NCLEX-RN clinical judgment practice questions, set 25
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 25
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 action represents the evaluation stage of the plan of care?
A. The nurse assigns a nursing diagnosis of Impaired Skin Integrity related to diminished skin circulation
B. The nurse assesses the client's vital signs and asks about symptoms
C. The nurse determines that the client is not meeting his set outcomes and makes revisions
D. The nurse discusses the client's health history
Show answer and rationale
Correct answer: C — The nurse determines that the client is not meeting his set outcomes and makes revisions
The correct answer is C. The evaluation stage of the nursing process involves reviewing the assessments, diagnoses, and interventions given to the client and then determining if the client is meeting expected outcomes. In this scenario, the nurse is assessing whether the client is meeting the outcomes set for their care plan and making revisions as needed. Choice A is incorrect as assigning a nursing diagnosis is part of the nursing diagnosis phase, not the evaluation phase. Choice B represents the assessment phase of the nursing process, not the evaluation phase. Choice D involves discussing the client's health history, which is more aligned with the assessment phase rather than the evaluation phase.
Question 2
Which of the following is TRUE about shock?
A. A patient with severe shock does not always have an abnormally low blood pressure.
B. Confusion and deteriorating mentation are indicative of hypotensive shock.
C. Patients with compensated shock may not be able to maintain a normal blood pressure.
D. A normal blood pressure does not imply that the patient is stable.
Show answer and rationale
Correct answer: B — Confusion and deteriorating mentation are indicative of hypotensive shock.
Confusion and deteriorating mentation are indeed indicative of hypotensive shock. It is important to note that a patient with hypotensive shock will likely exhibit deteriorating mental status. Choice A is incorrect because a patient in severe shock may not always have an abnormally low blood pressure, making it an unreliable indicator of shock severity. Choice C is incorrect because patients with compensated shock may present with normal blood pressure but still have inadequate tissue perfusion. Choice D is incorrect because a normal blood pressure does not guarantee the patient's stability, especially in cases of shock where tissue perfusion may be compromised despite normal blood pressure readings.
Question 3
Which method is most appropriate for managing moral distress in the workplace?
A. Recognizing that life is unfair and nurses cannot meet every need of every client
B. Declining to act when clients or visitors make requests that are not justifiable
C. Developing a new policy that would address the problematic situation
D. Both A and B
Show answer and rationale
Correct answer: C — Developing a new policy that would address the problematic situation
Moral distress involves negative feelings or frustration toward situations that are deemed unfair, unethical, or that cause the nurse to feel helpless in their work. It can lead to nurse burnout when ongoing issues are not resolved. The most appropriate method for managing moral distress is to develop new policies that address the problematic situations. By creating policies, nurses can work towards changing current standards and reducing the number of situations that lead to moral distress. Choices A and B are incorrect because recognizing life's unfairness and not taking action on unjustifiable requests do not actively address the root causes of moral distress or work towards resolving the issues.
Question 4
A client in the ICU has been intubated and placed on a ventilator. The physician orders synchronous intermittent mandatory ventilation (SIMV). Which statement best describes the work of this mode of ventilation?
A. The ventilator delivers a set rate and tidal volume regardless of whether the client is attempting to breathe
B. The ventilator coordinates delivered breaths with the client's respiratory efforts
C. The ventilator provides a supplemental breath for every third breath of the client
D. The ventilator provides breaths during the expiratory phase of the client's respirations
Show answer and rationale
Correct answer: B — The ventilator coordinates delivered breaths with the client's respiratory efforts
Synchronous intermittent mandatory ventilation (SIMV) is a ventilation mode that coordinates delivered breaths with the client's own respiratory efforts. This mode allows the client to initiate breaths, with the ventilator providing preset breaths at a controlled rate and volume. Option A is incorrect because in SIMV, the ventilator syncs with the client's respiratory efforts. Option C is incorrect as it does not accurately depict the way SIMV works. Option D is also incorrect as SIMV does not specifically provide breaths during the expiratory phase of the client's respirations. Therefore, the correct answer is B, where the ventilator coordinates breath delivery with the client's breathing efforts.
Question 5
A group of nurses who work on the quality assurance council of a unit have gathered to discuss ideas about how to educate their coworkers about Joint Commission requirements. Each of the nurses gives ideas, which are listed together without initial criticism. Eventually, all ideas on the list will be discussed as to their validity. This activity is known as:
A. Optimizing
B. Satisficing
C. Brainstorming
D. Centralizing
Show answer and rationale
Correct answer: C — Brainstorming
Brainstorming is the process in which group members generate ideas without immediate criticism or evaluation. This allows for a free flow of creative suggestions. The ideas are then listed together for consideration and discussion of their validity at a later stage. Optimizing, although related to improving efficiency, does not specifically address the initial idea generation process. Satisficing refers to accepting a satisfactory or 'good enough' solution rather than seeking the best possible option, which is not reflective of the scenario described. Centralizing typically refers to consolidating decision-making authority rather than the collaborative idea generation process seen in brainstorming.
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Question 6
Mrs. D is a pregnant client who is 33 weeks' gestation and is admitted for bright red vaginal bleeding. Her physician suspects placenta previa. All of the following nursing interventions are appropriate for this client except:
A. Institute complete bed rest for the client
B. Assess uterine tone to determine condition
C. Perform a vaginal exam to assess cervical dilation
D. Measure and record blood loss each shift
Correct answer:
A client with placenta previa has part of the placenta covering some or all of the cervical opening. Performing a vaginal exam for placenta previa may cause significant bleeding and should be avoided unless directed by a physician, and preparations are made for emergency delivery. **Choice A** is correct as complete bed rest is essential to decrease the risk of further bleeding. **Choice B** is appropriate as assessing uterine tone helps in determining the condition of the uterus and can provide important information for the healthcare team. **Choice D** is also a necessary intervention as monitoring and recording blood loss is crucial in assessing the client's condition and response to treatment.
Which of the following is recommended by Joint Commission guidelines regarding the use of restraints?
A. Vest restraints should be used because they are the least restrictive type.
B. Restraints should be used for 48 hours in non-psychiatric patients.
C. Restraints should be applied to prevent wandering behavior.
D. Alternative measures must be attempted first.
Correct answer:
When considering the use of restraints, Joint Commission guidelines emphasize the importance of attempting alternative measures before resorting to restraint application. This ensures that a comprehensive assessment is conducted and less restrictive interventions are explored. Using restraints solely based on their perceived level of restrictiveness, as stated in choice A, is not in line with the recommended approach. Restraints should not be used to manage wandering behavior, as indicated in choice C. Additionally, the statement in choice B regarding the duration of restraint use is inaccurate, as restraints on non-psychiatric patients should not exceed 24 hours according to The Joint Commission.
A client with schizophrenia is taking loxapine. Which of the following findings should the nurse identify as the most important to report?
A. Spasms of the tongue and face
B. Orthostatic hypotension
C. Dry mouth
D. Increased appetite
Correct answer:
Spasms of the muscles of the tongue, face, neck, and back are indicative of acute dystonia, an extrapyramidal manifestation associated with loxapine use. Acute dystonia is a serious condition that can lead to airway obstruction and respiratory compromise. Therefore, the nurse should prioritize reporting this finding to prevent potential harm to the client. Orthostatic hypotension, dry mouth, and increased appetite are common side effects of antipsychotic medications but are not as immediately life-threatening as acute dystonia. Monitoring and managing these side effects are essential for the client's overall well-being, but they do not pose the same level of urgency as addressing acute dystonia.
What is the cause of meningitis that is fatal in half of the infected patients?
A. Virus
B. Bacteria
C. Fungus
D. Noninfectious agent
Correct answer:
Bacterial meningitis is caused by bacterial pathogens such as Streptococcus pneumoniae, Haemophilus influenzae, Listeria monocytogenes, and Neisseria meningitidis. These bacteria commonly lead to acute onset meningitis, presenting with symptoms like fever, stiff neck, and altered consciousness. The statement that bacterial meningitis is fatal in about 50% of cases is accurate, making it a serious and life-threatening condition. Viruses can also cause meningitis, but they are not typically associated with the high fatality rate seen in bacterial meningitis. Fungal meningitis is less common and usually affects individuals with weakened immune systems. Noninfectious agents do not cause meningitis.
What is the primary purpose of a patient care meeting or conference?
A. the patient's ability to pay for the costs of their care
B. how the healthcare team can best meet the patient's needs
C. the patient's physical status and condition
D. the patient's psychosocial status and condition
Correct answer:
The primary purpose of a patient care meeting or conference is to determine how the healthcare team can best meet the patient's needs. These meetings involve discussions among healthcare professionals to tailor the care plan to the specific needs and preferences of the patient. Option A is incorrect because financial discussions are generally not the primary focus of patient care meetings. Option C is incorrect as the patient's physical status is usually already known and is not the primary purpose of the meeting. Option D is incorrect as psychosocial aspects, while important, are not the sole focus of the meeting, which is primarily about addressing the patient's overall needs and preferences.
The patient in the emergency room has a history of alprazolam (Xanax) abuse and abruptly stopped taking Xanax about 24 hours ago. He presents with visible tremors, pacing, fear, impaired concentration, and memory. Which intervention takes priority?
A. Have the patient lie down on a stretcher with bed rails raised
B. Offer the patient a cup of water and a small amount of food
C. Reassure the patient about his well-being
D. Inform the physician about the patient's Xanax withdrawal
Correct answer:
The 1-4 day period after Xanax withdrawal is critical as it poses the highest risk of life-threatening seizures. Alprazolam is a benzodiazepine, and sudden cessation can lead to severe withdrawal symptoms. The patient's visible tremors, fear, pacing, and cognitive impairment indicate a state of heightened distress and potential seizure risk. Placing the patient on a stretcher with raised bed rails is essential for seizure precautions, ensuring safety and preventing injury during a potential seizure. Offering water and food, reassuring the patient, or informing the physician about Xanax withdrawal are not immediate priorities compared to managing the risk of seizures in this high-risk situation.
During a class on cultural practices, the nurse hears the term cultural taboo. Which statement illustrates the concept of a cultural taboo?
A. Trying prayer before seeking medical help
B. Believing that illness is a punishment of sin
C. Refusing to accept blood products as part of treatment
D. Stating that a child's birth defect is the result of the parents' sins
Correct answer:
The concept of a cultural taboo involves practices that are forbidden or avoided within a particular culture. Refusing to accept blood products as part of treatment is a clear example of a cultural taboo, as some cultures or religions prohibit the use of blood products for medical purposes. This practice is deeply rooted in cultural beliefs and traditions. The other choices provided do not directly relate to cultural taboos. Trying prayer before seeking medical help, believing illness is a punishment of sin, and stating that a child's birth defect is the result of parents' sins are beliefs or actions based on religious or personal beliefs, but they do not specifically represent cultural taboos.
A victim of domestic violence states, 'If I were better, I would not have been beaten.' Which feeling best describes what the victim may be experiencing?
A. Fear
B. Helplessness
C. Self-blame
D. Rejection
Correct answer:
The correct answer is self-blame. In this scenario, the victim is attributing the abuse to their own inadequacies or faults, thinking that if they were different, the abuse would not occur. This is a common response seen in victims of domestic violence, where they wrongly internalize the blame for the abuser's actions. Fear (Choice A) is a valid emotion, but in this case, the victim is not expressing fear but rather self-blame. Helplessness (Choice B) is also a common feeling in victims of domestic violence, but in this specific statement, the victim is demonstrating self-blame. Rejection (Choice D) does not accurately reflect the victim's statement and emotional response in the given scenario.
A patient with severe Gastroesophageal Reflux Disease is receiving discharge teaching. Which of these statements by the patient indicates a need for more teaching?
A. ''I'm going to limit my meals to 2-3 per day to reduce acid secretion.''
B. ''I'm going to make sure to remain upright after meals and elevate my head when I sleep.''
C. ''I won't be drinking tea or coffee or eating chocolate anymore.''
D. ''I'm going to start trying to lose some weight.''
Correct answer:
The correct answer is ''I'm going to limit my meals to 2-3 per day to reduce acid secretion.'' This statement indicates a need for more teaching because large meals increase the volume and pressure in the stomach, delaying gastric emptying, and worsening symptoms of Gastroesophageal Reflux Disease (GERD). The recommended approach is to eat smaller, more frequent meals (4-6 small meals a day) to reduce acid reflux. Choices B, C, and D demonstrate good understanding of GERD management by highlighting the importance of staying upright after meals, avoiding trigger foods like tea, coffee, and chocolate, and addressing weight management, which are all appropriate strategies to manage GERD symptoms.
After an endoscopic procedure with general anesthesia, what is a priority nursing consideration for a patient in the day surgery center?
A. Raise the siderails of the patient's bed
B. Do not offer fluids, food, or any oral intake
C. Check the temperature of the patient
D. Teach the patient to avoid aspirin or NSAIDS
Correct answer:
After an endoscopic procedure with general anesthesia, the priority nursing consideration is to not offer fluids, food, or any oral intake to the patient. Endoscopies involve passing a tube through the mouth into the esophagus or upper GI. Anesthesia is often given to inactivate the gag reflex, making the patient vulnerable to aspiration. Raising the siderails of the patient's bed is important for safety but not the immediate priority. Checking the patient's temperature may be important but is not the priority immediately after the procedure. Teaching the patient to avoid aspirin or NSAIDS is important for post-procedure care but is not the priority immediately after the endoscopic procedure.
NCLEX-RN clinical judgment practice questions, set 25 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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