NCLEX-RN clinical judgment practice questions, set 42
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 42
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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 38-year-old patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care?
A. Restrict daily dietary protein intake.
B. Reposition the patient every 4 hours.
C. Place the patient on a pressure-relieving mattress.
D. Perform passive range of motion daily.
Show answer and rationale
Correct answer: C — Place the patient on a pressure-relieving mattress.
Placing the patient on a pressure-relieving mattress is crucial to decrease the risk of skin breakdown, especially with significant edema and ascites. Adequate dietary protein intake is essential in patients with ascites to improve oncotic pressure and prevent malnutrition. Repositioning the patient every 4 hours alone may not be sufficient to prevent skin breakdown, especially in areas prone to pressure ulcers. Performing passive range of motion exercises is important for maintaining joint mobility but does not directly address the risk of skin breakdown associated with prolonged pressure on vulnerable areas.
Question 2
When escorting a patient to the operating room on a stretcher, what should you do to prevent the patient from falling?
A. Ensure the safety belt or strap is secured on the patient while escorting them to the operating room
B. Use a safety belt or strap on the patient throughout their escort to the operating room
C. Lower the bed position when moving the patient from the bed to the stretcher
D. All of the above options are correct
Show answer and rationale
Correct answer: B — Use a safety belt or strap on the patient throughout their escort to the operating room
When escorting a patient to the operating room on a stretcher, it is crucial to secure a safety belt or strap on the patient to prevent falls during the transfer. This safety measure is not considered a restraint but a necessary precaution. Lowering the bed position is not necessary; in fact, the bed should be in a high position to align with the stretcher. Locking the wheels of the stretcher is essential to prevent accidents during patient transfer. Therefore, the correct action to prevent falls while moving a patient to the operating room is to use a safety belt or strap on the patient throughout the escort.
Question 3
The client starting an exercise program will progress to walking a 20-minute mile in one month.
A. Client will walk quickly three times a day
B. Client will be able to walk a mile
C. Client will have no alteration in breathing during the walk
D. Client will progress to walking a 20-minute mile in one month
Show answer and rationale
Correct answer: D — Client will progress to walking a 20-minute mile in one month
Outcome statements must be written in behavioral terms and identify specific, measurable client behaviors. They are stated in terms of the client with an action verb that, under identified conditions, will achieve the desired behavior. Choice A lacks specificity and does not mention a target time or goal. Choice B is vague and does not provide a specific target for improvement. Choice C focuses on a negative outcome (no alteration) rather than a positive goal. The correct answer, Choice D, is specific, measurable, and time-bound, making it a suitable outcome statement for a client starting an exercise program.
Question 4
Which information about a 60-year-old patient with MS indicates that the nurse should consult with the healthcare provider before giving the prescribed dose of dalfampridine (Ampyra)?
A. The patient has relapsing-remitting MS
B. The patient walks a mile a day for exercise
C. The patient complains of pain with neck flexion
D. The patient has an increased serum creatinine level
Show answer and rationale
Correct answer: D — The patient has an increased serum creatinine level
The correct answer is that the patient has an increased serum creatinine level. Dalfampridine should not be given to patients with impaired renal function as it can worsen their condition. Options A, B, and C are unrelated to the administration of dalfampridine. The fact that the patient has relapsing-remitting MS, walks for exercise, or experiences neck pain does not directly impact the decision to administer dalfampridine. However, an increased serum creatinine level is a contraindication for this medication and requires consultation with the healthcare provider to determine the appropriate course of action.
Question 5
Which information about a 60-year-old patient with MS indicates that the nurse should consult with the healthcare provider before giving the prescribed dose of dalfampridine (Ampyra)?
A. The patient has relapsing-remitting MS
B. The patient walks a mile a day for exercise
C. The patient complains of pain with neck flexion
D. The patient has an increased serum creatinine level
Show answer and rationale
Correct answer: D — The patient has an increased serum creatinine level
The correct answer is that the patient has an increased serum creatinine level. Dalfampridine should not be given to patients with impaired renal function as it can worsen their condition. Options A, B, and C are unrelated to the administration of dalfampridine. The fact that the patient has relapsing-remitting MS, walks for exercise, or experiences neck pain does not directly impact the decision to administer dalfampridine. However, an increased serum creatinine level is a contraindication for this medication and requires consultation with the healthcare provider to determine the appropriate course of action.
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Question 6
The nurse is assessing the vital signs of a 20-year-old marathon runner and documents the following vital signs: temperature"?36°C; pulse"?48 beats per minute; respirations"?14 breaths per minute; blood pressure"?104/68 mm Hg. Which statement is true concerning these results?
A. The patient is experiencing bradycardia.
B. These are normal vital signs for a healthy, athletic adult.
C. The patient's pulse rate is not normal"?no action is required.
D. The patient's next clinic visit should occur as scheduled.
Correct answer:
The correct answer is, 'These are normal vital signs for a healthy, athletic adult.' A pulse rate of 48 beats per minute is considered bradycardia in adults, but it is not a concern in well-trained athletes like marathon runners. Bradycardia is a normal physiological response to aerobic conditioning. Tachycardia, on the other hand, is defined as a pulse rate above 100 beats per minute, which is not the case here. The low pulse rate in this scenario is a reflection of the athlete's cardiovascular fitness. Therefore, there is no need to notify the physician or schedule a follow-up visit based on these findings.
The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq potassium chloride in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued?
A. Narrowed QRS complex
B. Shortened "PR"? interval
C. Tall peaked "T"? waves
D. Prominent "U"? waves
Correct answer:
A tall peaked T wave is a characteristic EKG pattern associated with hyperkalemia. Hyperkalemia refers to high levels of potassium in the blood, which can lead to cardiac arrhythmias and other serious complications. Tall peaked T waves are a red flag for potential cardiac issues and can indicate the need to discontinue potassium infusions. The other choices, such as narrowed QRS complex, shortened "PR"? interval, and prominent "U"? waves, are not typically associated with hyperkalemia. Therefore, recognizing tall peaked T waves is crucial for the nurse to take prompt action in managing the client's condition.
As a charge nurse, what is your primary responsibility for a 50-year-old blind and deaf patient admitted to your floor?
A. Inform others about the patient's deficits.
B. Communicate patient safety concerns to your supervisor.
C. Provide continuous updates to the patient about the social environment.
D. Provide a secure environment for the patient.
Correct answer:
The primary responsibility of the charge nurse for a blind and deaf patient is to provide a secure environment. Ensuring patient safety is crucial to prevent medical errors and adverse outcomes. By creating a safe environment, the nurse can protect the patient from harm and promote well-being. Option A is incorrect as the focus should be on ensuring patient safety rather than highlighting deficits. Option B is not the primary responsibility in this scenario, as the immediate concern is the patient's safety. Option C is irrelevant and does not address the patient's primary needs, which are safety and security.
A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would:
A. Instruct the client to maintain a regular diet the day prior to the examination
B. Restrict the client's fluid intake 4 hours prior to the examination
C. Administer a laxative to the client the evening before the examination
D. Inform the client that only 1 x-ray of his abdomen is necessary
Correct answer:
Administering a laxative to the client the evening before the examination is the correct action. Bowel prep is crucial for an Intravenous Pyelogram (IVP) as it helps in achieving better visualization of the bladder and ureters. Instructing the client to maintain a regular diet the day prior to the examination (Choice A) is not the appropriate preparation for an IVP. Restricting the client's fluid intake 4 hours prior to the examination (Choice B) is not necessary for this test. Informing the client that only 1 x-ray of his abdomen is necessary (Choice D) is not relevant to the preparation process for an IVP.
The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect?
A. Increased tactile fremitus
B. Dry, nonproductive cough
C. Hyperresonance to percussion
D. A grating sound on auscultation
Correct answer:
Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias, such as pneumococcal pneumonia. Dullness to percussion would be expected due to consolidation. Pneumococcal pneumonia typically presents with a loose, productive cough rather than a dry, nonproductive cough. Hyperresonance to percussion is not a typical finding in pneumonia and may suggest conditions like emphysema. Adventitious breath sounds such as crackles and wheezes are typical in pneumonia, but a grating sound on auscultation is more representative of a pleural friction rub rather than pneumonia.
Your patient has been diagnosed with a left ankle sprain. On the discharge instructions, the physician has prescribed the RICE protocol. This acronym stands for:
A. Rest, Ice, Compression, Elevation
B. Radiology, Ice, Compression, Elevation
C. Rest, Ice, Cast, Elevation
D. Radiology, Ice, Cast, Elevation
Correct answer:
The correct answer is Rest, Ice, Compression, Elevation. This acronym, RICE, is commonly used for the treatment of injuries like an ankle sprain. Rest allows the injured area to heal, Ice helps reduce swelling and pain (20 minutes on each hour while awake), Compression is usually achieved with an elastic bandage to minimize swelling, and Elevation of the foot above the level of the heart assists in reducing swelling and promoting healing. Choices B, C, and D are incorrect because they include irrelevant terms like Radiology and Cast, which are not part of the standard treatment protocol for an ankle sprain.
While receiving normal saline infusions to treat a GI bleed, the nurse notes that the patient's lower legs have become edematous and auscultates crackles in the lungs. What should the nurse do first?
A. Stop the saline infusion immediately
B. Notify the physician
C. Elevate the patient's legs
D. Continue the infusion, as these findings are normal
Correct answer:
The correct answer is to stop the saline infusion immediately. The patient is showing signs of fluid volume overload due to rapid fluid replacement, indicated by lower leg edema and lung crackles. Continuing the infusion could worsen the overload and potentially lead to complications. Notifying the physician is important but should come after stopping the infusion to address the immediate issue. Elevating the patient's legs may help with edema but is not the priority in this situation. Continuing the infusion when the patient is already showing signs of fluid overload is contraindicated and can be harmful.
A client who has undergone radiation therapy presents with itching, redness, burning pain, and skin sloughing on the chest and abdomen. Which nursing intervention is most appropriate for this client?
A. Apply ointment to the skin to avoid moisture
B. Wash the area gently with water and pat dry
C. Use a mild antiseptic soap to wash the area and pat dry
D. Apply talcum powder to keep the skin dry
Correct answer:
For a client experiencing skin symptoms like redness, itching, burning pain, and sloughing after radiation therapy, it is crucial to maintain proper skin care. Applying ointments, lotions, or powders can worsen the condition by trapping moisture and leading to further skin irritation. The most appropriate intervention is to wash the affected area gently with water to cleanse it without further irritating the skin. Using mild antiseptic soap or talcum powder can also be harsh on the compromised skin. Patting the skin dry helps prevent friction and trauma to the affected area, promoting healing and comfort.
A healthcare professional is asked to draw blood in the antecubital (AC) space. Which of the following veins are found in the AC?
A. Cephalic
B. Median cubital
C. Basilic
D. All of the above
Correct answer:
The correct answer is 'All of the above.' All three of these veins - the cephalic, median cubital, and basilic veins - are located in the antecubital space, which is the area in front of the elbow on the arm. The cephalic vein runs along the outer side of the arm, the basilic vein runs along the inner side of the arm, and the median cubital vein is a connecting vein between the cephalic and basilic veins. Therefore, all three veins can be accessed when drawing blood from the antecubital space. Choices A, B, and C are incorrect because each of these veins individually can be found in the antecubital space.
Which of the following clients have barriers to accessing healthcare?
A. A 36-year-old client who must use a wheelchair for mobility
B. A 44-year-old client who is visiting the United States on a visa from India
C. An 81-year-old client who is unable to drive
D. All of the above
Correct answer:
All of the provided clients have barriers to accessing healthcare. Clients with physical limitations, such as the 36-year-old client using a wheelchair, may face challenges in mobility and accessing healthcare facilities. The 44-year-old client from India visiting the United States on a visa may encounter barriers related to language, cultural differences, or insurance coverage. The 81-year-old client who is unable to drive may struggle with transportation to healthcare appointments. Therefore, all three clients face different barriers to accessing healthcare, making 'All of the above' the correct answer.
NCLEX-RN clinical judgment practice questions, set 42 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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