NCLEX-RN clinical judgment practice questions, set 30
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 30
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
When is the best time for the nurse to attempt to elicit the Moro reflex during an infant examination?
A. When the infant is sleeping
B. At the end of the examination
C. Before auscultation of the thorax
D. At about the middle of the examination
Show answer and rationale
Correct answer: B — At the end of the examination
The Moro reflex, also known as the startle reflex, is best elicited at the end of the examination because it can cause the infant to cry. This reflex is triggered by a sudden change in position or loud noise, and it involves the infant's arms extending and then coming back together as if embracing. By eliciting this reflex at the end of the examination, the nurse can observe the infant's response and ensure that the examination is completed without unnecessary distress. Choices A, C, and D are incorrect because the Moro reflex is typically elicited at the end of the examination to avoid disrupting the assessment process and causing unnecessary discomfort to the infant.
Question 2
Over a patient's lifespan, how does the pulse rate change?
A. starts out fast and decreases as the patient ages.
B. starts out slower and increases as the patient ages.
C. varies from slow to fast throughout the lifespan.
D. stays consistent from birth to death.
Show answer and rationale
Correct answer: A — starts out fast and decreases as the patient ages.
The correct answer is that the pulse rate starts out fast and decreases as the patient ages. In infants, the normal pulse rate is around 140 beats per minute, which then falls to an average of 80 beats per minute in adults. As individuals age, their pulse rate tends to decrease due to changes in cardiovascular function. Choice B is incorrect as the pulse rate typically decreases with age, rather than increases. Choice C is incorrect as there is a general trend of decreasing pulse rate as individuals age, rather than a continuous variation. Choice D is incorrect as the pulse rate does change over a patient's lifespan, starting fast in infants and decreasing as they age.
Question 3
The healthcare provider assesses a patient suspected of having an asthma attack. Which of the following is a common clinical manifestation of this condition?
A. Audible crackles and orthopnea
B. An audible wheeze and use of accessory muscles
C. Audible crackles and use of accessory muscles
D. Audible wheeze and orthopnea
Show answer and rationale
Correct answer: B — An audible wheeze and use of accessory muscles
Choice B, 'An audible wheeze and use of accessory muscles,' is the correct answer. In asthma, patients commonly present with wheezing due to airway constriction and the use of accessory muscles to aid in breathing. Audible crackles (rales) are more commonly associated with conditions like pneumonia, congestive heart failure, or pulmonary fibrosis. Orthopnea, which is difficulty breathing while lying flat, is typically seen in conditions like heart failure or chronic obstructive pulmonary disease, rather than asthma. Choice C is incorrect as crackles are not a typical finding in asthma. Choice D is incorrect as orthopnea is not a common clinical manifestation of asthma.
Question 4
A client in a long-term care facility tells the nurse, 'My daughter never visits me.' The nurse responds by telling the client that when her own mother was in a long-term care facility, she found it difficult to visit. This is an example of which communication technique?
A. Empathy
B. Self-disclosure
C. Disapproval
D. False reassurance
Show answer and rationale
Correct answer: B — Self-disclosure
Self-disclosure is a therapeutic communication technique that nurses use to build rapport and trust with clients. By sharing personal experiences, nurses can help clients feel understood and encourage them to open up. In this scenario, the nurse sharing her own struggle with visiting her mother demonstrates self-disclosure. Empathy (choice A) involves understanding and sharing the feelings of another, but in this case, the nurse is sharing her own experience rather than focusing solely on the client's emotions. Disapproval (choice C) and false reassurance (choice D) do not apply in this context as the nurse is not expressing disapproval or giving false hope or comfort.
Question 5
The body system that functions to maintain fluid balance, support immunity, and contains the spleen is the:
A. Lymphatic System
B. Digestive System
C. Urinary System
D. Respiratory System
Show answer and rationale
Correct answer: A — Lymphatic System
The Lymphatic System is responsible for maintaining fluid balance and supporting immunity. It contains organs like the spleen, tonsils, thymus, lymph nodes, and lymph vessels. The spleen, a part of the lymphatic system, plays a crucial role in filtering blood and storing blood cells. The Digestive System is primarily involved in the breakdown and absorption of nutrients, not fluid balance or immunity. The Urinary System is responsible for filtering waste products from the blood and regulating fluid balance, but it does not support immunity or contain the spleen. The Respiratory System is focused on gas exchange and oxygenating the blood, not fluid balance or immunity.
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Question 6
Septic, anaphylactic, and neurogenic shock are all categorized as:
A. Hypovolemic shock
B. Cardiogenic shock
C. Distributive shock
D. Obstructive shock
Correct answer:
Septic, anaphylactic, and neurogenic shock are all types of distributive shock. Distributive shock is characterized by a decrease in systemic vascular resistance, leading to poor tissue perfusion. Septic shock is caused by severe infection, anaphylactic shock is an extreme allergic reaction, and neurogenic shock results from damage to the nervous system. Hypovolemic shock (Choice A) is characterized by a decrease in intravascular volume, cardiogenic shock (Choice B) is due to heart failure, and obstructive shock (Choice D) results from obstruction of blood flow. Therefore, the correct categorization for septic, anaphylactic, and neurogenic shock is distributive shock.
Which of the following can cause coup-contrecoup injuries?
A. Rotational forces
B. Deformation forces
C. Deceleration forces
D. Acceleration forces
Correct answer:
Deceleration forces occur when the head is moving and abruptly comes to a stop, such as in a car crash. This sudden deceleration can cause the brain to hit against the skull, resulting in coup-contrecoup injuries. In a coup-contrecoup injury, the brain is damaged on opposite sides due to the initial impact and the rebound effect inside the skull. Rotational forces usually result in diffuse axonal injuries rather than coup-contrecoup injuries. Deformation forces can cause focal brain injuries but not coup-contrecoup injuries. Acceleration forces typically lead to diffuse brain injuries, not coup-contrecoup injuries. Therefore, the correct answer is deceleration forces.
A healthcare professional is putting together a presentation on meningitis. Which of the following microorganisms has not been linked to meningitis in humans?
A. S. pneumoniae
B. H. influenzae
C. N. meningitidis
D. Cl. difficile
Correct answer:
The correct answer is Cl. difficile. Clostridium difficile (C. diff) is not typically associated with meningitis in humans. This bacterium is known to cause severe diarrhea, usually as a result of antibiotic treatment. S. pneumoniae, H. influenzae, and N. meningitidis are all known to be causative agents of meningitis in humans. S. pneumoniae is a common cause of bacterial meningitis, especially in adults. H. influenzae, particularly type b (Hib), used to be a leading cause of meningitis in children before the introduction of the Hib vaccine. N. meningitidis is another significant pathogen responsible for causing meningitis, especially in young adults and adolescents.
A fragile 87-year-old female has recently been admitted to the hospital with increased confusion and falls over the last two weeks. She is also noted to have a mild left hemiparesis. Which of the following tests is most likely to be performed?
A. CBC (Complete Blood Count)
B. ECG (Electrocardiogram)
C. Thyroid Function Tests
D. CT Scan
Correct answer:
A CT scan is most likely to be performed in this scenario. A CT scan would be done to further investigate the cause of the left hemiparesis. Noncontrast CT scanning is commonly used in the acute evaluation of patients with suspected acute stroke to assess for ischemic changes or hemorrhage in the brain. While a CBC may provide information on blood cell counts and general health status, it is not the primary test for evaluating hemiparesis. An ECG is used to assess heart function and rhythm, which is not the main concern in this case. Thyroid function tests evaluate thyroid hormone levels and are not typically the initial tests for evaluating hemiparesis and confusion.
Which action will be included in the care for a patient who has recently been diagnosed with asymptomatic nonalcoholic fatty liver disease (NAFLD)?
A. Teach about symptoms of variceal bleeding
B. Draw blood for hepatitis serology testing
C. Discuss the need to increase caloric intake
D. Review the patient's current medication list
Correct answer:
The correct action for a patient diagnosed with asymptomatic nonalcoholic fatty liver disease (NAFLD) would be to review the patient's current medication list. This is important because certain medications can increase the risk for NAFLD, and they should be identified and possibly eliminated. Teaching about symptoms of variceal bleeding is not necessary as variceal bleeding is not a concern in a patient with asymptomatic NAFLD. Drawing blood for hepatitis serology testing is not indicated as NAFLD is not associated with hepatitis. Discussing the need to increase caloric intake is also not appropriate since weight loss is usually recommended in the management of NAFLD.
A client is undergoing radiation therapy for treatment of thyroid cancer. Following the radiation, the client develops xerostomia. Which of the following best describes this condition?
A. Cracks in the corners of the mouth
B. Peeling skin from the tongue and gums
C. Increased dental caries
D. Dry mouth
Correct answer:
Xerostomia, also known as dry mouth, is a common side effect of radiation therapy in the head and neck region. It occurs when the salivary glands are damaged during treatment, reducing saliva production and causing a dry sensation in the mouth. The correct answer is 'Dry mouth' (option D). Choice A, 'Cracks in the corners of the mouth,' describes angular cheilitis, a condition linked to nutritional deficiencies or candida infection. Choice B, 'Peeling skin from the tongue and gums,' is more indicative of conditions like oral thrush or mucositis. Choice C, 'Increased dental caries,' is a consequence of reduced saliva flow but does not specifically describe xerostomia.
A patient is scheduled for a computed tomography (CT) of the chest with contrast media. Which assessment finding should the nurse immediately report to the health care provider?
A. Patient is claustrophobic.
B. Patient is allergic to shellfish.
C. Patient recently used a bronchodilator inhaler.
D. Patient is not able to remove a wedding band.
Correct answer:
The correct answer is that the patient is allergic to shellfish. This is crucial because the contrast media used in CT scans is iodine-based, and individuals with iodine allergies, such as those allergic to shellfish, are at risk of adverse reactions. It is important to identify and address this allergy to prevent potential complications. The other options do not directly impact the safety or effectiveness of the CT scan with contrast media. Claustrophobia can be managed with patient support, the recent use of a bronchodilator inhaler does not typically affect the CT procedure, and not being able to remove a wedding band is not a critical concern for the scan itself.
To prevent a Valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would:
A. Assist the client in using the bedside commode.
B. Administer stool softeners daily as prescribed.
C. Administer antidysrhythmics prn as ordered.
D. Maintain the client on strict bed rest.
Correct answer:
Administering stool softeners daily is crucial to prevent straining during defecation, which can lead to the Valsalva maneuver. Straining can increase intrathoracic pressure, decrease venous return to the heart, and reduce cardiac output, potentially worsening the client's condition. If constipation occurs, the use of laxatives may be necessary to avoid straining. Administering antidysrhythmics on an as-needed basis is not indicated for preventing the Valsalva maneuver; they are used to manage dysrhythmias. Strict bed rest is not necessary and may lead to complications such as deconditioning, DVT, and respiratory issues in the absence of specific medical indications.
What is the correct action regarding thigh pressure when comparing it to arm pressure in an adolescent with high blood pressure?
A. The popliteal artery should be auscultated to obtain thigh pressure.
B. The best position to measure thigh pressure is the prone position.
C. If the blood pressure in the arm is high in an adolescent, then it should be compared with the thigh pressure.
D. Thigh pressure is generally higher than arm pressure due to the proximity to the heart and the size of the popliteal vessels.
Correct answer:
When blood pressure measured in the arm is significantly elevated, especially in adolescents and young adults, it is crucial to compare it with thigh pressure to assess for coarctation of the aorta. The popliteal artery, not the femoral artery, should be auscultated for the thigh pressure reading as the femoral artery is closer to the placement of the blood pressure cuff. Generally, thigh pressure is higher than arm pressure; however, if there is coarctation of the artery, arm pressures can be higher than thigh pressures. The preferred position for measuring thigh pressure is the prone position, not supine, with the knee slightly bent to facilitate accurate readings.
When assessing a child admitted to the hospital with pyloric stenosis, which symptom would the nurse likely find when asking the parent about the child's symptoms?
A. Watery diarrhea
B. Projectile vomiting
C. Increased urine output
D. Vomiting large amounts of bile
Correct answer:
In pyloric stenosis, hypertrophy of the circular muscles of the pylorus causes narrowing of the pyloric canal between the stomach and the duodenum. The hallmark symptom of pyloric stenosis is projectile vomiting, which is the forceful expulsion of stomach contents. Other common symptoms include irritability, hunger and crying, constipation, and signs of dehydration. Watery diarrhea (Choice A) is not a typical symptom of pyloric stenosis. Increased urine output (Choice C) is not directly associated with this condition. Vomiting large amounts of bile (Choice D) is not a characteristic symptom of pyloric stenosis; instead, the vomitus in pyloric stenosis is non-bilious.
NCLEX-RN clinical judgment practice questions, set 30 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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