NCLEX-RN clinical judgment practice questions, set 3
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 3
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 client is seen in the emergency room as a victim of suspected domestic violence. The nurse's aide brings the client to a center curtained area, gives her a gown to change into, and asks her to wait for the nurse. What is the most appropriate action of the nurse upon arrival?
A. Ask the client to undress to assess for injuries
B. Take the client into a private room
C. Notify the police to file a report
D. Notify the house supervisor to keep security on alert
Show answer and rationale
Correct answer: B — Take the client into a private room
When dealing with a client suspected of domestic violence, it is crucial to provide privacy and a safe environment. Taking the client into a private room allows for a confidential conversation and assessment without compromising the client's safety or dignity. The nurse should prioritize creating a safe space for the client to share information and receive support. Notification of authorities should only occur once a thorough assessment has been conducted to ensure the client's safety and well-being. Option A is incorrect because asking the client to undress should be done with sensitivity and respect for the client's privacy, focusing on assessing injuries rather than visualizing them. Option C is premature as involving the police should be based on a comprehensive assessment and the client's consent. Option D is not the most immediate and direct action required to address the client's immediate needs in a suspected domestic violence situation.
Question 2
When providing culturally competent care, nurses must incorporate cultural assessments into their health assessments. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an older American Indian patient?
A. "Are you of the Christian faith?"?
B. "Do you want to see a medicine man?"?
C. "How often do you seek help from medical providers?"?
D. "What cultural or spiritual beliefs are important to you?"?
Show answer and rationale
Correct answer: D — "What cultural or spiritual beliefs are important to you?"?
The nurse needs to assess the cultural beliefs and practices of the patient and should ask questions in a way that communicates acceptance of their beliefs and allows for open communication. Therefore, the most appropriate question to initiate an assessment of cultural beliefs with an older American Indian patient is "What cultural or spiritual beliefs are important to you?"? This question shows respect for the patient's beliefs and encourages them to share relevant information. Asking if they are of the Christian faith does not promote open communication and may not reflect the patient's actual beliefs. While some American Indians may seek assistance from a medicine man or shaman, it is not appropriate to make assumptions without direct input from the patient. Asking how often they seek help from medical providers is not directly related to understanding their cultural beliefs and may not provide relevant insights for culturally competent care.
Question 3
A woman who has lived in the United States for a year after moving from Europe has learned to speak English and is almost finished with her college studies. She now dresses like her peers and says that her family in Europe would hardly recognize her. This situation illustrates which concept?
A. Integration
B. Assimilation
C. Biculturalism
D. Heritage consistency
Show answer and rationale
Correct answer: B — Assimilation
Assimilation is a unidirectional, linear process moving from unacculturated to acculturated, in which a person develops a new cultural identity and becomes like members of the dominant culture. In this scenario, the woman has adapted to the new culture by learning the language, dressing like her peers, and expressing that her family in Europe would hardly recognize her. This aligns with the process of assimilation. Integration and biculturalism, on the other hand, involve bidirectional and bidimensional processes that induce reciprocal change in both cultures while maintaining aspects of the original culture in one's ethnic identity. Since there is no indication in the question that the woman has retained aspects of her original culture, integration and biculturalism are not the correct concepts. Heritage consistency refers to the degree to which one retains their original or traditional culture, which is not addressed in the scenario provided.
Question 4
Which of these statements is true regarding the use of Standard Precautions in the healthcare setting?
A. Standard Precautions apply to all body fluids, except sweat.
B. Alcohol-based hand rub should be used if hands are not visibly dirty.
C. Standard Precautions are intended for use with all patients, regardless of their risk or presumed infection status.
D. Standard Precautions are to be used only when non-intact skin, excretions containing visible blood, or expected contact with mucous membranes are present.
Show answer and rationale
Correct answer: C — Standard Precautions are intended for use with all patients, regardless of their risk or presumed infection status.
Standard Precautions are designed to reduce the risk for transmission of microorganisms from both recognized and unrecognized sources. They are intended for use with all patients, regardless of their risk or presumed infection status. Standard Precautions apply to all body fluids, secretions, and excretions except sweat - whether or not they contain visible blood, non-intact skin, or mucous membranes. Hands should be washed with soap and water if visibly soiled with blood or body fluids. Alcohol-based hand rubs can be used if hands are not visibly soiled. Choice A is incorrect because Standard Precautions apply to all body fluids, secretions, and excretions except sweat. Choice B is incorrect because alcohol-based hand rub should be used when hands are not visibly dirty. Choice D is incorrect because Standard Precautions are not limited to situations involving non-intact skin, excretions with visible blood, or expected mucous membrane contact.
Question 5
What action by the nurse is appropriate when examining a 16-year-old male teenager?
A. Discuss health teaching with the teenager to promote wellness.
B. Ask the parent to step out of the room during the history and physical examination to respect the teenager's privacy.
C. Use age-appropriate communication when speaking to the teenager to ensure understanding.
D. Provide feedback that his body is developing normally and discuss the wide variation among teenagers on the rate of growth and development.
Show answer and rationale
Correct answer: D — Provide feedback that his body is developing normally and discuss the wide variation among teenagers on the rate of growth and development.
During the examination of a 16-year-old male teenager, it is essential to provide feedback that his body is developing normally and to discuss the wide variation among teenagers regarding growth and development. This reassures the teenager about his health status and addresses any concerns about physical development. It is important to recognize that adolescents are very conscious of their body image and often compare themselves to their peers, hence the need for such feedback. Asking the parent to step out of the room respects the teenager's privacy and promotes open communication between the nurse and the teenager. Using age-appropriate communication is crucial to ensure that the teenager understands the information provided. Asking the parent to stay in the room may not be ideal as it can inhibit open discussion, and talking to the teenager as if they were a younger child is inappropriate and may undermine their autonomy and understanding.
Keep going past these 15 questions
Missed-question review, longer banks, and the rest of 20,000+ nursing practice questions open when you start studying.
Stems and choices stay public so you can still reason. Correct answers and full rationales unlock with the rest of the bank.
Question 6
The healthcare provider is managing a 20 lbs (9 kg) 6-month-old with a 3-day history of diarrhea, occasional vomiting, and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be immediately reported to the healthcare provider?
A. 3 episodes of vomiting in 1 hour.
B. Periodic crying and irritability.
C. Vigorous sucking on a pacifier.
D. No measurable voiding in 4 hours.
Correct answer:
The critical finding that should be reported immediately to the healthcare provider is 'No measurable voiding in 4 hours.' This finding raises concerns about possible hyperkalemia, which can result from continued potassium administration and a decrease in urinary output. Hyperkalemia can lead to serious complications, including cardiac arrhythmias. The management of acute hyperkalemia involves interventions such as administering calcium to protect the heart, shifting potassium into cells, and enhancing potassium elimination from the body. The other choices do not indicate an urgent issue that requires immediate attention. Three episodes of vomiting in 1 hour can be concerning but may not be as immediately critical as the risk of hyperkalemia. Periodic crying and irritability are common in infants and may not indicate a severe complication. Vigorous sucking on a pacifier is a normal behavior in infants and does not signal a medical emergency.
The nurse is caring for a 27-year-old female client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing?
A. Apply dressing using sterile technique
B. Improve the client's nutrition status
C. Initiate limb compression therapy
D. Begin proteolytic debridement
Correct answer:
Venous stasis occurs when venous blood collects and stagnates in the lower leg due to incompetent venous valves. This leads to inadequate oxygen and nutrient supply to the cells in the lower extremities, resulting in cell death or necrosis. Venous stasis ulcers, characterized by shallow brown wounds with irregular margins, typically develop on the lower leg or ankle. The primary goal in managing clients with venous stasis ulcers is to promote healing. Proper nutrition plays a crucial role in wound healing. Nutritional deficiencies are common causes of venous ulcers, and a diet rich in protein, iron, zinc, and vitamins C and A is recommended to enhance wound healing. Applying dressings with sterile technique, initiating limb compression therapy, and beginning proteolytic debridement are important interventions in wound care but may not directly address the underlying issue of poor nutrition that is essential for healing venous stasis ulcers.
A physician is explaining a procedure to a patient that may cure her recurring Staph infection. The doctor explains how the procedure is done, what to expect, the odds of the procedure curing the infection, and possible side effects and risks. The physician is:
A. Preparing the patient to give informed consent.
B. Protecting HIPAA by listing all the steps of the procedure with the risks involved.
C. Not required to inform the patient of any alternative therapies.
D. None of the above.
Correct answer:
The correct answer is preparing the patient to give informed consent. Giving informed consent is the process of providing a patient with all necessary information about a medical procedure, including how it's done, what to expect, the likelihood of success, and potential risks and side effects. This allows the patient to make an informed decision about their treatment. Protecting HIPAA (Health Insurance Portability and Accountability Act) involves safeguarding patient health information and is not directly related to the scenario described. It is important for physicians to inform patients of any alternative therapies available to them to ensure they have all relevant information to make a decision regarding their treatment. Therefore, choice C, 'Not required to inform the patient of any alternative therapies,' is incorrect. Choice D, 'None of the above,' is incorrect as the physician is indeed preparing the patient for informed consent.
Teresa is an 84-year-old with stage 4 ovarian cancer who has been admitted for a bowel obstruction. She recently stated that she has decided that she doesn't want any further aggressive care and is requesting to be placed under hospice care. Her husband and daughter are supportive of her decision. She spoke with her oncologist about it, and he stated that he did not agree and wrote orders on her chart for chemotherapy. What would be the best first response to this situation?
A. Give the patient a list of other oncologists
B. Tell the family to report the doctor to the state quality board
C. Notify the doctor that the patient refuses the chemotherapy
D. Give the patient hospice information
Correct answer:
The patient has the right to refuse any treatment, and the doctor should be notified that the orders on the chart cannot be performed, with appropriate documentation. In this situation, the best first response is to notify the doctor that the patient refuses the chemotherapy. This step ensures that the patient's wishes are respected and that inappropriate treatments are not administered. It also opens up a dialogue with the oncologist, giving him the opportunity to understand the patient's perspective and potentially support her decision. Providing hospice information is a good follow-up step after addressing the immediate issue of refusing chemotherapy, as it allows the patient to initiate her own hospice evaluation if desired. Giving the patient a list of other oncologists or telling the family to report the doctor to the state quality board are not appropriate initial responses and may not align with the patient's wishes or autonomy.
A triage nurse has four clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first?
A. A 2-month-old infant with a history of rolling off the bed and having a bulging fontanelle with crying
B. A teenager who suffered singed facial hair while camping
C. An elderly client with complaints of frequent liquid brown-colored stools
D. A middle-aged client with intermittent pain behind the right scapula
Correct answer:
The correct answer is the teenager who suffered singed facial hair while camping. This client is in the greatest danger with a potential risk of respiratory distress. Singed facial hair indicates exposure to heat or fire in close range, which could have caused serious damage to the interior of the lungs. It's crucial to prioritize this client as the interior lining of the lungs has no nerve fibers, so swelling may not be immediately noticeable. The other choices, while concerning, do not present an immediate life-threatening situation. The infant's condition may be serious but does not pose an immediate danger of respiratory distress. The elderly client's symptoms could indicate gastrointestinal issues, which are important but not as urgent as potential respiratory compromise. The middle-aged client's pain behind the right scapula, while uncomfortable, does not indicate an acute life-threatening condition requiring immediate attention.
A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client's temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is:
A. Maintain fluid and electrolyte balance
B. Control nausea
C. Manage pain
D. Prevent urinary tract infection
Correct answer:
In the scenario presented, the priority nursing goal for a client with renal calculi experiencing moderate to severe flank pain and nausea should be to manage pain. Pain management is crucial as it alleviates suffering, improves comfort, and enhances the quality of life for the client. In the case of ureteral colic from renal calculi, the cornerstone of management is effective pain control. Prompt analgesia, typically achieved with parenteral narcotics or nonsteroidal anti-inflammatory drugs (NSAIDs), is essential to provide relief and facilitate the passage of the calculi. While maintaining fluid and electrolyte balance is important in clients with renal calculi, addressing pain takes precedence as it directly impacts the client's immediate well-being. Controlling nausea and preventing urinary tract infections are also important aspects of care, but they are secondary to managing the primary concern of pain in this urgent situation.
Which technological advance is MOST likely to place you at risk for HIPAA violations?
A. Social media
B. Word processing programs
C. Spreadsheets
D. Cloud storage services (Clouds and SOEs)
Correct answer:
The correct answer is Social media. Social media platforms such as Facebook can significantly put you at risk for HIPAA violations. It is crucial to never share any patient-related information or comments on social media websites, as this breaches patient confidentiality and violates HIPAA regulations. Choices B, C, and D are less likely to directly lead to HIPAA violations. Word processing programs and spreadsheets are commonly used for documentation and data organization, focusing more on internal operations and not on external sharing of sensitive information that can compromise patient confidentiality. Cloud storage services (Clouds and SOEs) are designed for secure data storage and sharing within regulated environments, and HIPAA compliance can be maintained if used appropriately. However, social media's open and unsecured nature makes it a higher risk for HIPAA violations compared to the other technological advances mentioned.
A child has recently been diagnosed with Duchenne muscular dystrophy (DMD). The parents are receiving genetic counseling prior to planning another pregnancy. Which of the following statements includes the most accurate information?
A. Duchenne is an X-linked recessive disorder, so daughters have a 50% chance of being carriers and sons a 50% chance of developing the disease.
B. Duchenne is an X-linked recessive disorder, so both daughters and sons have a 50% chance of developing the disease.
C. Each child has a 1 in 4 (25%) chance of developing the disorder.
D. Sons only have a 1 in 4 (25%) chance of developing the disorder.
Correct answer:
The correct answer is that Duchenne is an X-linked recessive disorder, meaning the affected gene is located on one of the two X chromosomes of a female carrier. If a son receives the X chromosome bearing the gene, he will develop the disease, giving him a 50% chance of being affected. Daughters, on the other hand, are not affected by Duchenne but have a 50% chance of being carriers since they inherit one copy of the defective gene from the mother. The other X chromosome is inherited from the father, who cannot be a carrier. Therefore, choice A is accurate. Choice B is incorrect because daughters do not develop the disease, and sons have a 50% chance of developing, not both having a 50% chance. Choice C is incorrect as it does not consider the X-linked inheritance pattern of Duchenne. Choice D is inaccurate as it incorrectly states that only sons have a 25% chance of developing the disorder, omitting the carrier status of daughters.
A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would:
A. Instruct the client to maintain a regular diet the day prior to the examination.
B. Restrict the client's fluid intake 4 hours prior to the examination.
C. Administer a laxative to the client the evening before the examination.
D. Inform the client that only 1 x-ray of his abdomen is necessary.
Correct answer:
The correct preparation for an Intravenous Pyelogram (IVP) involves administering a laxative to the client the evening before the examination. This is crucial to ensure adequate bowel preparation, which in turn allows for better visualization of the bladder and ureters during the procedure. An IVP is an x-ray exam that utilizes contrast material to evaluate the kidneys, ureters, and bladder, aiding in the diagnosis of conditions like blood in the urine or pain in the side or lower back. Administering a laxative helps in achieving optimal imaging quality, which is essential for accurate diagnosis and subsequent treatment planning.
Choice A is incorrect because maintaining a regular diet is not the standard preparation for an IVP. Choice B is incorrect as fluid intake is not typically restricted for this procedure. Choice D is incorrect as an IVP involves multiple x-rays to assess the urinary system, not just one of the abdomen.
When caring for a patient hospitalized with active tuberculosis (TB), the nurse observes a student nurse who is assigned to take care of the patient. Which action, if performed by the student nurse, would require an intervention by the nurse?
A. The patient is offered a tissue from the box at the bedside.
B. A surgical face mask is applied before visiting the patient.
C. A snack is brought to the patient from the unit refrigerator.
D. Hand washing is performed before entering the patient's room.
Correct answer:
When caring for a patient with active tuberculosis (TB), it is crucial to use a high-efficiency particulate-absorbing (HEPA) mask instead of a standard surgical mask when entering the patient's room, as a HEPA mask can filter out 100% of small airborne particles, reducing the risk of transmission. Therefore, if the student nurse applies only a surgical face mask before visiting the patient, this action would require intervention by the nurse to ensure the appropriate protective equipment is used. Hand washing before entering the patient's room is essential to prevent the spread of infection and is a correct action. Bringing a snack to the patient from the unit refrigerator is appropriate and helps address potential issues with anorexia and weight loss in patients with TB. While hand washing after handling a tissue used by the patient is necessary, no special precautions are required when offering the patient an unused tissue.
NCLEX-RN clinical judgment practice questions, set 3 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.
Keep going past these 15 questions
Missed-question review, longer banks, and the rest of 20,000+ nursing practice questions open when you start studying.
