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NCLEX-RN clinical judgment practice questions, set 29

NCLEX-RN · clinical judgment

NCLEX-RN clinical judgment practice questions set 29

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

A patient is being discharged from the med-surgical unit. The patient has a history of gastritis. The nurse questions the patient on their usual routine at home. Which of these statements would alert the nurse that additional teaching is required?

  1. A. I avoid NSAIDs. I only take a daily aspirin for my heart health.
  2. B. I always avoid eating hot and spicy foods.
  3. C. I will continue taking my antacids with or immediately after meals.
  4. D. I will only drink coffee once a week, if even that often.
Show answer and rationale

Correct answer: A — I avoid NSAIDs. I only take a daily aspirin for my heart health.

The correct answer is, 'I avoid NSAIDs. I only take a daily aspirin for my heart health.' Aspirin is classified as an NSAID and can exacerbate existing stomach problems, such as gastritis. Therefore, patients with gastritis should avoid aspirin just like any other NSAID. Choice B, 'I always avoid eating hot and spicy foods,' is a good practice for a patient with gastritis. Choice C, 'I will continue taking my antacids with or immediately after meals,' indicates understanding of the correct timing for antacid use. Choice D, 'I will only drink coffee once a week, if even that often,' shows a suitable limitation of coffee intake, which is beneficial for patients with gastritis.

Question 2

While working with an obese adolescent, it is important for the nurse to recognize that obesity in adolescents is most often associated with what other behavior?

  1. A. Sexual promiscuity
  2. B. Poor body image
  3. C. Dropping out of school
  4. D. Drug experimentation
Show answer and rationale

Correct answer: B — Poor body image

When addressing obesity in adolescents, it is crucial to consider that poor body image is a common behavior associated with obesity. As adolescents gain weight, they may experience a decrease in self-esteem and a negative perception of their body. This can contribute to a cycle of unhealthy behaviors and impact their overall well-being. The other choices are less commonly associated with obesity in adolescents. Sexual promiscuity may be influenced by various factors unrelated to obesity, dropping out of school is more often linked to academic challenges or social issues, and drug experimentation can stem from a range of influences but is not directly correlated with obesity.

Question 3

You have been asked to record the amount of food that the person has eaten during each meal. What kinds of words or numbers would you use to record this food intake?

  1. A. A little, a moderate amount, or all of the meal
  2. B. 50 cc, 100 cc, or 500 cc of the meal
  3. C. 25%, 50%, or 100% of the meal
  4. D. Either A or C
Show answer and rationale

Correct answer: C — 25%, 50%, or 100% of the meal

Food intake is typically measured in terms of the percentage (%) of food that has been eaten. Using percentages allows for a more precise and standardized way of recording food consumption. For instance, you would record 25% of the vegetable if the person has eaten about a quarter of the vegetables on the plate. Choices A and B are incorrect. Choice A's terms 'a little' and 'a moderate amount' are vague and not specific enough for accurate documentation. Choice B's use of cc is more appropriate for measuring fluids, not solid foods. Choice D is also incorrect as it combines vague terms with percentages, which could lead to confusion in accurately documenting the food intake.

Question 4

A nurse is caring for a client who was recently diagnosed with breast cancer. The oncologist uses the TNM staging system to classify this case as T2, N2, M0. The nurse understands that TNM stands for:

  1. A. Tumor, Necrosis, Metastasis
  2. B. Tumor, Node Involvement, Mastectomy
  3. C. Tumor, Node Involvement, Metastasis
  4. D. Therapy, Necrosis, Metastasis
Show answer and rationale

Correct answer: B — Tumor, Node Involvement, Mastectomy

The TNM staging system is a classification system for determining the size and extent of cancerous tissue. The TNM system helps providers to identify the most accurate forms of treatment. The T stands for tumor, the N stands for node involvement, and the M stands for metastasis. Choice A, 'Tumor, Necrosis, Metastasis,' is incorrect because it does not include the node involvement component. Choice B, 'Tumor, Node Involvement, Mastectomy,' is incorrect as it erroneously includes the treatment approach 'Mastectomy' instead of 'Metastasis.' Choice D, 'Therapy, Necrosis, Metastasis,' is incorrect because it includes 'Therapy' instead of the correct component 'Node Involvement.'

Question 5

A 20-year-old female attending college is found unconscious in her dorm room. She has a fever and a noticeable rash. She has just been admitted to the hospital. Which of the following tests is most likely to be performed first?

  1. A. Blood sugar check
  2. B. CT scan
  3. C. Blood cultures
  4. D. Arterial blood gases
Show answer and rationale

Correct answer: C — Blood cultures

The most likely test to be performed first in this scenario is blood cultures. Blood cultures are crucial to investigate the fever and rash symptoms in an unconscious patient. This test is used to detect foreign invaders like bacteria, yeast, and other microorganisms in the blood, which could indicate a blood infection (bacteremia). A positive blood culture result confirms the presence of bacteria in the blood. A blood sugar check (choice A) may be important but is less likely to be the first test in this context. A CT scan (choice B) and arterial blood gases (choice D) are generally not the initial tests performed to investigate a fever and rash with altered mental status.

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Ten more NCLEX-RN clinical judgment questions

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Question 6

During a general survey of a patient, which finding is considered normal?

  1. A. Body mass index (BMI) of 20.
  2. B. When standing, the patient's base is narrow.
  3. C. The patient appears older than their stated age.
  4. D. Arm span (fingertip to fingertip) is greater than the height.
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Question 7

A client is admitted to a nursing unit with a remittent fever. Which statement best describes this pattern of fever?

  1. A. A fever that spikes and then lowers without returning to normal
  2. B. A fever that lasts 2 days followed by normal temperature for 2 days, followed by fever again
  3. C. A fever that lasts 2 days followed by normal temperature for 12 hours, followed by fever again
  4. D. A persistent fever that has lasted over 24 hours
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Question 8

Where is the pulse point located on the top of the foot?

  1. A. the dorsalis pedis
  2. B. This is the pulse point checked in patients with peripheral vascular problems.
  3. C. This pulse point may be absent in some patients due to a congenital anomaly.
  4. D. All of the above.
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Question 9

In which part of the plan of care should a nurse record the item 'Encourage patient to attend one psychoeducational group daily'?

  1. A. Assessment
  2. B. Analysis
  3. C. Planning
  4. D. Implementation
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Question 10

The nurse is working in a support group for clients with HIV. Which point is most important for the nurse to stress?

  1. A. They must inform household members of their condition.
  2. B. They must take their medications exactly as prescribed.
  3. C. They must abstain from substance use.
  4. D. They must avoid large crowds.
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Question 11

The nurse is caring for a 13-year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate post-operative period?

  1. A. Raise the head of the bed at least 30 degrees
  2. B. Encourage ambulation within 24 hours
  3. C. Maintain in a flat position, logrolling as needed
  4. D. Encourage leg contraction and relaxation after 48 hours
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Question 12

A client has no pulse or respirations. After calling for help, what should the nurse's first action be?

  1. A. Start a peripheral IV
  2. B. Initiate high-quality chest compressions
  3. C. Establish an airway
  4. D. Obtain the crash cart
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Question 13

A client needs to give informed consent for electroconvulsive therapy treatments. Which of the following actions should the nurse take?

  1. A. Explain the adverse effects the client might experience from the treatment
  2. B. Verify the client gave consent voluntarily for the treatment
  3. C. Describe the benefits of the treatment to the client
  4. D. Outline possible alternatives to the treatment for the client
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Question 14

The healthcare professional is preparing to auscultate the abdomen. How should they proceed?

  1. A. Warm the endpiece of the stethoscope by rubbing it between their hands.
  2. B. Ensure the patient is adequately covered and comfortable during the examination.
  3. C. Ensure that the diaphragm side of the stethoscope is in use.
  4. D. Check the room temperature and offer blankets to the patient if needed.
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Question 15

A pregnant woman who is 36 weeks' pregnant and has hepatitis B is being informed by a nurse. Which of the following statements from the client indicates understanding of this condition?

  1. A. Now I know my baby will need a cesarean section.
  2. B. My baby will need two shots soon after birth.
  3. C. I will not be able to breastfeed.
  4. D. My baby's father does not need testing; I know I am the one with hepatitis.
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About these NCLEX-RN clinical judgment questions

NCLEX-RN clinical judgment practice questions, set 29 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.

No. Nursier is independent practice. Register through the official path named on the NCLEX-RN exam guide.

The first five questions already include the rationale. Start full practice to unlock the remaining keys, missed-question review, and the rest of the bank.

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