NCLEX-RN clinical judgment practice questions, set 34
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 34
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
Which of the following types of antipsychotic medications is most likely to produce extrapyramidal effects?
A. Atypical antipsychotic drugs
B. First-generation antipsychotic drugs
C. Third-generation antipsychotic drugs
D. Dopamine system stabilizers
Show answer and rationale
Correct answer: B — First-generation antipsychotic drugs
The correct answer is first-generation antipsychotic drugs. These drugs are potent antagonists of D2, D3, and D4 receptors, making them effective in treating target symptoms but also leading to numerous extrapyramidal side effects due to the blockade of D2 receptors. Atypical or second-generation antipsychotic drugs, as mentioned in choice A, are relatively weak D2 blockers, which results in a lower incidence of extrapyramidal side effects. Third-generation antipsychotic drugs, as in choice C, and dopamine system stabilizers, as in choice D, are not typically associated with significant extrapyramidal effects compared to first-generation antipsychotics.
Question 2
A 55-year-old patient admitted with an abrupt onset of jaundice and nausea has abnormal liver function studies, but serologic testing is negative for viral causes of hepatitis. Which question by the nurse is most appropriate?
A. Is there any history of IV drug use?
B. Do you use any over-the-counter drugs?
C. Are you taking corticosteroids for any reason?
D. Have you recently traveled to a foreign country?
Show answer and rationale
Correct answer: B — Do you use any over-the-counter drugs?
The most appropriate question for the nurse to ask in this scenario is whether the patient uses any over-the-counter drugs. The patient's symptoms, negative serologic testing for viral hepatitis, and sudden onset of symptoms point towards toxic hepatitis, which can be triggered by commonly used over-the-counter medications like acetaminophen (Tylenol). Asking about IV drug use is relevant for viral hepatitis, not toxic hepatitis. Inquiring about recent travel to a foreign country is more pertinent to potential exposure to infectious agents causing viral hepatitis. Corticosteroid use is not typically associated with the symptoms described in the case.
Question 3
In which of the following examples would informed consent not be required?
A. A patient is apprehensive about an upcoming surgery and chooses not to learn of the risks involved with the procedure.
B. A child is rushed to the Emergency Room after falling from a third-story window.
C. An adult in a coma in a mental health institution with no listed next of kin.
D. Informed consent is not required in any of the above examples.
Show answer and rationale
Correct answer: D — Informed consent is not required in any of the above examples.
In emergency situations where immediate treatment is necessary to prevent further harm or save a life, such as in option B where a child is rushed to the Emergency Room after a fall, informed consent may be waived to provide prompt care. In option A, though the patient is apprehensive about surgery and chooses not to learn the risks, informed consent is not required as it is the patient's right to refuse information. In option C, when an adult is in a coma with no next of kin listed, decisions may be made in the patient's best interest following legal and ethical guidelines. Therefore, informed consent is not needed in any of the scenarios presented.
Question 4
A patient is being admitted to the ICU with a severe case of encephalitis. Which of these drugs would the nurse not expect to be prescribed for this condition?
A. Acyclovir (Zovirax)
B. Mannitol (Osmitrol)
C. Lactated Ringer's
D. Phenytoin (Dilantin)
Show answer and rationale
Correct answer: C — Lactated Ringer's
In the treatment of encephalitis, medications like Acyclovir and Phenytoin are commonly prescribed. Acyclovir is an antiviral medication used to treat viral infections like herpes simplex virus, which can cause encephalitis. Phenytoin is an antiepileptic drug that may be used to manage seizures associated with encephalitis. Mannitol is a diuretic used to reduce intracranial pressure (ICP) by decreasing cerebral edema. Lactated Ringer's solution, on the other hand, is primarily used in fluid replacement therapy and may not be indicated if a patient is at risk for high ICP, as excessive fluid administration could worsen cerebral edema and increase ICP.
Question 5
Which of the following descriptors is most appropriate to use when stating the 'problem' part of a nursing diagnosis?
A. Grimacing
B. Anxiety
C. Oxygenation saturation 93%
D. Output 500 mL in 8 hours
Show answer and rationale
Correct answer: B — Anxiety
The problem part of a nursing diagnosis in the context of nursing care plans should focus on the client's response to a life process, event, or stressor. This response is what is used to identify the nursing diagnosis. 'Anxiety' is the most appropriate descriptor for the problem part of a nursing diagnosis as it reflects a psychological response that can be addressed by nursing interventions. 'Grimacing' is a physical manifestation and not the problem itself. 'Oxygenation saturation 93%' and 'Output 500 mL in 8 hours' are data points or cues that a nurse would use to formulate the nursing diagnostic statement, not the actual problem being addressed.
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Question 6
A new staff nurse completes orientation to the psychiatric unit. This nurse will expect to ask an advanced practice nurse to perform which action for patients?
A. Perform mental health assessment interviews
B. Establish therapeutic relationships
C. Prescribe psychotropic medications
D. Individualize nursing care plans
Correct answer:
Prescriptive privileges are granted to Master's-prepared nurse practitioners who have taken special courses on prescribing medications. The nurse prepared at the basic level performs mental health assessments, establishes relationships, and provides individualized care planning. In this scenario, the new staff nurse would ask the advanced practice nurse to prescribe psychotropic medications, as this is within their scope of practice and expertise. Establishing therapeutic relationships, performing mental health assessments, and individualizing care plans are typically responsibilities of staff nurses at the basic level, not advanced practice nurses.
A client is having difficulties reading an educational pamphlet. He cannot find his glasses. In order to read the words, he must hold the pamphlet at arm's length, which allows him to read the information. Which vision deficit does this client most likely suffer from?
A. Cataracts
B. Glaucoma
C. Astigmatism
D. Presbyopia
Correct answer:
Presbyopia is a condition that occurs when the lens of the eye loses accommodation and is unable to focus light on objects nearby. As a result, clients are unable to see or read items up close but may have success when holding the same item at arm's length. Many clients with presbyopia must wear bifocals, but long-distance vision remains unaffected. Cataracts involve clouding of the eye's lens, leading to blurry vision. Glaucoma is associated with increased intraocular pressure that damages the optic nerve, causing vision loss. Astigmatism is a refractive error where the cornea or lens has an irregular shape, leading to distorted or blurred vision.
The UAP who has just been accepted to nursing school says to a client, 'You must be so pleased with your progress.' The nurse later explains to the UAP that this is an example of what type of question?
A. Close-ended question
B. Open-ended question
C. Leading question
D. Neutral question
Correct answer:
The statement 'You must be so pleased with your progress' is an example of a leading question. Leading questions guide the respondent towards a particular answer or response, potentially biasing the data collected. In this scenario, the UAP's question implies that the client should be pleased with their progress, steering the client's response. Closed-ended questions typically elicit brief factual responses or a 'yes' or 'no.' Open-ended questions encourage clients to provide detailed responses and share their thoughts and feelings freely. Neutral questions do not lead or influence the client's response, allowing for unbiased information gathering.
Cheryl M. has a serious swallowing disorder. She has asked you for a glass of water. The doctor has ordered honey thickness liquids for her. Water is not a honey thickness liquid. It is much thinner. What should you do?
A. Tell the resident that she cannot have water.
B. Give her applesauce instead of the water.
C. Tell Cheryl that she is NPO until midnight.
D. Thicken the water and give it to her.
Correct answer:
You can give Cheryl the water that she has requested; however, since water is not a honey-thick liquid as ordered by the doctor, you must thicken it with a commercial thickener before giving it to her. This will ensure that the water is at the appropriate consistency for her swallowing disorder. Choices A, B, and C are incorrect: A) Telling the resident she cannot have water is not the best course of action without attempting to modify it first. B) Giving her applesauce instead of water does not address the specific request for water. C) Placing Cheryl on NPO status until midnight is unnecessary and does not address her immediate request for water.
The nurse is writing out discharge instructions for the parents of a child diagnosed with celiac disease. The nurse should focus primarily on which aspect of care?
A. Restricting activity
B. Following a gluten-free diet
C. Following a lactose-free diet
D. Giving medication to manage the condition
Correct answer:
The primary nursing consideration in the care of a child with celiac disease is to instruct the child and parents about proper dietary management. The cornerstone of managing celiac disease is maintaining a strict gluten-free diet to prevent symptoms and long-term complications. While medications may be part of the treatment plan, dietary adjustments, particularly following a gluten-free diet, are crucial for managing the condition effectively. Restricting activity is not the primary focus of care for celiac disease. A lactose-free diet is not typically necessary unless the child also has lactose intolerance, which is distinct from celiac disease.
What question must the nurse ask when formulating a nursing diagnosis?
A. What diagnosis did the physician make for this client?
B. What is the issue that I can solve for this client?
C. What physician orders will resolve this issue?
D. What underlying disease does this client have?
Correct answer:
When formulating a nursing diagnosis, the nurse should focus on identifying the client's specific health problems that can be addressed through nursing interventions. The correct answer emphasizes the nurse's role in identifying and addressing client-specific issues through nursing care. Choice A is incorrect because nursing diagnoses are distinct from medical diagnoses made by physicians. Choice C is incorrect as it focuses on physician orders rather than the nurse's role in diagnosing and addressing client problems. Choice D is incorrect because it pertains to identifying underlying diseases, which is not the primary focus of nursing diagnoses.
A 1-year-old child is diagnosed with intussusception, and the mother of the child asks the student nurse to describe the disorder. Which statement by the student nurse indicates correct understanding of this disorder?
A. It is an acute bowel obstruction.
B. It is a condition that causes an acute inflammatory process in the bowel.
C. It is a condition in which a distal segment of the bowel prolapses into a proximal segment of the bowel.
D. It is a condition in which a proximal segment of the bowel prolapses into a distal segment of the bowel.
Correct answer:
Intussusception is a condition in which a proximal segment of the bowel telescopes or prolapses into a distal segment of the bowel. This leads to bowel obstruction and potential ischemia. It is not an acute bowel obstruction, as the obstruction is caused by the telescoping of bowel segments rather than a blockage in the bowel lumen. Intussusception is not primarily an inflammatory process; instead, it is a mechanical issue involving bowel invagination. Choice A is incorrect as it does not accurately describe the pathophysiology of intussusception. Choice C is incorrect because it presents the opposite scenario of what happens in intussusception.
The nurse reviews the record of a newborn infant and notes that a diagnosis of esophageal atresia with tracheoesophageal fistula is suspected. The nurse expects to note which most likely sign of this condition documented in the record?
A. Incessant crying
B. Coughing at nighttime
C. Choking with feedings
D. Severe projectile vomiting
Correct answer:
In esophageal atresia and tracheoesophageal fistula, the esophagus ends before it reaches the stomach, forming a blind pouch, and there is an abnormal connection (fistula) with the trachea. Any child who exhibits the '3 Cs'"?coughing and choking with feedings and unexplained cyanosis"?should be suspected to have tracheoesophageal fistula. Option A, 'Incessant crying,' is not a typical sign of esophageal atresia with tracheoesophageal fistula. Option B, 'Coughing at nighttime,' is not a specific sign associated with this condition. Option D, 'Severe projectile vomiting,' is not a common sign of esophageal atresia with tracheoesophageal fistula.
The infection control nurse is assigned to a patient with osteomyelitis related to a heel ulcer. The wound is 5cm in diameter and the drainage saturates the dressing so that it must be changed every hour. What is her priority intervention?
A. Place the patient under contact precautions
B. Use strict aseptic technique when caring for the wound
C. Place another dressing to reinforce the first one
D. Elevate the patient's leg to prevent more drainage
Correct answer:
The priority intervention for a patient with osteomyelitis related to a heel ulcer, with a wound that saturates the dressing every hour, is to place the patient under contact precautions. Contact precautions are essential when managing infectious wounds to prevent the spread of infection to healthcare workers, other patients, and visitors. Strict aseptic technique (Choice B) should always be used with wound care but is secondary to implementing contact precautions in this scenario. Placing another dressing (Choice C) or elevating the patient's leg (Choice D) may be necessary but do not address the immediate need for infection control measures.
Which of the following is a local sign of infection?
A. Swelling
B. Rapid pulse
C. Fever
D. High white blood count
Correct answer:
A local sign of infection refers to symptoms that are specific to the area of infection. Swelling, heat, pain, and redness near the infected site are examples of local signs. In the context of infection, swelling occurs due to an accumulation of fluid and immune cells at the site of infection. Rapid pulse, fever, and high white blood count are more systemic responses to infection and not specific local signs. Rapid pulse can indicate systemic distress or sepsis, fever is a systemic response to infection, and high white blood count is a laboratory finding that suggests an immune response but is not a direct sign of infection at a specific site.
NCLEX-RN clinical judgment practice questions, set 34 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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