NCLEX-RN clinical judgment practice questions, set 31

NCLEX-RN · clinical judgment

NCLEX-RN clinical judgment practice questions set 31

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's intake and output are being calculated by a nurse. During the last shift, the client consumed ½ cup of gelatin, a skinless chicken breast, 1 cup of green beans, and 300 cc of water. The client also urinated 250 cc and had 2 bowel movements. What is this client's intake and output for this shift?

  1. A. 420 cc intake, 250 cc output
  2. B. 300 cc intake, 250 cc output
  3. C. 550 cc intake, 550 cc output
  4. D. 300 cc intake, 550 cc output
Show answer and rationale

Correct answer: A — 420 cc intake, 250 cc output

The correct answer is 420 cc intake and 250 cc output for this shift. To calculate the intake, ½ cup of gelatin (approximately 120 cc) and 300 cc of water should be added together, resulting in 420 cc. Food intake like the chicken breast and green beans is not converted to cc's but may be documented for hospital protocol. Output includes urine (250 cc in this case) and other forms like vomit, diarrhea, or gastric suction. Bowel movements are not converted to cc's, but the nurse may need to document the number of stools passed. Choices B, C, and D are incorrect because they do not accurately reflect the intake and output calculations based on the information provided.

Question 2

A child is prescribed baclofen (Lioresal) via intrathecal pump to treat severe muscle spasms related to cerebral palsy. What teaching does the nurse provide the child and parents?

  1. A. Do not let this prescription run out.
  2. B. The medication may cause gingival hyperplasia.
  3. C. Periodic serum drug levels are needed.
  4. D. Watch for excessive facial hair growth.
Show answer and rationale

Correct answer: A — Do not let this prescription run out.

The correct teaching for the child and parents when a child is prescribed baclofen via an intrathecal pump is to not let the prescription run out. Abrupt discontinuation of intrathecal baclofen can lead to severe effects like high fever, altered mental status, and rebound spasticity and muscle rigidity. It is crucial for the parents to ensure there is always an adequate supply of this medication to prevent these adverse effects. Choices B and D are incorrect because gingival hyperplasia and hirsutism are side effects associated with phenytoin (Dilantin), not baclofen. Choice C is incorrect as serum drug levels are not typically monitored for intrathecal medications.

Question 3

The clinic nurse is assessing jaundice in a child with hepatitis. Which anatomical area would provide the best data regarding the presence of jaundice?

  1. A. The nail beds.
  2. B. The skin in the sacral area.
  3. C. The skin in the abdominal area.
  4. D. The membranes in the ear canal.
Show answer and rationale

Correct answer: A — The nail beds.

Jaundice, if present, can be best assessed in areas such as the sclera, nail beds, and mucous membranes due to the yellowing of these tissues. The nail beds specifically provide a good indication of jaundice. The skin in the sacral area (Option B) is not typically the best area for assessing jaundice as it is less visible and not as reliable as the nail beds. The skin in the abdominal area (Option C) may show generalized jaundice, but the nail beds are more specific for detecting early signs. Lastly, assessing the membranes in the ear canal (Option D) is not a standard method for evaluating jaundice; the sclera and nail beds are more commonly used for this purpose.

Question 4

A nursing student caring for a 6-month-old infant is asked to collect a sample for urinalysis from the infant. How should the student collect the specimen?

  1. A. Catheterizing the infant using the smallest available Foley catheter
  2. B. Attaching a urinary collection device to the infant's perineum for collection
  3. C. Obtaining the specimen from the diaper by squeezing the diaper after the infant voids
  4. D. Noting the time of the next expected voiding and then preparing a specimen cup for the urine
Show answer and rationale

Correct answer: B — Attaching a urinary collection device to the infant's perineum for collection

The correct method for collecting a urine sample from an infant for urinalysis is by attaching a urinary collection device to the infant's perineum. This device is a plastic bag with an adhesive opening that allows it to be secured to the perineum to collect urine. Catheterizing the infant with a Foley catheter should not be done unless specifically prescribed due to the risk of infection. Obtaining the specimen from the diaper by squeezing it after the infant voids may not provide an accurate sample for urinalysis. Trying to predict the time of the next voiding to prepare a specimen cup is not practical or reliable in ensuring an appropriate sample for urinalysis.

Question 5

You are attempting to teach the wife of a Greek patient how to administer his gastrostomy tube feedings once he returns home. She smiles and nods through your explanations, but when you ask her for a return demonstration, she looks confused and shakes her head. Her daughter enters the room and states that she does not speak English. What would be most helpful in this situation?

  1. A. Teach the daughter instead
  2. B. Teach both and ask the daughter to translate for you
  3. C. Contact a home health agency to provide care
  4. D. Provide a pamphlet with detailed instructions
Show answer and rationale

Correct answer: B — Teach both and ask the daughter to translate for you

Teaching both the patient's wife and the daughter is the best option in this situation. The daughter may not always be available, and the wife is eager to care for her husband at home. While a hospital interpreter is often preferred, asking the daughter to interpret is a good alternative. This approach allows the daughter to receive instruction and reinforce it for herself as she translates it to her mother. Contacting a home health agency may not be necessary if family members are willing and able to assist. Providing a pamphlet with detailed instructions would not be as effective in ensuring the wife fully understands the procedure and can carry it out correctly.

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.

Ten more NCLEX-RN clinical judgment questions

Stems and choices stay public so you can still reason. Correct answers and full rationales unlock with the rest of the bank.

Question 6

Which playroom activities should the nurse organize for a small group of 7-year-old hospitalized children?

  1. A. Sports and games with rules.
  2. B. Finger paints and water play.
  3. C. "Dress-up"? clothes and props.
  4. D. Chess and television programs
Answer and rationale unlock in the Nursier study hub. Unlock answers

Question 7

Mr. V is receiving treatment for a spinal cord injury after falling off of his deck at home. He has undergone spinal surgery and has been placed in a halo traction device. Which of the following nursing interventions is most appropriate for a client with a spinal cord injury?

  1. A. Turn the client and use incentive spirometry each shift
  2. B. Administer stool softeners as ordered
  3. C. Turn the head slowly to avoid further damage to the spine
  4. D. Change NPO status
Answer and rationale unlock in the Nursier study hub. Unlock answers

Question 8

When printing out an EKG, a nurse notices that the QRS complexes are extremely small. What should be the next step?

  1. A. Alert the physician immediately as this is a sign of impending cardiac arrest.
  2. B. Check to see that all leads are attached and rerun the EKG.
  3. C. Increase the sensitivity control to 20 mm deflection.
  4. D. Decrease the run speed to 50.
Answer and rationale unlock in the Nursier study hub. Unlock answers

Question 9

A nurse admits a 3-week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would be most consistent with this diagnosis?

  1. A. Gestational age assessment suggested growth retardation
  2. B. Meconium was cleared from the airway at delivery
  3. C. Phototherapy was used to treat Rh incompatibility
  4. D. The infant received mechanical ventilation for 2 weeks
Answer and rationale unlock in the Nursier study hub. Unlock answers

Question 10

The client with multiple sclerosis is being educated by the nurse on exercises and physical activities. Which statement by the client indicates a need for further teaching?

  1. A. "I can lift weights and engage in resistance training."?
  2. B. "I should exercise until I am exhausted."?
  3. C. "I can incorporate aerobic exercises into my routine."?
  4. D. "I should perform proper stretching before starting my routine."?
Answer and rationale unlock in the Nursier study hub. Unlock answers

Question 11

What ethical principle has led to the need for informed consent?

  1. A. Autonomy
  2. B. Justice
  3. C. Fidelity
  4. D. Beneficence
Answer and rationale unlock in the Nursier study hub. Unlock answers

Question 12

What does an anti-kickback statute prevent?

  1. A. It prevents healthcare workers from providing food or hosting parties to celebrate special occasions at work.
  2. B. It promotes thorough and complete documentation when a client becomes injured.
  3. C. It forbids giving or accepting gifts to promote or provide referrals for certain services.
  4. D. It prevents physicians from ordering treatments that may require nursing care beyond the usual amount.
Answer and rationale unlock in the Nursier study hub. Unlock answers

Question 13

Which of the following is a disadvantage of using a dry heat application?

  1. A. Dry heat is more likely to cause burns than moist heat
  2. B. Dry heat does not penetrate deeply into the tissues
  3. C. Dry heat causes the skin to dry out more quickly
  4. D. Dry heat can quickly cause skin breakdown
Answer and rationale unlock in the Nursier study hub. Unlock answers

Question 14

A child has just been diagnosed with juvenile idiopathic arthritis. Which of the following statements about the disease is most accurate?

  1. A. The child has a poor chance of recovery without joint deformity.
  2. B. Most children progress to adult rheumatoid arthritis.
  3. C. Nonsteroidal anti-inflammatory drugs are the first choice in treatment.
  4. D. Physical activity should be minimized.
Answer and rationale unlock in the Nursier study hub. Unlock answers

Question 15

The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What are the priority nursing diagnoses at this time?

  1. A. Altered tissue perfusion
  2. B. Risk for fluid volume deficit
  3. C. High risk for hemorrhage
  4. D. Risk for infection
Answer and rationale unlock in the Nursier study hub. Unlock answers

About these NCLEX-RN clinical judgment questions

NCLEX-RN clinical judgment practice questions, set 31 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.