NCLEX-RN clinical judgment practice questions, set 38
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 38
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 has been taking mood stabilizing medication but is afraid of needles. They ask the nurse what medication would NOT require regular lab testing. What is the nurse's best response?
A. Valproic Acid (Depakote)
B. Clozapine (Clozaril)
C. Lithium
D. Risperidone (Risperdal)
Show answer and rationale
Correct answer: D — Risperidone (Risperdal)
The correct answer is Risperidone (Risperdal) because it is the only medication among the options that does not require regular lab testing. Risperidone is not associated with the need for routine blood draws to monitor medication levels or potential side effects. Choices A, B, and C (Valproic Acid, Clozapine, Lithium) are all known to require frequent lab monitoring due to various reasons such as potential toxicity, therapeutic drug levels, or adverse effects on certain organ functions. Therefore, considering the patient's fear of needles and the desire to avoid frequent blood tests, Risperidone would be the most suitable option.
Question 2
The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed?
A. A large air leak in the water-seal chamber
B. 400 mL of blood in the collection chamber
C. Complaint of pain with each deep inspiration
D. Subcutaneous emphysema at the insertion site
Show answer and rationale
Correct answer: B — 400 mL of blood in the collection chamber
The nurse should be most concerned if 400 mL of blood is observed in the collection chamber as it may indicate the patient is at risk of developing hypovolemic shock. A large air leak in the water-seal chamber is expected initially after chest tube placement for a pneumothorax. While pain with deep inspiration should be treated, it is not as urgent as the risk of continued hemorrhage. Subcutaneous emphysema is not uncommon in a patient with pneumothorax and is usually harmless. However, a large amount of blood in the collection chamber is a more critical finding that requires immediate attention to prevent potential complications.
Question 3
Why should direct care providers avoid glued-on artificial nails?
A. Interfere with dexterity of the fingers.
B. Could fall off in a patient's bed.
C. Harbor microorganisms.
D. Can scratch a patient.
Show answer and rationale
Correct answer: C — Harbor microorganisms.
Direct care providers, including nurses, should avoid glued-on artificial nails because studies have shown that artificial nails, especially when cracked, broken, or split, create crevices where microorganisms can thrive and multiply. This can lead to an increased risk of transmitting infections to patients. Therefore, the primary reason for avoiding glued-on artificial nails is their potential to harbor harmful microorganisms, making option C the correct choice. Options A, B, and D are incorrect because while they may present some issues, the primary concern is the risk of microbial contamination associated with artificial nails.
Question 4
A newly admitted patient with major depression has lost 20 pounds over the past month and has suicidal ideation. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis.
A. Imbalanced nutrition: Less than body requirements
B. Chronic low self-esteem
C. Risk for suicide
D. Hopelessness
Show answer and rationale
Correct answer: B — Chronic low self-esteem
The priority nursing diagnosis in this scenario is 'Risk for suicide.' When a patient presents with major depression, significant weight loss, suicidal ideation, and lack of symptom improvement despite medication, the immediate concern is to address the risk of suicide. 'Risk for suicide' takes precedence as it involves a direct threat to the patient's life. 'Imbalanced nutrition: Less than body requirements' may be a concern but does not take priority over the risk of suicide. 'Chronic low self-esteem' and 'Hopelessness' are relevant issues in depression but are not as urgent as addressing the immediate risk of suicidal behavior.
Question 5
The nurse is caring for a patient in the ICU who has had a spinal cord injury. She observes that his last blood pressure was 100/55, and his pulse is 48. These have both trended downwards from the baseline. What should the nurse expect to be the next course of action ordered by the physician?
A. Assess the patient for decreased level of consciousness
B. Administer Normal Saline
C. Insert an NG Tube
D. Connect and read an EKG
Show answer and rationale
Correct answer: B — Administer Normal Saline
The patient is entering neurogenic shock due to the spinal cord injury, leading to hypotension and bradycardia. Administering Normal Saline is essential to replace fluid volume, which can help in treating the hypotension and bradycardia symptomatically. This intervention aims to stabilize the patient's cardiovascular status. Assessing for decreased level of consciousness (Choice A) may be important but addressing the hemodynamic instability takes precedence. Inserting an NG Tube (Choice C) and connecting and reading an EKG (Choice D) are not the immediate actions required for the presenting symptoms of hypotension and bradycardia.
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Question 6
The BRAT diet is often prescribed for patients with gastroenteritis. This acronym stands for:
A. Bananas, Rice, Applesauce, and Toast
B. Bread, Rice, Apricots, and Tapioca
C. Bananas, Rolls, Apricots, and Toast
D. Bananas, Rolls, Applesauce, and Tapioca
Correct answer:
The BRAT diet, which stands for Bananas, Rice, Applesauce, and Toast, is commonly recommended for patients with gastroenteritis. These easily digestible foods help firm up stools due to their low fiber content and provide essential nutrients lost during vomiting and diarrhea. Choice B is incorrect because it includes apricots, which are not part of the traditional BRAT diet. Choice C is incorrect as it includes rolls, which are not typically included in the BRAT diet. Choice D is incorrect as it includes tapioca, which is not part of the traditional BRAT diet. Therefore, the correct answer is Bananas, Rice, Applesauce, and Toast.
Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?
A. Listen to a patient's lung sounds for wheezes or rhonchi.
B. Label specimens obtained during percutaneous lung biopsy.
C. Instruct a patient about how to use home spirometry testing.
D. Measure induration at the site of a patient's intradermal skin test.
Correct answer:
Labeling specimens obtained during a percutaneous lung biopsy is a task that can be appropriately delegated to unlicensed assistive personnel (UAP) as it does not require nursing judgment. UAP can perform this task safely under the supervision of a nurse. Listening to a patient's lung sounds for wheezes or rhonchi, instructing a patient about how to use home spirometry testing, and measuring induration at the site of a patient's intradermal skin test all require nursing judgment and interpretation of findings. These tasks should be performed by licensed nursing personnel to ensure accurate assessment and appropriate intervention.
Which of the following is an example of a living will?
A. A client's son has been appointed to make his healthcare decisions if he becomes incapacitated
B. A client has designated which of his children will receive his home and property before he dies
C. A client has instructions that he does not want to be resuscitated through chest compressions if his heart stops beating
D. A client designates what type of burial or cremation services he would want after his death
Correct answer:
A living will is a type of advanced directive that a client develops to stipulate his preferences for healthcare in the event that he is unable to do so. This includes specific instructions about medical treatments in certain situations. Choice C is the correct answer as it reflects a scenario where the client has clearly outlined their preference regarding resuscitation through chest compressions. Choices A, B, and D do not pertain to a living will. Choice A involves a healthcare proxy or agent, choice B involves a will or estate planning, and choice D involves funeral or burial arrangements, which are not part of a living will.
You have accompanied the physician into the family waiting room to tell a young husband that his wife has not survived the car accident she was in. The husband is crying and distraught. What is the most appropriate approach to supporting this family member?
A. Ask if he would like to donate his wife's organs
B. Sit quietly with him
C. Ask about funeral arrangements
D. Consult social services
Correct answer:
The most caring and supportive approach in a time of extreme distress is usually to sit quietly with the distressed individual until they have had the opportunity to absorb the news and gather themselves. Providing a supportive presence is often the most valuable tool a caregiver can use when circumstances bring overwhelming emotional pain to those they are caring for. Asking about organ donation at this moment may come off as insensitive and should not be a priority. Inquiring about funeral arrangements and consulting social services can be addressed later, once the husband has had time to process the initial shock and emotions.
A patient with pneumonia has a fever of 101.4 F (38.6 C), a nonproductive cough, and an oxygen saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the highest priority?
A. Hyperthermia related to infectious illness
B. Impaired transfer ability related to weakness
C. Ineffective airway clearance related to thick secretions
D. Impaired gas exchange related to respiratory congestion
Correct answer:
The correct answer is 'Impaired gas exchange related to respiratory congestion.' While all the nursing diagnoses are relevant to the patient's condition, the priority should be given to impaired gas exchange due to the patient's low oxygen saturation level of 88%. This indicates a significant risk of hypoxia for all body tissues unless the gas exchange is improved. Addressing impaired gas exchange is crucial to ensure adequate oxygenation and prevent further complications. Hyperthermia, impaired transfer ability, and ineffective airway clearance are important concerns but addressing gas exchange takes precedence in this scenario.
Mr. K is admitted to the orthopedic unit one morning in preparation for a total knee replacement to start in two hours. Which of the following is a priority topic to instruct this client on admission?
A. The approximate length of the surgery
B. The type of anticoagulants that will be prescribed
C. The time of the next meal of solid food
D. The length of time until the client can return to work
Correct answer:
The priority topic to instruct a client admitted for a total knee replacement surgery should be the approximate length of the surgery. Pre-surgical teaching should focus on preparing the client for the upcoming procedure. Providing information about the duration of the surgery can help manage the client's expectations, reduce anxiety, and ensure they are mentally prepared for the operation. While details about post-operative care, anticoagulants, meals, and return to work are important, they are not the immediate priority during the preoperative phase. These aspects can be addressed at a later stage in the client's care journey.
A client was recently diagnosed with diverticulosis. What types of foods should the nurse recommend for this client?
A. Whole grain cereal
B. Eggs
C. Cottage cheese
D. Fish
Correct answer:
Diverticulosis is a condition characterized by small protrusions in the intestinal tract. To manage diverticulosis, a high-fiber diet is recommended. Foods rich in fiber help prevent constipation and reduce the risk of inflammation in the intestines. Whole grain cereals are an excellent source of fiber and can aid in maintaining bowel regularity. Eggs, cottage cheese, and fish are not high-fiber foods and may not provide the necessary dietary support for a client with diverticulosis. While protein-rich foods like eggs and fish are beneficial for overall health, they are not the primary recommendation for managing diverticulosis.
You are creating a teaching plan for a patient with newly diagnosed migraine headaches. Which key item should NOT be included in the teaching plan?
A. Avoid foods that contain tyramine, such as alcohol and aged cheese.
B. Avoid drugs such as Tagamet, nitroglycerin, and Nifedipine.
C. Continue taking estrogen as prescribed by your physician.
D. A potential side effect of medications is rebound headache.
Correct answer:
The correct answer is C: Continue taking estrogen as prescribed by your physician. Medications such as estrogen supplements may actually trigger a migraine headache attack. Fluctuations in estrogen, such as before or during menstrual periods, pregnancy, and menopause, seem to trigger headaches in many women. Choices A and B are important to include in the teaching plan for a patient with migraines as avoiding foods containing tyramine and certain drugs can help prevent migraine triggers. Choice D is also relevant as it is essential for the patient to be aware of potential side effects of medications, including rebound headaches.
When teaching a Vietnamese patient who has been treated for pneumonia and needs to complete her antibiotic regimen at home, what is an important cultural component to consider?
A. Cupping will help to pull toxins from the body
B. Coining will help to release the wind or bad energy from the body
C. Once symptoms disappear there is no longer an illness
D. Most households consist of at least 3 generations
Correct answer:
The correct answer is 'Once symptoms disappear there is no longer an illness'. In Vietnamese culture, there is a belief that once symptoms go away, the illness is no longer present and does not require further treatment. This is crucial to understand when educating Vietnamese patients about completing their antibiotic regimen. Choices A and B (cupping and coining) are traditional Vietnamese healing practices that are not directly related to completing antibiotic therapy. Choice D, about households consisting of multiple generations, is not directly relevant to the completion of antibiotic treatment for pneumonia in this context.
A patient with Addison's disease asks a nurse for nutrition and diet advice. Which of the following diet modifications is not recommended?
A. A diet high in grains
B. A diet with adequate caloric intake
C. A high protein diet
D. A restricted sodium diet
Correct answer:
For a patient with Addison's disease, a restricted sodium diet is not recommended. These patients require normal dietary sodium to prevent excess fluid loss. Patients with primary adrenal insufficiency (Addison disease) should have ample access to salt because of the salt wasting that occurs if their condition is untreated. Therefore, a diet high in grains, a diet with adequate caloric intake, and a high protein diet are all recommended for patients with Addison's disease to support their nutritional needs and overall health. However, restricting sodium can be detrimental for these patients due to the nature of their condition.
NCLEX-RN clinical judgment practice questions, set 38 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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