NCLEX-RN clinical judgment practice questions, set 39
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 39
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
What does the 'B' in the SBAR acronym stand for?
A. Background
B. Basic
C. Beginning
D. Break
Show answer and rationale
Correct answer: A — Background
The 'B' in the SBAR acronym stands for Background. SBAR is a standardized communication tool used in healthcare to effectively communicate critical information. In this context, 'Background' refers to providing relevant information about the patient's history, current status, and any other pertinent details. This information helps ensure clear and concise communication between healthcare providers, enhancing patient care. Choice B, 'Basic,' is incorrect as the 'B' specifically emphasizes the detailed background information. Choices C and D, 'Beginning' and 'Break,' are not accurate in the context of the SBAR communication tool.
Question 2
The Sims' position is MOST similar to the ________ position.
A. prone
B. lateral
C. supine
D. Fowler's
Show answer and rationale
Correct answer: B — lateral
The correct answer is 'lateral.' The Sims' position is characterized by the patient lying on their side with the upper knee flexed and the upper arm positioned in front of the body. This is similar to the lateral position where the patient is also lying on their side. The prone position (choice A) is when the patient lies face down, the supine position (choice C) is when the patient lies face up, and Fowler's position (choice D) is a seated position with the head of the bed elevated at a 45-90 degree angle. Therefore, the lateral position is the most similar to the Sims' position as both involve the patient lying on their side.
Question 3
A client complained of nausea, a metallic taste in her mouth, and fine hand tremors 2 hours after her first dose of lithium carbonate (Lithane). What is the nurse's best explanation of these findings?
A. These side effects are common and should subside in a few days.
B. The client is probably having an allergic reaction and should discontinue the drug.
C. Taking the lithium on an empty stomach should decrease these symptoms.
D. Decreasing dietary intake of sodium and fluids should minimize the side effects.
Show answer and rationale
Correct answer: A — These side effects are common and should subside in a few days.
The correct answer is, 'These side effects are common and should subside in a few days.' Nausea, metallic taste, and fine hand tremors are common side effects of lithium carbonate (Lithane) and typically diminish within a few days as the body adjusts to the medication. Option B is incorrect because these symptoms are not indicative of an allergic reaction. Option C is incorrect as taking lithium on an empty stomach does not directly address or decrease these specific side effects. Option D is also incorrect as reducing sodium and fluid intake is not the recommended approach to managing these particular side effects of lithium.
Question 4
What drives respiration in a patient with advanced chronic respiratory failure?
A. Hypoxemia
B. Hypocapnia
C. Hypercapnia
D. None of the above
Show answer and rationale
Correct answer: A — Hypoxemia
In patients with advanced chronic respiratory failure, such as those with chronic obstructive pulmonary disease (COPD), the respiratory drive shifts from being primarily stimulated by high levels of carbon dioxide (hypercapnia) to being driven by low oxygen levels (hypoxemia). This shift is due to the body's adaptation to chronic respiratory acidosis and hypoxemia. As a result, hypoxemia becomes the primary stimulus for respiration in these patients. Hypocapnia, a low level of carbon dioxide, is not a common driver of respiration in patients with advanced chronic respiratory failure. Therefore, the correct answer is hypoxemia.
Question 5
The functional health pattern assessment data states: 'Eats three meals a day and is of normal weight for height.' The nurse should draw which of the following conclusions about this data? Select all that apply.
A. Client has an actual health problem
B. Client has a wellness diagnosis
C. Collaborative health problem needs to be written
D. Possible nursing diagnosis exists
Show answer and rationale
Correct answer: B — Client has a wellness diagnosis
The assessment data provided indicates a healthy pattern of nutrition and a normal weight for height, suggesting a positive health status. This aligns with a wellness diagnosis, such as 'Potential for enhanced nutrition,' which focuses on improving health further. An actual health problem refers to a current health issue present in the client, which is not evident in this data. Collaborative health problems involve interprofessional collaboration and are not indicated based on the information provided. While a diet assessment may be needed to evaluate food quality, the initial data suggests a wellness-focused approach to care.
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Question 6
During an adolescent examination, the nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting?
A. Spinal flexibility
B. Leg length disparity
C. Hypostatic blood pressure
D. Scoliosis
Correct answer:
The correct answer is scoliosis. During the assessment for scoliosis, the nurse asks the adolescent to bend forward at the waist with arms hanging freely to observe for any lateral deviation of the spine, uneven rib levels, or asymmetry. This assessment is a routine part of an adolescent examination, especially in females, as scoliosis is more common in this population. Choices A, B, and C are incorrect. Spinal flexibility is usually assessed through different maneuvers, leg length disparity is evaluated by measuring the length of the legs, and hypostatic blood pressure refers to a decrease in blood pressure due to immobility.
A patient with severe mitral regurgitation and decreased cardiac output is being cared for by a nurse. The nurse assesses the patient for mental status changes. What is the rationale for this intervention?
A. Decreased cardiac output can cause hypoxia to the brain
B. Mental status changes may be a side effect of the patient's medication
C. Mitral regurgitation is a complication associated with some neurological disorders
D. The patient may be confused about his diagnosis
Correct answer:
When caring for a patient with severe mitral regurgitation and decreased cardiac output, assessing for mental status changes is crucial. Decreased cardiac output can lead to inadequate perfusion and oxygenation of vital organs, including the brain, resulting in hypoxia. This hypoxia can manifest as mental status changes such as confusion, restlessness, or lethargy. Therefore, monitoring mental status helps in identifying potential hypoxic states and guiding appropriate interventions. The other options are incorrect as they do not directly correlate decreased cardiac output with potential hypoxia-induced mental status changes.
During the admission assessment of a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate due to this condition?
A. "I have constant blurred vision."?
B. "I can't see on my left side."?
C. "I have to turn my head to see my room."?
D. "I have specks floating in my eyes."?
Correct answer:
In chronic bilateral glaucoma, peripheral visual field loss occurs due to elevated intraocular pressure, leading to the need to turn the head to compensate for the visual field deficit. This symptom is characteristic of advanced glaucoma. Choice A is incorrect as constant blurred vision is a common symptom but not specific to peripheral vision loss in glaucoma. Choice B is incorrect because specific visual field deficits are more common than complete loss on one side. Choice D is incorrect as seeing floaters (specks floating in the eyes) is associated with other eye conditions like posterior vitreous detachment, not glaucoma.
A client is being admitted to the hospital because of a seizure that occurred at his home. The client has no previous history of seizures. In planning the client's nursing care, which of the following measures is most essential at the time of admission?
A. Place a padded tongue depressor at the head of the bed.
B. Pad the bed with blankets.
C. Inform the client about the importance of wearing a medical identification tag.
D. Teach the client about seizures.
Correct answer:
The most essential measure when admitting a client who had a seizure is to pad the bed with blankets (Option B). This is crucial to prevent injury in case of another seizure. Placing a padded tongue depressor at the head of the bed (Option A) is incorrect as current nursing guidelines advise against putting anything in the client's mouth during a seizure. Informing the client about wearing a medical identification tag (Option C) and teaching the client about seizures (Option D) are important but are more relevant once the cause of the seizure is known. It's crucial to remember that not all seizures are classified as epilepsy.
Which vacutainer tubes should be used when a requisition calls for blood to be drawn for an H&H and glucose test?
A. One light blue, one red
B. Two lavenders
C. One lavender, one grey
D. One green, one red
Correct answer:
The correct answer is 'One green, one red.' An H&H test involves hemoglobin and hematocrit, which are components of a complete blood count and are typically drawn in a lavender tube. On the other hand, blood for glucose testing is collected in grey tubes. Therefore, when drawing blood for both an H&H and glucose test, one green tube for glucose and one red tube for H&H should be used. The other choices are incorrect because light blue tubes are used for coagulation studies, lavender tubes are for complete blood counts, and green tubes are for chemistry tests like glucose, while grey tubes are specifically for glucose testing.
Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal?
A. The adolescent gives away a DVD player and a cherished autographed picture of a performer.
B. The adolescent runs out of group therapy, swearing at the group leader, and then goes to her room.
C. The adolescent becomes angry while speaking on the phone and slams down the receiver.
D. The adolescent gets angry with her roommate when the roommate borrows her clothes without asking.
Correct answer:
The correct answer is when the adolescent gives away a DVD player and a cherished autographed picture of a performer. This behavior is concerning because a depressed suicidal client often gives away things of value as a way of saying goodbye and wanting to be remembered. Choices B, C, and D all involve anger and acting-out behaviors, which are common in adolescents but do not specifically indicate suicidal ideation. Running out of group therapy, swearing, and going to her room, becoming angry and slamming the phone receiver, or getting upset when her roommate borrows her clothes are not clear indications of suicidal thoughts.
Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure?
A. Angina at rest
B. Thrombus formation
C. Dizziness
D. Falling blood pressure
Correct answer:
Thrombus formation is a critical complication of cardiac catheterization that the nurse should monitor for in the initial 24 hours after the procedure. A thrombus can form in the blood vessels, obstructing blood flow and potentially leading to serious consequences such as embolism or organ ischemia. While angina at rest, dizziness, and falling blood pressure are potential complications following cardiac catheterization, they are not typically associated with the immediate post-procedural period. Monitoring for thrombus formation is essential to ensure early detection and intervention, which can prevent serious complications.
The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test?
A. Is there any family history of TB?
B. How long have you lived in the United States?
C. Do you take any over-the-counter (OTC) medications?
D. Have you received the bacille Calmette-Guerin (BCG) vaccine for TB?
Correct answer:
It is crucial for the nurse to inquire about whether the patient has received the bacille Calmette-Guerin (BCG) vaccine for TB before performing the skin test. Patients who have received the BCG vaccine can have a positive Mantoux test, leading to the need for alternative screening methods, such as a chest x-ray, to determine TB infection. While family history of TB and length of time in the United States are relevant factors, they do not directly impact the decision to perform the TB skin test. Asking about over-the-counter medications, unless relevant to TB treatment, is not as critical as assessing BCG vaccination status.
Which example best describes a nurse who exhibits moral courage?
A. A nurse feels angry when a parent refuses important treatment for his child.
B. A nurse considers seeking help for depression when she feels she cannot meet the needs of her clients in the oncology unit.
C. A nurse contacts a physician for further orders when he fails to order comfort measures for a client with a terminal illness.
D. A nurse is frustrated when the laboratory is slow in responding to an order for a stat blood glucose.
Correct answer:
Moral courage involves taking action to do what is right, even when there might be negative consequences. The nurse who contacted a physician for further orders acted as a client advocate to seek help, even though she may have faced consequences such as lost time, decreased productivity, or criticism from the physician. Choices A, B, and D do not directly involve advocating for a client's needs or challenging a situation that goes against ethical standards. Feeling angry, seeking help for personal issues, or being frustrated with work processes do not necessarily demonstrate moral courage in the context of nursing practice.
A nurse is caring for a patient after a coronary angiogram. Which of these actions taken by the nursing assistant would most require the nurse's immediate intervention?
A. The nursing assistant fills the patient's pitcher with ice-cold drinking water
B. The nursing assistant elevates the head of the bed to 60 degrees for a meal
C. The nursing assistant refills the ice pack placed on the insertion site
D. The nursing assistant places an extra pillow under the patient's head upon request
Correct answer:
After a coronary angiogram, patients need to maintain bed rest and keep the head of the bed at no more than 30 degrees for 3-6 hours, depending on the insertion site. Elevating the head of the bed to 60 degrees for a meal could increase the risk of bleeding or complications at the insertion site. Refilling the ice pack placed on the insertion site is appropriate for managing potential swelling or discomfort. Filling the patient's pitcher with ice-cold drinking water is a standard care task. Placing an extra pillow under the patient's head upon request is a comfort measure and does not pose a risk to the patient's recovery.
NCLEX-RN clinical judgment practice questions, set 39 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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