NCLEX-RN clinical judgment practice questions, set 27
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 27
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
The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first?
A. Assist the patient to sit upright in a chair.
B. Splint the patient's chest during coughing.
C. Medicate the patient with prescribed morphine.
D. Observe the patient use the incentive spirometer.
Show answer and rationale
Correct answer: C — Medicate the patient with prescribed morphine.
The correct answer is to medicate the patient with prescribed morphine. A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain, which can worsen with deep breathing and coughing. The priority is to address the incisional pain to facilitate effective coughing and deep breathing, which are essential for clearing the airways and preventing complications. Assisting the patient to sit upright, splinting the patient's chest during coughing, and observing the patient using the incentive spirometer are all appropriate interventions to improve airway clearance, but they should be implemented after addressing the incisional pain with medication.
Question 2
A patient scheduled for cataract surgery asks the nurse why they developed cataracts and how to prevent it in the future. What is the nurse's best response?
A. Age is the biggest factor contributing to cataracts.
B. Unprotected exposure to UV lights can cause cataracts.
C. Age, eye injury, corticosteroids, and unprotected sunlight exposure are contributing factors to cataracts.
D. Unfortunately, there is really nothing you can do to prevent cataracts, but they are amongst the most easily treated eye conditions.
Show answer and rationale
Correct answer: C — Age, eye injury, corticosteroids, and unprotected sunlight exposure are contributing factors to cataracts.
The correct answer is C: 'Age, eye injury, corticosteroids, and unprotected sunlight exposure are contributing factors to cataracts.' This response is the best choice as it covers the most common contributing factors for cataracts and includes preventable risk factors. Choice A is incorrect because while age is a significant factor in cataract development, it is not the only one. Choice B is incorrect as UV light exposure is a risk factor for cataracts but not the most comprehensive response. Choice D is incorrect as there are preventive measures individuals can take to reduce their risk of developing cataracts, such as protecting their eyes from UV light and managing other risk factors.
Question 3
Which response would best assist the chemically impaired client in dealing with issues of guilt?
A. Addiction usually causes people to feel guilty. Don't worry, it is a typical response due to your drinking behavior.
B. What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?
C. Don't focus on your guilty feelings. These feelings will only lead you to drinking and taking drugs.
D. You've caused a great deal of pain to your family and close friends, so it will take time to undo all the things you've done.
Show answer and rationale
Correct answer: B — What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?
The correct response is, 'What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?' This response encourages the client to reflect on their actions, identify sources of guilt, and develop a plan to address and reduce these feelings constructively. Choice A is incorrect as it dismisses the client's guilt as typical, potentially invalidating their emotions. Choice C is incorrect as it suggests avoiding guilty feelings by turning to substance use, which is counterproductive. Choice D is incorrect as it focuses on the negative consequences of the client's actions without offering a constructive way to address and alleviate guilt.
Question 4
The parent of an infant diagnosed with gastroesophageal reflux disease is receiving feeding instructions from the nurse. Which instruction should the nurse give to the parent to assist in reducing the episodes of emesis?
A. Provide smaller, more frequent feedings.
B. Burp the infant frequently during feedings.
C. Thin the feedings by adding water to the formula.
D. Thicken the feedings by adding rice cereal to the formula.
Show answer and rationale
Correct answer: D — Thicken the feedings by adding rice cereal to the formula.
Gastroesophageal reflux disease involves the backward flow of gastric contents into the esophagus due to sphincter issues. To reduce episodes of emesis, it is recommended to thicken feedings by adding rice cereal to the formula. This helps to weigh down the contents in the stomach, making regurgitation less likely. Providing smaller, more frequent feedings and burping the infant frequently are beneficial strategies for gastroesophageal reflux. However, in this case, thickening the feedings is the most appropriate intervention. Thinning the feedings by adding water to the formula is not recommended as it can decrease the caloric density of the formula and may not help in reducing reflux.
Question 5
What is the most important step that healthcare personnel can take to prevent the transmission of microorganisms in the hospital setting?
A. Wear protective eyewear at all times.
B. Wear gloves whenever in direct contact with patients.
C. Wash hands before and after contact with each patient.
D. Clean the stethoscope with an alcohol swab between patients.
Show answer and rationale
Correct answer: C — Wash hands before and after contact with each patient.
The most crucial step in preventing the transmission of microorganisms in the hospital setting is proper hand hygiene. Healthcare personnel should wash their hands thoroughly before and after each patient contact to reduce the risk of spreading infections. While cleaning the stethoscope with an alcohol swab between patients is recommended, it is secondary to hand hygiene. Wearing protective eyewear at all times is not necessary for routine patient care unless specifically indicated, and wearing gloves only when in direct contact with patients is important but not as critical as proper handwashing. Therefore, the correct answer is to wash hands before and after contact with each patient.
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Question 6
A child is diagnosed with a Greenstick Fracture. Which of the following most accurately describes the broken bone?
A. compound fracture of the fibula
B. a partial break in a long bone
C. fracture of the growth plate of the ulna near the wrist
D. Colles fracture of the tibia
Correct answer:
A Greenstick Fracture is commonly found in children due to their bones being more flexible. This type of fracture occurs when a bone bends and partially breaks, resembling what happens when a green stick from a tree is bent in half. Therefore, the most accurate description of a Greenstick Fracture is 'a partial break in a long bone.' Choice A, 'compound fracture of the fibula,' is incorrect as a Greenstick Fracture is not a compound fracture. Choice C, 'fracture of the growth plate of the ulna near the wrist,' is incorrect as it describes a different type of fracture. Choice D, 'Colles fracture of the tibia,' is incorrect as it refers to a specific type of fracture in a different bone.
How does the procedure for taking a pulse rate on an infant differ from an adult?
A. Pulse rates are taken on infants using a different method.
B. The apical pulse method is used on infants.
C. Pulse rates on infants are taken with a sphygmomanometer.
D. Pulse rates on infants are taken apically in the third intercostal space.
Correct answer:
The correct answer is B: The apical pulse method is used on infants. This method involves placing a stethoscope in the fifth intercostal space, mid-clavicular line, and counting the beats for a full minute. It is a preferred method for infants due to their small size and the difficulty in palpating peripheral pulses accurately. Choices A, C, and D are incorrect. Choice A is incorrect as pulse rates are indeed taken on infants, albeit using a different method. Choice C is incorrect as a sphygmomanometer is typically used for measuring blood pressure, not pulse rates. Choice D is incorrect as pulse rates on infants are usually taken apically in the fifth intercostal space, not the third.
During change-of-shift report, the nurse learns about the following four patients. Which patient requires assessment first?
A. 40-year-old with chronic pancreatitis who has gnawing abdominal pain
B. 58-year-old who has compensated cirrhosis and is complaining of anorexia
C. 55-year-old with cirrhosis and ascites who has an oral temperature of 102°F (38.8°C)
D. 36-year-old recovering from a laparoscopic cholecystectomy who has severe shoulder pain
Correct answer:
When prioritizing patient assessments, the nurse should address the patient with cirrhosis and ascites who has an elevated oral temperature of 102°F (38.8°C) first. This presentation suggests a potential infection, which is critical to address promptly in a patient with liver disease. An infection in a patient with cirrhosis can quickly progress to severe complications. The other options, such as chronic pancreatitis with abdominal pain, compensated cirrhosis with anorexia, and post-laparoscopic cholecystectomy with shoulder pain, do not indicate an immediate life-threatening situation requiring urgent assessment compared to a possible infection in a patient with cirrhosis and ascites.
The nurse is discussing negativism with the parents of a 30-month-old child. How should the nurse advise the parents to best respond to this behavior?
A. Reprimand the child and give a 15-minute 'time out'
B. Maintain a permissive attitude for this behavior
C. Use patience and a sense of humor to deal with this behavior
D. Assert authority over the child through limit setting
Correct answer:
Use patience and a sense of humor to deal with this behavior. The nurse should help the parents understand that negativism is a normal part of a toddler's growth towards autonomy. Reacting with patience and humor can help diffuse the situation and maintain a positive relationship with the child. Reprimanding the child and giving a 'time out' (Choice A) may not be effective for addressing negativism and can lead to power struggles. Maintaining a permissive attitude (Choice B) may reinforce negative behavior. Asserting authority through limit setting (Choice D) may be necessary in some situations, but using patience and humor is a more effective initial approach for handling negativism.
Albert is a patient in the hospital who is scheduled for surgery the following morning. After the pre-operative visit from the anesthesia staff member who has obtained surgical consent, Albert asks for an explanation of what type of surgery he is going to have. He states that he's not sure what he just signed. What is your best response?
A. Don't worry, they'll explain it in the operating room.
B. It's standard procedure to get the consent; you don't need to worry.
C. Let me ask the nurse anesthetist to come back and explain it further.
D. Someone will review it with you prior to surgery.
Correct answer:
The correct response is to ensure that the patient fully understands the nature of the surgery they are about to undergo. If the patient expresses uncertainty about the procedure they signed consent for, it indicates a lack of informed consent, which is essential before any surgery. By requesting the nurse anesthetist to return and provide a more detailed explanation, the patient can make an informed decision. Choices A, B, and D do not address the issue of the patient's lack of understanding and the need for informed consent, making them incorrect. Option C is the best course of action to rectify the situation and ensure the patient's understanding and consent are properly obtained.
The discharge planning team is discussing plans for the dismissal of a 16-year-old admitted for complications associated with asthma. The client's mother has not participated in any of the discharge planning processes but has stated that she wants to be involved. Which of the following reasons might prohibit this mother from participating in discharge planning?
A. The client is an emancipated minor
B. The mother has to work and is unavailable
C. The client has a job and a driver's license
D. The mother does not speak English
Correct answer:
In this scenario, the correct answer is that the client is an emancipated minor. Emancipated minors, even if they are under the age of 18, have the legal right to make decisions about their own healthcare and planning, which may include not wanting their parent involved in the discharge planning process. This status grants them independence from parental involvement in certain situations. The other choices are incorrect because the mother's work schedule, the client's job and possession of a driver's license, and the mother's language proficiency do not inherently prevent her from participating in the discharge planning process, unlike the legal status of being an emancipated minor.
Patients who cannot move in their bed on their own should be turned at least ________________.
A. once a day
B. twice a day
C. every 2 hours
D. every 4 hours
Correct answer:
Patients who are unable to move in bed are at high risk of developing pressure ulcers and skin breakdown due to prolonged pressure on specific body areas. Turning these patients at least every 2 hours is crucial to relieve pressure, improve circulation, and prevent skin damage. More frequent turning may be necessary for patients with specific needs, such as those who are incontinent of urine and require additional care. Turning patients less frequently, such as once a day, twice a day, or every 4 hours, increases the risk of developing pressure ulcers and other complications. Therefore, the correct answer is to turn patients who cannot move in their bed on their own every 2 hours.
Why should a 30-year-old Caucasian woman who works the night shift take Vitamin D supplements?
A. It's a standard part of the overall nutritional treatment for the prevention of osteomalacia.
B. It helps your intestines absorb calcium, which is important for bone formation.
C. It stimulates skin cells to produce calcium, which is then released into the bloodstream to be used for bone formation.
D. Vitamin D supplements should not be taken by someone of your age.
Correct answer:
The correct answer is B: 'It helps your intestines absorb calcium, which is important for bone formation.' Vitamin D plays a crucial role in aiding the absorption of calcium from the intestines into the bloodstream, which is essential for bone health and formation. Choice A is incorrect because it does not specifically address the role of Vitamin D in calcium absorption. Choice C is incorrect as Vitamin D does not stimulate skin cells to produce calcium; rather, it helps regulate calcium levels in the body. Choice D is incorrect as age alone is not a contraindication for Vitamin D supplementation; the need for supplementation is based on individual health status and risk factors.
A patient born in 1955 had hepatitis A infection 1 year ago. According to Centers for Disease Control and Prevention (CDC) guidelines, which action should the nurse include in care when the patient is seen for a routine annual physical exam?
A. Start the hepatitis B immunization series.
B. Teach the patient about hepatitis A immune globulin.
C. Ask whether the patient has been screened for hepatitis C.
D. Test for anti-hepatitis-A virus immune globulin M (anti-HAV-IgM).
Correct answer:
The correct action for the nurse to include in care when the patient is seen for a routine annual physical exam, according to CDC guidelines, is to ask whether the patient has been screened for hepatitis C. CDC guidelines recommend screening patients born between 1945 and 1965 for hepatitis C due to the high prevalence of undiagnosed cases in this age group. Starting the hepatitis B immunization series is not necessary as the patient already had hepatitis A infection. Teaching the patient about hepatitis A immune globulin is not indicated in this scenario. Testing for anti-hepatitis-A virus immune globulin M (anti-HAV-IgM) is not needed as the patient has already had hepatitis A.
A nurse in the emergency department is observing a 4-year-old child for signs of increased intracranial pressure after a fall from a bicycle, resulting in head trauma. Which of the following signs or symptoms would be cause for concern?
A. Bulging anterior fontanel
B. Repeated vomiting
C. Signs of sleepiness at 10 PM
D. Inability to read short words from a distance of 18 inches
Correct answer:
Increased intracranial pressure after head trauma can lead to serious complications. Repeated vomiting is a concerning sign as it can indicate stimulation of the vomiting center within the brainstem due to increased pressure. This can be an early indicator of raised intracranial pressure and the need for urgent medical intervention. Bulging anterior fontanel may not be immediately apparent in a 4-year-old child and is more common in infants. Signs of sleepiness at a particular time of day are not specific to increased intracranial pressure. Inability to read short words from a distance of 18 inches may indicate vision problems but is not directly related to intracranial pressure.
NCLEX-RN clinical judgment practice questions, set 27 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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