concerns, respectively.
A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is
A. Surgical repair of a diseased coronary artery.
B. Placement of an automatic internal cardiac defibrillator.
C. Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow.
D. Non-invasive radiographic examination of the heart.
Correct answer:
Percutaneous transluminal coronary angioplasty (PTCA) is a procedure that involves compressing plaque against the wall of a diseased coronary artery to improve blood flow. It is a minimally invasive procedure performed during a cardiac catheterization to open blockages in the coronary arteries. Surgical repair of a diseased coronary artery refers to procedures like coronary artery bypass grafting (CABG), not PTCA. Placement of an automatic internal cardiac defibrillator is a different intervention used for managing cardiac arrhythmias, not for improving coronary blood flow. A non-invasive radiographic examination of the heart would typically refer to procedures like a cardiac CT scan or an MRI, not PTCA.
NCLEX-RN clinical judgment practice questions, set 23 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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