NCLEX-RN clinical judgment practice questions, set 40
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 40
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
As you are assessing the fetus during labor, you are determining the fetal lie, presentation, attitude, station, and position. Your client asks you what all these assessments are. Among other things, how should you respond to the mother?
A. You should explain that fetal lie is where the fetus's presenting part is within the birth canal during labor, among other information about the other assessments.
B. You should explain that fetal presentation is the relationship of the fetus's spine to the mother's spine, among other information about the other assessments.
C. You should explain that fetal attitude is the relationship of the fetus's presenting part to the anterior, posterior, right, or left side of the mother's pelvis, among other information about the other assessments.
D. You should explain that fetal station is the level of the fetus's presenting part in relationship to the mother's ischial spines, among other information about the other assessments.
Show answer and rationale
Correct answer: D — You should explain that fetal station is the level of the fetus's presenting part in relationship to the mother's ischial spines, among other information about the other assessments.
You should explain that fetal station is the level of the fetus's presenting part in relationship to the mother's ischial spines. Fetal station is measured in terms of the number of centimeters above or below the mother's ischial spines. When the fetus is 1 to 5 centimeters above the ischial spines, the fetal station is -1 to -5, and when the fetus is 1 to 5 centimeters below the level of the maternal ischial spines, the fetal station is +1 to +5. Choices A, B, and C provide incorrect information about fetal lie, presentation, and attitude, respectively, which do not align with the definitions of these terms in obstetrics.
Question 2
The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first?
A. A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled
B. A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath
C. A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes
D. A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 100.2 F (37.8 C)
Show answer and rationale
Correct answer: B — A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath
The correct answer is the 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath. Patients on bed rest who are immobile are at high risk for deep vein thrombosis (DVT). Sudden onset of shortness of breath in a patient with a DVT suggests a pulmonary embolism, which requires immediate assessment and action such as oxygen administration to maintain adequate oxygenation. The other patients should also be assessed as soon as possible, but they do not present with an immediate life-threatening condition that requires urgent intervention like the patient experiencing sudden shortness of breath.
Question 3
Which of the following measures would be appropriate for a nurse to teach the parent of a nine-month-old infant about diaper dermatitis?
A. Use only cloth diapers that are rinsed in bleach
B. Do not use occlusive ointments on the rash
C. Use commercial baby wipes with each diaper change
D. Discontinue a new food that was added to the infant's diet just prior to the rash
Show answer and rationale
Correct answer: D — Discontinue a new food that was added to the infant's diet just prior to the rash
Diaper dermatitis can be caused by various factors, one of which includes introducing new foods to the infant's diet. Discontinuing the new food that was added just before the rash can help identify and eliminate the potential cause. Options A and C are not directly related to addressing the cause of diaper dermatitis. While using cloth diapers rinsed in bleach may be a preventive measure for diaper dermatitis, it is not addressing a specific cause. Option B, advising against using occlusive ointments on the rash, may actually be beneficial in managing diaper dermatitis, but it does not address the cause of the condition.
Question 4
Mr. Freeman has difficulty getting out of bed. The nurse should encourage Mr. Freeman to ______________.
A. ask for assistance before getting out of bed.
B. remain in bed because it is safer and he will not fall.
C. instruct him to stand up quickly from the bed.
D. lean forward and push up and off the bed.
Show answer and rationale
Correct answer: A — ask for assistance before getting out of bed.
The nurse should encourage Mr. Freeman to use his call bell and ask for assistance before getting out of bed. This can prevent him from falling. Patients should not stay in bed; they should be encouraged to get out of bed as much as possible to prevent complications like pressure ulcers and muscle weakness. Instructing a patient to stand up quickly from the bed is unsafe as it can lead to dizziness and falls. Similarly, leaning forward and pushing off the bed can increase the risk of falls and should be avoided. Asking for assistance is the safest and most appropriate option to ensure patient safety and prevent accidents.
Question 5
Rales and rhonchi are frequently noted during an examination of lung sounds. What is the difference between the two?
A. Rales are louder.
B. Rhonchi are noted only in infants.
C. Rales occur on inspiration, rhonchi on expiration.
D. Rales are noted only in infants.
Show answer and rationale
Correct answer: C — Rales occur on inspiration, rhonchi on expiration.
The correct answer is that rales occur on inspiration, while rhonchi occur on expiration. Rales are typically heard during inhalation when there is fluid in the alveoli or air passages. Rhonchi, on the other hand, are caused by air passing through obstructed airways during exhalation due to secretions in the respiratory tract. Choice A is incorrect because the loudness of the sounds is not the primary distinguishing factor between rales and rhonchi. Choice B is incorrect as rhonchi can be heard in individuals beyond infancy. Choice D is incorrect as rales can be present in patients of various age groups, not just infants.
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Question 6
If you are caring for a patient of the Hindu culture, what may you anticipate regarding visitors?
A. Limited visitors, respectful of privacy
B. Family members only
C. Large number of visitors/community support
D. None of the above
Correct answer:
In Hindu culture, there is a strong sense of community and support. It is common for a patient to receive a large number of visitors, indicative of the community coming together to provide emotional and practical support. This support network is crucial for the patient's well-being and healing process. Option A, limited visitors, is incorrect as the Hindu culture values community involvement. Option B, family members only, is incorrect as the support network extends beyond just family. Option D, none of the above, is incorrect as the Hindu culture typically involves community support and a significant number of visitors.
The healthcare professional needs to validate which of the following statements pertaining to an assigned client?
A. The client has a hard, raised, red lesion on his right hand.
B. A weight of 185 lbs. is recorded in the chart.
C. The client reported an infected toe.
D. The client's blood pressure is 124/70.
Correct answer:
Validation is the process of confirming that data are actual and factual. Data that can be measured can be accepted as factual, as in options 1, 3, and 4. The weight, blood pressure, and physical appearance of a lesion can be objectively verified. However, option C, the client reporting an infected toe, requires the nurse to directly assess the client's toe to confirm the statement. This choice involves subjective data that needs to be validated through direct observation, making it the correct answer. Options A, B, and D provide data that can be measured objectively and verified without the need for further assessment.
A 34-year-old female has recently been diagnosed with an autoimmune disease. She has also recently discovered that she is pregnant. Which of the following is the only immunoglobulin that will provide protection to the fetus in the womb?
A. IgA
B. IgD
C. IgE
D. IgG
Correct answer:
IgG is the only immunoglobulin that can cross the placental barrier, providing passive immunity to the fetus. About 70-80% of the immunoglobulins in the blood are IgG. Specific IgG antibodies are generated after an initial exposure to an antigen, offering long-term protection against microorganisms. IgG antibodies are critical for protecting the fetus as they can be rapidly reproduced upon re-exposure to the same antigen. IgA is primarily found in mucosal areas, IgD is involved in antigen recognition, and IgE is associated with allergic reactions, but they do not provide the same level of protection to the fetus as IgG.
The parents of a newborn male with hypospadias want their child circumcised. The best response by the nurse is to inform them that
A. Circumcision is delayed so the foreskin can be used for the surgical repair
B. This procedure is contraindicated because of the permanent defect
C. There is no medical indication for performing a circumcision on any child
D. The procedure should be performed as soon as the infant is stable
Correct answer:
Circumcision is delayed so the foreskin can be used for the surgical repair. Even if mild hypospadias is suspected, circumcision is not done to save the foreskin for surgical repair if needed. Choice B is incorrect because circumcision is not contraindicated due to a permanent defect; it is delayed for potential surgical needs. Choice C is incorrect as there are situations where a circumcision may be indicated for medical or cultural reasons. Choice D is incorrect because circumcision for hypospadias-related repair is not done immediately but rather delayed to preserve the foreskin for potential reconstructive surgery.
A patient who was admitted the previous day with pneumonia complains of a sharp pain of 7 (based on a 0 to 10 scale) whenever taking a deep breath. Which action will the nurse take next?
A. Auscultate breath sounds.
B. Administer PRN morphine.
C. Have the patient cough forcefully.
D. Notify the patient's healthcare provider.
Correct answer:
The patient's complaint of sharp pain when taking a deep breath is concerning for pleurisy or pleural effusion. The nurse should auscultate breath sounds to assess for a pleural friction rub or decreased breath sounds, which could indicate these conditions. It is crucial to gather assessment data before initiating any pain medications. Asking the patient to cough forcefully may exacerbate the pain and should be avoided until further assessment. Contacting the healthcare provider should be based on the assessment findings; therefore, it is premature to notify the provider without conducting a thorough assessment first.
When asked to describe in layman's terms an overview of the condition called osteomyelitis, what would be the nurse's best response?
A. Osteomyelitis is a gradual breakdown and weakening of your bones. It's most often age-related.
B. Osteomyelitis is caused by not having enough Vitamin D, which in turn causes your bones to be softer and demineralized.
C. Osteomyelitis is an infection in the bone. It can be caused by bacteria reaching your bone from outside or inside your body.
D. This is a question that should be directed to your healthcare provider.
Correct answer:
Osteomyelitis is an infection in the bone that can be caused by bacteria reaching the bone either from outside the body (such as through an open fracture) or inside the body (such as through the bloodstream). This response provides a concise and accurate explanation of osteomyelitis, making it the best choice. Choices A and B provide inaccurate information about the condition, attributing it to age-related bone breakdown and Vitamin D deficiency, which are not correct causes of osteomyelitis. Choice D deflects the question instead of providing the patient with a clear explanation, making it an inappropriate response.
A patient with Meningitis is being treated with Vancomycin intravenously 3 times per day. The nurse notes that the urine output during the last 8 hours was 200mL. What is the nurse's priority action?
A. Check the patient's last BUN levels
B. Ask the patient to increase their fluid intake
C. Ask the physician to order a diuretic
D. Notify the physician of this finding
Correct answer:
Vancomycin is a nephrotoxic drug and can cause impaired renal perfusion, which would lead to decreased urine output. This is a serious adverse effect that should be promptly reported to the physician. Checking the patient's last BUN levels (Choice A) may provide additional information but does not address the urgency of the situation. Asking the patient to increase fluid intake (Choice B) may not be appropriate if the cause is related to Vancomycin toxicity. Ordering a diuretic (Choice C) without physician evaluation can exacerbate the issue, making notifying the physician (Choice D) the most critical action to take.
When caring for children with a different cultural perspective, what challenge may the nurse recognize?
A. Children have spiritual needs that are influenced by their stages of development
B. Children have spiritual needs that are direct reflections of what is occurring in their homes
C. Religious beliefs rarely affect the parents' perceptions of the illness
D. Parents are often the decision-makers, and they have no knowledge of their children's spiritual needs
Correct answer:
When caring for children with different cultural perspectives, nurses should acknowledge that children have spiritual needs that are influenced by their stages of development. This understanding is crucial as children, like adults, have varying spiritual needs based on their age and the religious environment within their family. Recognizing and addressing these spiritual needs is essential for providing holistic care. Choices B, C, and D are incorrect as they do not accurately reflect the influence of children's developmental stages on their spiritual needs and the importance of considering these needs in their care.
The categories such as ethnicity, gender, and religion illustrate which concept?
A. Family
B. Cultures
C. Spirituality
D. Subcultures
Correct answer:
Within cultures, various groups of people share different beliefs, values, and attitudes due to factors such as ethnicity, religion, education, occupation, age, and gender. When these distinct groups coexist within a broader culture, they are referred to as subcultures. While ethnicity, gender, and religion are important components of individuals' identities, they do not represent the concepts of family, cultures, or spirituality. The correct answer is 'Subcultures' as these categories reflect differences within a larger cultural context, emphasizing the unique characteristics shared by members of subcultural groups.
C. Computer screens should be visible only to authorized personnel.
D. Technology enhances HIPAA confidentiality.
Correct answer:
Technology can expose us to HIPAA violations. For instance, leaving a computer screen unattended and visible to unauthorized individuals can result in breaches of patient confidentiality, leading to HIPAA violations. While computers can indeed aid in sharing information, this is not directly related to HIPAA compliance. Ensuring that computer screens are only visible to authorized personnel is a good practice, but it does not address the broader risks and challenges posed by technological advancements in maintaining HIPAA compliance. Therefore, the correct answer is that technology can expose us to HIPAA violations.
NCLEX-RN clinical judgment practice questions, set 40 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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