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NCLEX-RN clinical judgment practice questions, set 36

NCLEX-RN · clinical judgment

NCLEX-RN clinical judgment practice questions set 36

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 patient is admitted to the emergency department with an open stab wound to the left chest. What is the first action that the nurse should take?

  1. A. Position the patient so that the left chest is dependent
  2. B. Tape a nonporous dressing on three sides over the chest wound
  3. C. Cover the sucking chest wound firmly with an occlusive dressing
  4. D. Keep the head of the patient's bed at no more than 30 degrees elevation
Show answer and rationale

Correct answer: B — Tape a nonporous dressing on three sides over the chest wound

The correct initial action for a patient with an open stab wound to the chest is to tape a nonporous dressing on three sides over the chest wound. This dressing technique allows air to escape during expiration but prevents air from entering the pleural space during inspiration, helping to prevent tension pneumothorax. Placing the patient so that the left chest is dependent or covering the wound with an occlusive dressing can trap air in the pleural space, leading to tension pneumothorax. Keeping the head of the bed elevated at 30 to 45 degrees helps facilitate breathing and is not the first action to take when managing an open chest wound.

Question 2

A patient comes to the emergency department with abdominal pain. Work-up reveals the presence of a rapidly enlarging abdominal aortic aneurysm. Which of the following actions should the nurse expect?

  1. A. The patient will be admitted to the medicine unit for observation and medication.
  2. B. The patient will be admitted to the day surgery unit for sclerotherapy.
  3. C. The patient will be admitted to the surgical unit and resection will be scheduled.
  4. D. The patient will be discharged home to follow-up with his cardiologist in 24 hours.
Show answer and rationale

Correct answer: C — The patient will be admitted to the surgical unit and resection will be scheduled.

A rapidly enlarging abdominal aortic aneurysm is at significant risk of rupture, which can be life-threatening. The standard treatment for a rapidly enlarging abdominal aortic aneurysm is surgical intervention to prevent rupture. Therefore, the appropriate action for the nurse to expect is that the patient will be admitted to the surgical unit, and resection will be scheduled. Observation and medication (Choice A) are not sufficient for a rapidly enlarging aneurysm, and sclerotherapy (Choice B) is not typically used for aortic aneurysms. Discharging the patient home (Choice D) would be inappropriate and dangerous given the risk of rupture.

Question 3

What nursing action demonstrates the nurse understands the priority nursing diagnosis when caring for patients being treated with splints, casts, or traction?

  1. A. The nurse assesses extremity pulse, temperature, color, pain, and feeling every hour.
  2. B. The nurse orders meals with adequate protein and calcium for the patient.
  3. C. The nurse teaches the patient never to insert objects under a cast to scratch an itch.
  4. D. The nurse administers oral painkillers as ordered.
Show answer and rationale

Correct answer: A — The nurse assesses extremity pulse, temperature, color, pain, and feeling every hour.

The correct answer is to assess extremity pulse, temperature, color, pain, and feeling every hour. This action aligns with the priority nursing diagnosis of Risk for Peripheral Neurovascular Dysfunction related to fractures. Monitoring these factors is crucial to detect any signs of compromised circulation or nerve function promptly. Option B is incorrect as it does not directly address the priority nursing diagnosis. Option C is important but does not directly relate to the neurovascular aspect. Option D, administering painkillers, is necessary but does not specifically address the priority nursing diagnosis of neurovascular dysfunction.

Question 4

A patient is being treated in the Neurology Unit for Meningitis. Which of these is a priority assessment for the nurse to make?

  1. A. Assess the patient for nuchal rigidity
  2. B. Determine the patient's past exposure to infectious organisms
  3. C. Check the patient's WBC lab values
  4. D. Monitor for increased lethargy and drowsiness
Show answer and rationale

Correct answer: D — Monitor for increased lethargy and drowsiness

Monitoring for increased lethargy and drowsiness is crucial as these symptoms indicate a decreased level of consciousness, which is the cardinal sign of increased Intracranial Pressure (ICP). Elevated ICP can lead to serious complications and requires immediate intervention. Assessing for nuchal rigidity is important in suspected cases of meningitis but monitoring lethargy and drowsiness takes precedence due to its direct correlation with ICP. Determining past exposure to infectious organisms and checking WBC lab values are important for diagnosing and treating meningitis but do not directly address the immediate concern of increased ICP.

Question 5

A client diagnosed with schizophrenia is slow to respond and appears to be listening to unseen others. Which medication should a nurse expect a physician to order to address this type of symptom?

  1. A. Haloperidol (Haldol) to address the negative symptom
  2. B. Clonazepam (Klonopin) to address the positive symptom
  3. C. Risperidone (Risperdal) to address the positive symptom
  4. D. Clozapine (Clozaril) to address the negative symptom
Show answer and rationale

Correct answer: C — Risperidone (Risperdal) to address the positive symptom

The correct medication to address the symptom described, where the client is slow to respond and appears to be listening to unseen others, is Risperidone (Risperdal). Risperidone is an atypical antipsychotic that is commonly used to manage positive symptoms of schizophrenia. Positive symptoms can include hallucinations, delusions, and disorganized thinking. Haloperidol (Haldol) and Clozapine (Clozaril) are typically used for addressing negative symptoms, such as lack of motivation or social withdrawal. Clonazepam (Klonopin) is a benzodiazepine primarily used for anxiety disorders and seizures, not for addressing symptoms of schizophrenia.

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Ten more NCLEX-RN clinical judgment questions

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Question 6

What should the nurse in the emergency department do first for a new patient who is vomiting blood?

  1. A. Insert a large-gauge IV catheter.
  2. B. Draw blood for coagulation studies.
  3. C. Check blood pressure (BP), heart rate, and respirations.
  4. D. Place the patient in the supine position.
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Question 7

An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding?

  1. A. Yellow-tinged skin
  2. B. Orange-colored sputum
  3. C. Thickening of the fingernails
  4. D. Difficulty hearing high-pitched voices
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Question 8

Which of these is a correctly stated outcome goal written by the nurse?

  1. A. The client will walk 2 miles daily by March 19
  2. B. The client will understand how to give insulin by discharge
  3. C. The client will regain their former state of health by April 1
  4. D. The client achieve desired mobility by May 7
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Question 9

Patients have a right to ______________.

  1. A. only enough information so they can comply with care
  2. B. ALL of their health-related information
  3. C. small amounts of information so they do not get nervous
  4. D. moderate amounts of information unless they are old
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Question 10

The nurse is caring for clients in the pediatric unit. A 6-year-old patient is admitted with 2nd and 3rd degree burns on his arms. The nurse should assign the new patient to which of the following roommates?

  1. A. A 4-year-old with sickle-cell disease
  2. B. A 12-year-old with chickenpox
  3. C. A 6-year-old undergoing chemotherapy
  4. D. A 7-year-old with a high temperature
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Question 11

A child is admitted to the hospital with a diagnosis of Wilms tumor, stage II. Which of the following statements most accurately describes this stage?

  1. A. The tumor is less than 3 cm in size and requires no chemotherapy.
  2. B. The tumor did not extend beyond the kidney and was completely resected.
  3. C. The tumor extended beyond the kidney but was completely resected.
  4. D. The tumor has spread into the abdominal cavity and cannot be resected.
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Question 12

A child is admitted to the hospital with a diagnosis of Wilms tumor, stage II. Which of the following statements most accurately describes this stage?

  1. A. The tumor is less than 3 cm in size and requires no chemotherapy.
  2. B. The tumor did not extend beyond the kidney and was completely resected.
  3. C. The tumor extended beyond the kidney but was completely resected.
  4. D. The tumor has spread into the abdominal cavity and cannot be resected.
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Question 13

What does the term 'Afferent Nerve' mean?

  1. A. Carrying an impulse to the brain
  2. B. Carrying an impulse away from the brain
  3. C. Carrying impulses to the motor neurons of the appendicular muscles
  4. D. None of the above
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Question 14

In educating clients on ways to manage pain, which topic can be appropriately delegated to an LPN/LVN who will continue under supervision?

  1. A. Acupuncture
  2. B. Guided Imagery
  3. C. Alternating Rest/Activity
  4. D. Over-the-counter medications
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Question 15

What does an individual who believes in the magicoreligious theory of illness and disease think is the cause of illness?

  1. A. Germs and viruses
  2. B. Supernatural forces
  3. C. Eating imbalanced (hot/cold) foods
  4. D. Imbalance within his or her spiritual nature
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About these NCLEX-RN clinical judgment questions

NCLEX-RN clinical judgment practice questions, set 36 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.

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