NCLEX-RN clinical judgment practice questions, set 43
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 43
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 resident brings several electronic devices to a nursing home. One of the devices has a two-pronged plug. What rationale should the nurse provide when explaining why an electrical device must have a three-pronged plug?
A. Controls stray electrical currents.
B. Promotes efficient use of electricity.
C. Shuts off the appliance if there is an electrical surge.
D. Divides the electricity among the appliances in the room.
Show answer and rationale
Correct answer: A — Controls stray electrical currents.
A three-pronged plug functions as a ground to dissipate stray electrical currents. This helps prevent electrical shocks and ensures the safety of the user. Choice B is incorrect because the number of prongs on a plug does not impact the efficient use of electricity. Choice C is incorrect because a three-pronged plug does not shut off the appliance during an electrical surge; that role is typically fulfilled by surge protectors. Choice D is incorrect as a three-pronged plug does not divide electricity among appliances in a room; it primarily serves as a safety measure to handle excess electrical currents.
Question 2
A nonimmunized child appears at the clinic with a visible rash. Which of the following observations indicates the child may have rubeola (measles)?
A. Small blue-white spots are visible on the oral mucosa.
B. The rash begins on the trunk and spreads outward.
C. There is low-grade fever.
D. The lesions have a "teardrop-on-a-rose-petal"? appearance.
Show answer and rationale
Correct answer: A — Small blue-white spots are visible on the oral mucosa.
The presence of small blue-white spots on the oral mucosa, known as Koplik's spots, is characteristic of measles (rubeola) infection. These spots typically appear on the buccal mucosa opposite the second molars, 1-2 days before the rash onset, and last until 2 days after the rash appears. While Koplik's spots are pathognomonic for measles, their absence does not rule out the diagnosis. Therefore, choice A is the correct answer. Choices B, C, and D are incorrect because the rash pattern, presence of low-grade fever, and characteristic appearance of lesions are not specific indicators of measles infection.
Question 3
When cleansing the genital area during perineal care, the nurse should _____________.
A. cleanse the penis with a circular motion starting from the base and moving toward the tip.
B. replace the foreskin after it has been pushed back to cleanse an uncircumcised penis.
C. cleanse the rectal area first and then clean the patient's genital area.
D. use the same area on the washcloth for each washing and rinsing stroke for a female resident.
Show answer and rationale
Correct answer: B — replace the foreskin after it has been pushed back to cleanse an uncircumcised penis.
During perineal care, when cleansing the genital area of an uncircumcised male patient, it is crucial to retract the foreskin to clean the area underneath. This helps in the removal of smegma, a substance that can accumulate and lead to bacterial growth and infection if not cleaned properly. The foreskin should then be replaced back to its original position after cleaning to ensure proper hygiene and prevent any potential complications. Choices A, C, and D are incorrect because they do not address the specific care required for an uncircumcised penis, which involves retracting and replacing the foreskin.
Question 4
A nonimmunized child appears at the clinic with a visible rash. Which of the following observations indicates the child may have rubeola (measles)?
A. Small blue-white spots are visible on the oral mucosa.
B. The rash begins on the trunk and spreads outward.
C. There is low-grade fever.
D. The lesions have a "teardrop-on-a-rose-petal"? appearance.
Show answer and rationale
Correct answer: A — Small blue-white spots are visible on the oral mucosa.
The presence of small blue-white spots on the oral mucosa, known as Koplik's spots, is characteristic of measles (rubeola) infection. These spots typically appear on the buccal mucosa opposite the second molars, 1-2 days before the rash onset, and last until 2 days after the rash appears. While Koplik's spots are pathognomonic for measles, their absence does not rule out the diagnosis. Therefore, choice A is the correct answer. Choices B, C, and D are incorrect because the rash pattern, presence of low-grade fever, and characteristic appearance of lesions are not specific indicators of measles infection.
Question 5
The nurse plans health care for a community with a large number of recent immigrants from Vietnam. Which intervention is the most important for the nurse to implement?
A. Hepatitis testing
B. Tuberculosis screening
C. Contraceptive teaching
D. Colonoscopy information
Show answer and rationale
Correct answer: B — Tuberculosis screening
Tuberculosis (TB) is prevalent in many parts of Asia, including Vietnam, and the incidence of TB is higher in immigrants from Vietnam compared to the general U.S. population. Conducting tuberculosis screening is crucial to identify and address any cases promptly, especially in a community with recent immigrants from Vietnam. While teaching about contraceptive use, providing colonoscopy information, and testing for hepatitis may be relevant for certain individuals in the community, they are not as universally important as tuberculosis screening due to the increased risk of TB among Vietnamese immigrants.
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Question 6
The nurse plans health care for a community with a large number of recent immigrants from Vietnam. Which intervention is the most important for the nurse to implement?
A. Hepatitis testing
B. Tuberculosis screening
C. Contraceptive teaching
D. Colonoscopy information
Correct answer:
Tuberculosis (TB) is prevalent in many parts of Asia, including Vietnam, and the incidence of TB is higher in immigrants from Vietnam compared to the general U.S. population. Conducting tuberculosis screening is crucial to identify and address any cases promptly, especially in a community with recent immigrants from Vietnam. While teaching about contraceptive use, providing colonoscopy information, and testing for hepatitis may be relevant for certain individuals in the community, they are not as universally important as tuberculosis screening due to the increased risk of TB among Vietnamese immigrants.
A 49-year-old patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information will the nurse include in patient teaching?
A. Recommendation to drink at least 4 L of fluid daily
B. Need to avoid driving or operating heavy machinery
C. How to draw up and administer injections of the medication
D. Use of contraceptive methods other than oral contraceptives
Correct answer:
When initiating treatment with glatiramer acetate (Copaxone), patient education should focus on teaching the patient how to draw up and administer injections of the medication. Copaxone is administered via self-injection, hence understanding the correct technique is crucial for successful treatment. Recommendations regarding fluid intake or the need to avoid driving heavy machinery are not directly related to glatiramer acetate therapy. Additionally, while discussing contraceptive methods may be important, the use of oral contraceptives does not specifically contraindicate the use of glatiramer acetate.
A 49-year-old patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information will the nurse include in patient teaching?
A. Recommendation to drink at least 4 L of fluid daily
B. Need to avoid driving or operating heavy machinery
C. How to draw up and administer injections of the medication
D. Use of contraceptive methods other than oral contraceptives
Correct answer:
When initiating treatment with glatiramer acetate (Copaxone), patient education should focus on teaching the patient how to draw up and administer injections of the medication. Copaxone is administered via self-injection, hence understanding the correct technique is crucial for successful treatment. Recommendations regarding fluid intake or the need to avoid driving heavy machinery are not directly related to glatiramer acetate therapy. Additionally, while discussing contraceptive methods may be important, the use of oral contraceptives does not specifically contraindicate the use of glatiramer acetate.
What is the anatomic structure located in the middle of the heart that separates the right and left ventricles?
A. Septum
B. Sputum
C. Separator
D. None of the above
Correct answer:
The correct answer is the septum. The septum is a structure located in the middle of the heart that separates the right and left ventricles. It plays a crucial role in maintaining the separation between the two ventricles to ensure efficient blood flow. The other choices, 'Sputum' and 'Separator,' are incorrect as they do not refer to the anatomic structure in the heart that serves this specific function. 'Sputum' is a term used to describe phlegm or mucus, not an anatomical structure, and 'Separator' is a generic term that does not specifically identify the cardiac structure mentioned in the question.
While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action?
A. Check vital signs.
B. Massage the fundus.
C. Offer a bedpan.
D. Check for perineal lacerations.
Correct answer:
The nurse's first action should be to massage the fundus until it is firm as uterine atony is the primary cause of bleeding in the first hour after delivery. Massaging the fundus helps to stimulate uterine contractions, which can help control the bleeding. Checking vital signs would be important but addressing the primary cause of bleeding takes precedence. Offering a bedpan is not a priority in this situation as the focus should be on managing the postpartum bleeding. Checking for perineal lacerations is also important but not the initial action needed to address the boggy uterus and vaginal bleeding.
The healthcare professional notices that a colleague is preparing to check the blood pressure of a patient who is obese by using a standard-sized blood pressure cuff. How would this likely affect the blood pressure reading?
A. Yield a falsely low blood pressure
B. Yield a falsely high blood pressure
C. Be the same, regardless of cuff size
D. Vary as a result of the technique of the person performing the assessment
Correct answer:
Using a cuff that is too narrow for an obese patient would likely yield a falsely high blood pressure reading. This occurs because the standard cuff is too small for the arm's circumference, requiring more pressure to compress the artery. A tight cuff can lead to inaccurate and elevated blood pressure readings. Choices A, C, and D are incorrect because using an improperly sized cuff would not yield a falsely low blood pressure, the blood pressure reading does vary with cuff size, and the technique of the person performing the assessment is not the primary factor affecting the reading in this situation.
When counting an infant's respirations, which technique is correct?
A. Watching the chest rise and fall
B. Observing the movement of the abdomen
C. Placing a hand across the infant's chest
D. Using a stethoscope to listen to the breath sounds
Correct answer:
The correct technique for counting an infant's respirations is to observe the movement of the abdomen. Infants typically have more diaphragmatic breathing than thoracic, so watching the abdomen provides a more accurate count. Placing a hand on the chest or listening with a stethoscope can alter the infant's breathing pattern and provide inaccurate results. Therefore, options A, C, and D are incorrect methods for counting an infant's respirations. By observing the movement of the abdomen, healthcare providers can accurately assess an infant's respiratory rate without influencing their breathing pattern.
A patient who is displaying the defense mechanism of Compensation would:
A. Refuse to hear unwanted information.
B. Transfer feelings of negativity to someone else.
C. Overemphasize behaviors which accommodate for perceived weaknesses.
D. Place blame on others for personal actions or mistakes.
Correct answer:
The correct answer is 'Overemphasize behaviors which accommodate for perceived weaknesses.' Compensation involves overemphasizing or exaggerating a particular behavior or trait to make up for or cover up perceived weaknesses in oneself. This defense mechanism allows individuals to focus on their strengths rather than acknowledging their shortcomings. Choices A, B, and D are incorrect. Refusing to hear unwanted information relates more to denial, transferring feelings of negativity to someone else is projection, and placing blame on others is an example of the defense mechanism known as externalization.
A patient has a goal of eating at least 50% of each meal. The patient refuses to eat, so a nurse force-feeds the patient in order for them to reach their goal of eating at least 50% of the meal. The nurse has committed __________ against this patient.
A. assault
B. battery
C. physical neglect
D. emotional neglect
Correct answer:
The correct answer is 'battery.' Battery occurs when there is unwanted physical contact or force applied to a person without their consent. In this scenario, force-feeding the patient against their will constitutes battery as the nurse is physically interfering with the patient's body without permission. Assault involves the threat of physical harm, which is not present in the situation described. Physical neglect refers to the failure to provide basic care needs, which is not the case here. Emotional neglect involves the failure to address emotional needs, which is also not applicable in this context.
A patient with Parkinson's disease is experiencing difficulty swallowing. What potential problem associated with dysphagia has the greatest influence on the plan of care?
A. Anorexia
B. Aspiration
C. Self-care deficit
D. Inadequate intake
Correct answer:
When a person experiences dysphagia (difficulty swallowing), the greatest concern is aspiration. Aspiration occurs when food or fluids enter the trachea and lungs instead of going down the esophagus. This can lead to serious complications such as choking, airway obstruction, and aspiration pneumonia. Anorexia (Choice A) refers to a loss of appetite, which is not the primary concern with dysphagia. Self-care deficit (Choice C) and inadequate intake (Choice D) are important considerations but do not have as direct an impact on the immediate safety and health risks associated with aspiration in dysphagia.
NCLEX-RN clinical judgment practice questions, set 43 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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