NCLEX-RN clinical judgment practice questions, set 35
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 35
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
An adult's blood pressure reads 40/20. You place the patient in a Trendelenberg position before rechecking the blood pressure. What actions will you take to position the patient correctly?
A. lower the head of the bed and raise the foot of the bed
B. raise the head of the bed up to about 60 to 75 degrees
C. raise the head of the bed up to about 75 to 90 degrees
D. raise the siderails and place the bed in the high position
Show answer and rationale
Correct answer: A — lower the head of the bed and raise the foot of the bed
In a Trendelenberg position, used for low blood pressure, the correct action is to lower the head of the bed and raise the foot of the bed. This positioning facilitates the return of blood to the heart and helps increase blood pressure. Option B, raising the head of the bed to 60 to 75 degrees, is incorrect as it is not the Trendelenberg position. Option C, raising the head of the bed to 75 to 90 degrees, is incorrect as it does not align with the Trendelenberg position. Option D, raising the siderails and placing the bed in the high position, is incorrect as it does not address the specific positioning required for the Trendelenberg position.
Question 2
Which of the following is the most likely cause of constipation in a client?
A. Postponing bowel movement when the urge to defecate occurs
B. Intestinal infection
C. Antibiotic use
D. Food allergies
Show answer and rationale
Correct answer: A — Postponing bowel movement when the urge to defecate occurs
The correct answer is to postpone bowel movement when the urge to defecate occurs. Clients who delay bowel movements by ignoring the urge to defecate or not evacuating promptly, such as in situations where they are not near a bathroom, are at higher risk of developing constipation. This behavior leads to a decrease in bowel movement frequency, slowed intestinal motility, and increased fecal water absorption, resulting in hard, dry stools that are difficult to pass. Intestinal infection (choice B), antibiotic use (choice C), and food allergies (choice D) are less likely to be direct causes of constipation compared to postponing bowel movements.
Question 3
The instructor is teaching a class on basic assessment skills. Which of the following statements is true regarding the stethoscope and its use?
A. Slope of the earpieces should point forward toward the examiner's nose.
B. It blocks out extraneous room noise but does not magnify sound.
C. The tubing length should be 14 to 18 inches to prevent sound distortion.
D. Both fit and quality of the stethoscope are important.
Show answer and rationale
Correct answer: B — It blocks out extraneous room noise but does not magnify sound.
The stethoscope does not magnify sound but effectively blocks out extraneous room noises. The correct orientation of the earpieces is with the slope pointing forward toward the examiner's nose, not posteriorly. The tubing length of a stethoscope should ideally be between 14 to 18 inches (36 to 46 cm) to avoid sound distortion. Using tubing longer than this range can distort sound. Both the fit and quality of the stethoscope are crucial for accurate auscultation and assessment, highlighting their significance in clinical practice. Therefore, the correct answer is that the stethoscope blocks out extraneous room noise but does not magnify sound.
Question 4
A nurse is using active listening as a form of therapeutic communication when:
A. She uses humor to put the client at ease in a situation
B. She restates what the client said in slightly different words
C. She uses eye contact and maintains an open stance while the client is talking
D. She provides personal information to show the client she can relate to him
Show answer and rationale
Correct answer: C — She uses eye contact and maintains an open stance while the client is talking
Active listening is a form of therapeutic communication that involves the nurse encouraging a client to express their thoughts and feelings. Maintaining eye contact and an open stance while the client is talking demonstrates active listening and shows the client that they are being heard and understood. Using humor (Choice A) may not always be appropriate or therapeutic in all situations. Restating what the client said (Choice B) is a technique known as paraphrasing and is also a form of active listening. Providing personal information (Choice D) can shift the focus from the client to the nurse, which is not the intention of active listening.
Question 5
Which of the following clients is most appropriate for receiving telemetry?
A. A client with syncope potentially related to cardiac dysrhythmia
B. A client with unstable angina
C. A client with sinus rhythm and PVCs
D. A client who had a myocardial infarction 6 hours ago
Show answer and rationale
Correct answer: A — A client with syncope potentially related to cardiac dysrhythmia
Telemetry is used to monitor the cardiac rhythms of clients with potentially unstable conditions or those rhythms that affect activities. Clients with syncope potentially related to cardiac dysrhythmia require continuous monitoring to detect any potential life-threatening dysrhythmias. Unstable angina can be monitored in a telemetry unit, but syncope with potential cardiac causes takes precedence. Clients with sinus rhythm and PVCs may not necessitate telemetry unless there are further indications of instability. A client who had a myocardial infarction 6 hours ago is typically monitored in an intensive care unit rather than a telemetry unit.
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Question 6
A client is preparing to administer an enema to a 64-year-old client. Which of the following actions of the nurse is most appropriate?
A. Assist the client to lie in the semi-Fowler position
B. Apply lubricating jelly to the tip of the catheter before insertion
C. Instill a total of 30cc of fluid into the client's rectum
D. Ask the client to hold the solution in for 30 seconds
Correct answer:
When administering an enema to a client, the nurse should place the client in the Sims' position for easy access. The correct action is to apply lubricating jelly to the tip of the catheter before insertion to facilitate a smoother procedure. It is essential to instill a maximum of 750 to 1000 cc of fluid for an adult client, not just 30cc. Following administration, the nurse should ask the client to hold the solution for at least 5 minutes to allow for the desired effect of the enema. Therefore, choice B is the most appropriate action, as choices A, C, and D are incorrect due to inaccuracies in positioning, enema volume, and retention time.
The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs two (2) hours ago. The nurse should
A. Place a call to the client's healthcare provider for instructions
B. Send him to the emergency room for evaluation
C. Reassure the client's wife that the symptoms are transient
D. Instruct the client's wife to call the doctor if his symptoms become worse
Correct answer:
In this scenario, the client is presenting with concerning symptoms of lethargy and confusion after a fall. These symptoms could indicate a serious underlying issue, such as a head injury or internal bleeding. The nurse's priority is to ensure the client receives immediate evaluation and treatment to prevent any further harm. Option B is the correct choice as it emphasizes the urgency of the situation. Choices A, C, and D are incorrect because they do not address the critical nature of the client's condition. Contacting the healthcare provider, reassuring the wife, or waiting for symptoms to worsen could delay necessary medical intervention.
After a bronchoscopy, what is the most appropriate intervention for a patient with a chronic cough?
A. Elevate the head of the bed to 80 to 90 degrees.
B. Keep the patient NPO until the gag reflex returns.
C. Place the patient on bed rest for at least 4 hours after bronchoscopy.
D. Notify the health care provider about blood-tinged mucus.
Correct answer:
The correct intervention is to keep the patient NPO until the gag reflex returns after a bronchoscopy. This is important because a local anesthetic is used during the procedure to suppress the gag and cough reflexes. Monitoring the return of these reflexes helps prevent the risk of aspiration and ensures the patient can safely resume oral intake. While blood-tinged mucus can occur after bronchoscopy, it is a common occurrence and not a cause for immediate concern. Placing the patient on bed rest for an extended period is unnecessary, and elevating the head of the bed to a high-Fowler's position is not specifically required post-bronchoscopy.
While explaining an illness to a 10-year-old, what should the nurse keep in mind about the cognitive development at this age?
A. They are able to make simple associations of ideas
B. They are able to think logically in organizing facts
C. Interpretation of events originates from their own perspective
D. Conclusions are based on previous experiences
Correct answer:
At the age of 10, children are in the concrete operations stage according to Piaget. They are capable of mature thought when allowed to manipulate and organize objects. This means they can think logically, organize facts, and understand cause-and-effect relationships. Choices A, C, and D are incorrect. While simple associations of ideas may occur, the key cognitive ability at this stage is the capacity for logical thought and organization of information. Interpretation of events from their own perspective is more characteristic of younger children, and conclusions based on previous experiences are more aligned with older children or adults.
Choose the BEST answer. To ensure adequate protection for legal issues, offices should maintain patients' charts for:
A. 10 years
B. Forever
C. Until the age of majority
D. 2 years after the patient was last seen in the office
Correct answer:
The correct answer is 'Forever.' Maintaining patients' charts indefinitely ensures comprehensive legal protection by having all relevant information available in case of litigation or if patient history needs to be referenced in the future. Choice A, '10 years,' may not be sufficient to cover the entire period within which legal issues may arise. Choice C, 'Until the age of majority,' is not ideal as legal matters may extend beyond this age limit. Choice D, '2 years after the patient was last seen in the office,' is inadequate as legal actions can occur beyond this timeframe, necessitating the need for long-term retention of patient charts.
For the nursing diagnostic statement, Self-care deficit: feeding related to bilateral fractured wrists in casts, what is the major related factor or risk factor identified by the nurse?
A. Discomfort
B. Deficit
C. Feeding
D. Fractured wrists
Correct answer:
The correct answer is 'Fractured wrists.' In a nursing diagnostic statement, the related factor or risk factor is the underlying cause of the identified problem. In this case, the major factor affecting the self-care deficit in feeding is the bilateral fractured wrists in casts. The fractured wrists directly impact the client's ability to feed themselves, making it the primary related factor. Choices A, B, and C are incorrect as discomfort, deficit, and feeding are not the primary cause of the feeding problem in this scenario; rather, it is the physical limitation caused by the fractured wrists that is the focus of the nursing intervention.
A patient is diagnosed with essential hypertension. Which of the following blood pressures would you expect to see in this patient prior to taking medications for the condition?
A. 142/92
B. 118/72
C. 120/80
D. 138/88
Correct answer:
Before starting medications for essential hypertension, a patient would typically present with a blood pressure reading equal to or greater than 140/90. This indicates high blood pressure and is characteristic of essential hypertension. Choice A, 142/92, falls within this range, making it the correct answer. Choices B (118/72), C (120/80), and D (138/88) all have blood pressure readings that are within the normal range and would not typically be expected in a patient diagnosed with essential hypertension. Therefore, choices B, C, and D are incorrect as they do not align with the elevated blood pressure levels seen in essential hypertension.
The mother of a child with hepatitis A tells the home care nurse that she is concerned because the child's jaundice seems worse. What is the nurse's best response?
A. You need to change the child's diet.
B. The child probably is infectious again.
C. The jaundice may worsen before it resolves.
D. You need to call the primary health care provider.
Correct answer:
The best response for the nurse in this situation is to explain to the mother that jaundice may seem to worsen before it eventually gets better. This is a common occurrence in hepatitis A. Option A about changing the child's diet is irrelevant to the concern raised by the mother and not supported by evidence. Option B suggesting the child is infectious again is incorrect and may cause unnecessary alarm as jaundice does not indicate reinfection. Option D, advising the mother to call the primary health care provider, is premature as the nurse can first provide education and reassurance regarding the expected course of jaundice in hepatitis A.
The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea over the last 3 days. Which finding is most important for the nurse to report to the healthcare provider?
A. Respirations are 36 breaths/minute.
B. Anterior-posterior chest ratio is 1:1.
C. Lung expansion is decreased bilaterally.
D. Hyperresonance to percussion is present.
Correct answer:
The correct answer is 'Respirations are 36 breaths/minute.' An increased respiratory rate is a crucial sign of respiratory distress in patients with COPD, necessitating immediate interventions like oxygen therapy or medications. The other options are common chronic changes seen in COPD patients. Option B, the 'Anterior-posterior chest ratio is 1:1,' is related to the barrel chest commonly seen in COPD due to hyperinflation. Option C, 'Lung expansion is decreased bilaterally,' is expected in COPD due to air trapping. Option D, 'Hyperresonance to percussion is present,' is typical in COPD patients with increased lung volume and air trapping.
A client is in need of hemodialysis for end-stage renal failure. The physician has inserted an AV fistula. Which of the following nursing interventions is appropriate when caring for this access site?
A. Assess for clotting in fistula tubing
B. Apply a dressing over the fistula site
C. Assess for a bruit or thrill at the site of the fistula
D. Assess circulation proximal to the fistula site
Correct answer:
When caring for an AV fistula used for hemodialysis, it is important to assess for a bruit (a humming sound) or thrill (a vibrating sensation) at the site of the fistula. These indicate proper blood flow through the fistula, ensuring it is patent and suitable for hemodialysis. Assessing for clotting in fistula tubing (Choice A) is not a routine nursing intervention for AV fistulas. Applying a dressing over the fistula site (Choice B) is not necessary as the site needs to be accessible for hemodialysis. Assessing circulation proximal to the fistula site (Choice D) is important but not specific to caring for the access site of an AV fistula.
NCLEX-RN clinical judgment practice questions, set 35 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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