NCLEX-RN clinical judgment practice questions, set 37
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 37
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
The nurse is preparing to examine a 4-year-old child. Which action by the nurse is appropriate for this age group?
A. Explain the procedures briefly to alleviate the child's anxiety.
B. Give the child feedback and reassurance during the examination.
C. Ask the child to undress as needed for the examination.
D. Perform an examination of the head last.
Show answer and rationale
Correct answer: B — Give the child feedback and reassurance during the examination.
For a 4-year-old child, short and simple explanations should be provided to avoid overwhelming the child. It is important to give feedback and reassurance during the examination to create a comforting environment for the child. Asking the child to undress as needed is appropriate for a thorough examination, as children at this age are usually willing to do so. Performing an examination of the head last allows the child to become more comfortable during the assessment. Therefore, the most appropriate action for a 4-year-old child is to provide feedback and reassurance during the examination, ensuring a positive experience for the child.
Question 2
Which of the following statements best describes footdrop?
A. The foot is permanently fixed in the dorsiflexion position
B. The foot is permanently fixed in the plantar flexion position
C. The toes of the foot are permanently fanned
D. The heel of the foot is permanently rotated outward
Show answer and rationale
Correct answer: B — The foot is permanently fixed in the plantar flexion position
Footdrop results in the foot becoming permanently fixed in a plantar flexion position, not dorsiflexion. This position points the toes downward. The client may be unable to put weight on the foot, making ambulation difficult. Footdrop can be caused by immobility or chronic illnesses that cause muscle changes, such as multiple sclerosis or Parkinson's disease. Choice A is incorrect because footdrop leads to plantar flexion, not dorsiflexion. Choice C is incorrect as it describes a different condition known as 'toe fanning.' Choice D is incorrect as it describes an external rotation of the heel, which is not a characteristic of footdrop.
Question 3
A client is found unresponsive in his room by a nurse. The client is not breathing and does not have a pulse. After calling for help, what is the next action the nurse should take?
A. Administer 2 ventilations
B. Perform a head-tilt, chin lift to open the airway
C. Begin chest compressions
D. Perform a jaw thrust to open the airway
Show answer and rationale
Correct answer: C — Begin chest compressions
After finding an unresponsive client who is not breathing and has no pulse, the nurse's immediate action should be to call for help and start chest compressions. Chest compressions should be initiated at a rate of at least 100 per minute and a depth of at least 2 inches. Choice A, administering ventilations, is not the initial step as compressions take priority. Choice B, performing a head-tilt, chin lift, is also not the first step; chest compressions are crucial before airway management. Choice D, performing a jaw thrust, is typically used in cases of suspected cervical spine injury and is not the immediate action in this scenario.
Question 4
A student is late for an appointment and has rushed across campus to the health clinic. How should the nurse proceed?
A. Allow 5 minutes for the student to relax and rest before checking their vital signs.
B. Check the blood pressure in both arms, expecting a difference in the readings due to the recent exercise.
C. Immediately monitor the student's vital signs upon arrival at the clinic and then 5 minutes later, recording any differences.
D. Check the student's blood pressure in the supine position to provide a more accurate reading and allow the student to relax at the same time.
Show answer and rationale
Correct answer: A — Allow 5 minutes for the student to relax and rest before checking their vital signs.
To ensure an accurate blood pressure reading, it is important for the student to be in a relaxed state. Allowing at least a 5-minute rest period helps reduce anxiety and provides a valid blood pressure measurement. Checking the blood pressure in both arms is unnecessary unless there is a specific reason to suspect an issue, and recent exercise should not significantly impact the readings. Monitoring vital signs immediately upon arrival may not yield accurate results due to the rush and anxiety of the student. Checking blood pressure in the supine position is not necessary in this scenario and does not provide a more accurate reading.
Question 5
A patient is deciding whether they should take the live influenza vaccine (nasal spray) or the inactivated influenza vaccine (shot). The nurse reviews the client's history. Which condition would NOT contraindicate the nasal (live vaccine) route of administration?
A. The patient takes long-term corticosteroids
B. The patient is not feeling well today
C. The patient is 55 years old
D. The patient has young children
Show answer and rationale
Correct answer: D — The patient has young children
The correct answer is that the patient has young children. Having young children is not a contraindication for the live influenza vaccine unless the children are immunocompromised, which is not mentioned. Choice A, the patient taking long-term corticosteroids, is a contraindication for the live vaccine due to potential immunosuppression. Choice B, the patient not feeling well today, is a general precaution for vaccination and not a contraindication specific to the live influenza vaccine. Choice C, the patient being 55 years old, is not a contraindication for the live vaccine unless there are other specific medical conditions present.
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Question 6
Which of the following is an example of physical abuse?
A. A slap to the person's hand
B. Threatening the person
C. Ignoring and isolating a person
D. Leaving a patient soiled for hours
Correct answer:
The correct answer is 'A slap to the person's hand.' Slapping, hitting, and punching are clear examples of physical abuse. Physical abuse involves actions that can cause physical harm or injury to a person. Choice B, 'Threatening the person,' falls under the category of emotional or psychological abuse, where threats can cause fear and emotional distress but do not involve physical harm. Choice C, 'Ignoring and isolating a person,' is a form of neglect or emotional abuse, not physical abuse. Choice D, 'Leaving a patient soiled for hours,' is an example of neglect or lack of proper care, which is also not classified as physical abuse.
A child weighing 30 kg arrives at the clinic with diffuse itching as the result of an allergic reaction to an insect bite. Diphenhydramine (Benadryl) 25 mg 3 times a day is prescribed. The correct pediatric dose is 5 mg/kg/day. Which of the following best describes the prescribed drug dose?
A. It is the correct dose
B. The dose is too low
C. The dose is too high
D. The dose should be increased or decreased, depending on the symptoms
Correct answer:
The correct pediatric dose of diphenhydramine is 5 mg/kg/day. This child weighs 30 kg, so the calculated dose would be 5 mg/kg x 30 kg = 150 mg/day. Since the prescription is for 25 mg 3 times a day, the total daily dose is 25 mg x 3 = 75 mg/day, which is lower than the calculated dose of 150 mg/day. Therefore, the prescribed dose of 25 mg 3 times a day is too low for this child. The dose should be adjusted to meet the correct dosage of 150 mg/day, which would be 50 mg 3 times a day. It is important not to titrate the dosage based on symptoms without consulting a physician, as this can lead to inappropriate medication administration.
A child weighing 30 kg arrives at the clinic with diffuse itching as the result of an allergic reaction to an insect bite. Diphenhydramine (Benadryl) 25 mg 3 times a day is prescribed. The correct pediatric dose is 5 mg/kg/day. Which of the following best describes the prescribed drug dose?
A. It is the correct dose
B. The dose is too low
C. The dose is too high
D. The dose should be increased or decreased, depending on the symptoms
Correct answer:
The correct pediatric dose of diphenhydramine is 5 mg/kg/day. This child weighs 30 kg, so the calculated dose would be 5 mg/kg x 30 kg = 150 mg/day. Since the prescription is for 25 mg 3 times a day, the total daily dose is 25 mg x 3 = 75 mg/day, which is lower than the calculated dose of 150 mg/day. Therefore, the prescribed dose of 25 mg 3 times a day is too low for this child. The dose should be adjusted to meet the correct dosage of 150 mg/day, which would be 50 mg 3 times a day. It is important not to titrate the dosage based on symptoms without consulting a physician, as this can lead to inappropriate medication administration.
What is the BEST blood collection location for a newborn?
A. the AC
B. the veins of the forehead
C. the heel
D. the fingertips
Correct answer:
When collecting blood from newborns, it is safest and most commonly done by collecting blood from the lateral or medial aspect of the baby's heel. This location is preferred due to the accessibility of the veins and the minimal discomfort caused to the newborn. Veins in the forehead are not commonly used for blood collection in newborns. The fingertips are not optimal for blood collection in newborns due to their small size and the potential for causing discomfort. The AC (antecubital) area, typically used in adults for blood collection, is not recommended for newborns due to the size of their veins and the potential risk of injury.
A patient has been diagnosed with acute gastritis in a clinic. Which of the following medications would be contraindicated for this patient?
A. Naproxen sodium (Naprosyn)
B. Calcium carbonate
C. Clarithromycin (Biaxin)
D. Furosemide (Lasix)
Correct answer:
Naproxen sodium is a nonsteroidal anti-inflammatory drug that can cause inflammation of the upper GI tract. For this reason, it is contraindicated in a patient with gastritis. Gastritis involves inflammation of the stomach lining, and medications like Naproxen can exacerbate this condition. Calcium carbonate is an antacid that can help neutralize stomach acid and may actually provide relief for gastritis symptoms. Clarithromycin is an antibiotic used to treat H. pylori infection, a common cause of gastritis. Furosemide is a loop diuretic used to treat conditions like edema and hypertension, not directly contraindicated in gastritis.
A woman in her third trimester complains of severe heartburn. What is appropriate teaching by the nurse to help the woman alleviate these symptoms?
A. Drink small amounts of liquids frequently
B. Eat the evening meal at least 2-3 hours before bedtime
C. Take sodium bicarbonate after each meal
D. Sleep with head propped on several pillows
Correct answer:
During the third trimester, many women experience heartburn due to the pressure of the growing uterus on the stomach. Elevating the head while sleeping can help prevent gastric contents from refluxing back into the esophagus, thus reducing heartburn symptoms. Drinking small amounts of liquids frequently may exacerbate heartburn by increasing stomach distension. Eating the evening meal just before retiring can also worsen heartburn symptoms as lying down shortly after eating can promote reflux. Taking sodium bicarbonate after each meal is not recommended as it can disrupt the body's natural pH balance and lead to other complications.
Which of the following statements best describes substance P?
A. Substance P decreases a client's sensitivity to pain
B. Substance P levels are drawn before administration of narcotic analgesics
C. Substance P is found in the brain and is responsible for pain control and management of depression
D. Substance P is found in the dorsal horn of the spinal column
Correct answer:
Substance P is a neurotransmitter found in the brain and the dorsal horn of the spinal column, not just in the brain. It is associated with pain transmission and modulation. Substance P is known to cause inflammation, edema, and pain. While it plays a role in pain perception, it does not decrease a client's sensitivity to pain (Choice A), nor are its levels typically drawn before administering narcotic analgesics (Choice B). Although substance P is involved in pain control, it is not responsible for managing depression (Choice C). Therefore, the correct statement is that substance P is found in the dorsal horn of the spinal column.
Thrombolytic therapy is frequently used in the treatment of suspected stroke. Which of the following is a significant complication associated with thrombolytic therapy?
A. Air embolism.
B. Cerebral hemorrhage.
C. Expansion of the clot.
D. Resolution of the clot.
Correct answer:
Cerebral hemorrhage is a significant complication associated with thrombolytic therapy in stroke treatment. Thrombolytic therapy aims to dissolve clots, but it increases the risk of bleeding, including cerebral hemorrhage. This risk is especially high when the therapy is administered quickly after a stroke, sometimes before confirming the type of stroke. Air embolism (Choice A) is not a common complication of thrombolytic therapy. Expansion of the clot (Choice C) and resolution of the clot (Choice D) are not expected outcomes of thrombolytic therapy; the therapy is specifically used to dissolve clots, not to expand or resolve them.
A 24-year-old female contracts hepatitis from contaminated food. During the acute (icteric) phase of the patient's illness, what would serologic testing most likely reveal?
A. antibody to hepatitis D (anti-HDV).
B. hepatitis B surface antigen (HBsAg).
C. anti-hepatitis A virus immunoglobulin G (anti-HAV IgG).
D. anti-hepatitis A virus immunoglobulin M (anti-HAV IgM).
Correct answer:
Hepatitis A is primarily transmitted through the oral-fecal route. During the acute phase of hepatitis A, serologic testing typically reveals anti-hepatitis A virus immunoglobulin M (anti-HAV IgM). This antibody appears early in the course of the infection. The presence of anti-HAV IgM indicates an acute infection with hepatitis A. Choices A and B are incorrect as hepatitis D and hepatitis B antigens are not typically associated with acute hepatitis A. Choice C, anti-hepatitis A virus immunoglobulin G (anti-HAV IgG), would indicate a past infection and lifelong immunity, which is not expected during the acute phase of the illness.
When assessing the respiratory system of an older patient, which finding indicates that the nurse should take immediate action?
A. Weak cough effort
B. Barrel-shaped chest
C. Dry mucous membranes
D. Bilateral crackles at lung bases
Correct answer:
Bilateral crackles at lung bases indicate a potential acute issue like heart failure. Immediate action is necessary in this situation. The nurse should conduct further assessments such as oxygen saturation and inform the healthcare provider promptly. A barrel-shaped chest and hyperresonance to percussion are typical signs of aging and do not require immediate action. A weak cough effort is common in older patients due to age-related changes, and dry mucous membranes are also expected in older individuals. While these findings may warrant further evaluation, they do not demand immediate action like bilateral crackles at lung bases.
NCLEX-RN clinical judgment practice questions, set 37 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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