NCLEX-RN clinical judgment practice questions, set 44
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 44
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
The nurse is preparing to examine a 6-year-old child. Which action is most appropriate?
A. The child is asked to undress from the waist up.
B. The head is examined before the thorax, abdomen, and genitalia.
C. The nurse should keep in mind that a child at this age will have a sense of modesty.
D. Talking about the equipment being used is avoided to prevent increasing the child's anxiety.
Show answer and rationale
Correct answer: C — The nurse should keep in mind that a child at this age will have a sense of modesty.
When examining a 6-year-old child, it is important to consider their sense of modesty. The child should undress themselves, leaving underpants on and using a gown or drape to maintain privacy. Additionally, a school-age child like a 6-year-old is curious about how equipment works, so it is beneficial to explain the purpose and function of the tools being used. The examination sequence should typically progress from the child's head to the toes to ensure a thorough assessment. Therefore, choices A, B, and D are incorrect as they do not align with the appropriate approach to examining a 6-year-old child.
Question 2
The priority goal for a family who practices Chinese medicine would be to:
A. Achieve harmony
B. Maintain a balance of energy
C. Respect life
D. Restore yin and yang
Show answer and rationale
Correct answer: D — Restore yin and yang
In Chinese medicine, the concept of yin and yang represents the balance of opposing forces in the body. When there is an imbalance between yin and yang, it can result in illness. Therefore, the priority goal for a family practicing Chinese medicine would be to restore the harmony and balance between yin and yang. Choices A, B, and C are not the priority goal in Chinese medicine. While achieving harmony, maintaining a balance of energy, and respecting life are important aspects of Chinese medicine, the fundamental principle revolves around maintaining the equilibrium of yin and yang for optimal health.
Question 3
Which pathologic condition is described as 'increased intraocular pressure of the eye'?
A. Detached Retina
B. Fovea Centralis
C. Presbyopia
D. Glaucoma
Show answer and rationale
Correct answer: D — Glaucoma
The correct answer is Glaucoma. Glaucoma is a condition characterized by increased intraocular pressure in the eye, which can lead to optic nerve damage, vision loss, and blindness if left untreated. Detached Retina (A), Fovea Centralis (B), and Presbyopia (C) are not conditions associated with increased intraocular pressure like Glaucoma. Detached Retina is a separation of the retina from its underlying tissue, Fovea Centralis is a part of the retina responsible for sharp central vision, and Presbyopia is an age-related condition affecting near vision due to the loss of flexibility in the eye's lens.
Question 4
A nurse and client are discussing the client's progress toward understanding his behavior under stress. This is typical of which phase in the therapeutic relationship?
A. Pre-interaction
B. Orientation
C. Working
D. Termination
Show answer and rationale
Correct answer: C — Working
The correct answer is the working phase. During this phase, the nurse and client actively work together to explore alternative behaviors and techniques. Discussions in this phase focus on understanding the underlying meaning behind the behavior and implementing strategies for change. Pre-interaction (choice A) refers to the phase before the nurse and client first meet and establish a relationship. The orientation phase (choice B) involves introductions, setting goals, and establishing boundaries. Termination (choice D) is the phase where the therapeutic relationship concludes, and closure is achieved.
Question 5
Which of the following is the most appropriate example of anticipatory guidance for a 16-year-old who has been hospitalized for an ankle fracture?
A. Changes associated with puberty
B. Driving and staying safe
C. The health hazards of smoking
D. Social media influences
Show answer and rationale
Correct answer: B — Driving and staying safe
Anticipatory guidance is an educational process that provides information important to a client's situation. When considering a 16-year-old who has been hospitalized for an ankle fracture, the most suitable anticipatory guidance would be regarding driving and staying safe. This guidance is crucial as it is age-appropriate and relevant to preventing future injuries. Choices A, C, and D are less pertinent in this scenario. Changes associated with puberty, health hazards of smoking, and social media influences may not directly address the immediate safety concerns of a 16-year-old with an ankle fracture.
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Question 6
A healthcare professional has just received a medication order that is not legible. Which statement best reflects assertive communication?
A. I cannot give this medication as it is written. I have no idea what you mean.
B. Would you please clarify what you have written so I am sure I am reading it correctly?
C. I am having difficulty reading your handwriting. It would save me time if you would be more careful.
D. Please print in the future so I do not have to spend extra time attempting to read your writing.
Correct answer:
Assertive communication respects the rights and responsibilities of both parties. Choice B is the best example of assertive communication in this scenario. It addresses the issue directly by requesting clarification without blaming or devaluing the prescriber. This approach shows concern for safe practice and acknowledges the importance of clear communication in healthcare. Choices A, C, and D either involve self-depreciation, blaming the prescriber, or making demands without a respectful request for clarification, making them less effective in promoting effective communication and safe patient care.
The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective?
A. I will avoid being outdoors whenever possible.
B. My husband will be sleeping in the guest bedroom.
C. I will take the bus instead of driving to visit my friends.
D. I will keep the windows closed at home to contain the germs.
Correct answer:
To prevent the transmission of pulmonary tuberculosis, it is important for the infected individual to minimize exposure to close contacts and household members. Sleeping alone in a separate room, like the guest bedroom, is an effective measure. The other choices are not ideal: Choice A is incorrect because spending time outdoors is encouraged for ventilation; Choice C is incorrect as using public transportation increases the risk of transmission; Choice D is incorrect because keeping windows closed limits ventilation, which is necessary to reduce the concentration of infectious particles in the air.
A nurse is caring for a patient admitted to the emergency room for an ischemic stroke with marked functional deficits. The physician is considering the use of fibrinolytic therapy with TPA (tissue plasminogen activator). Which history-gathering question would not be important for the nurse to ask?
A. What time did you first notice symptoms consistently appearing?
B. Have you been taking any blood thinners such as heparin, lovenox, or warfarin?
C. Have you had another stroke or head trauma in the previous 3 months?
D. Have you had any blood transfusions within the previous year?
Correct answer:
The correct answer is 'Have you had any blood transfusions within the previous year?' This question is not relevant in the context of considering fibrinolytic therapy with TPA for an ischemic stroke. Blood transfusions within the previous year do not directly impact the decision to use TPA in the treatment of an acute ischemic stroke. The focus should be on factors such as the time of symptom onset, current medications like blood thinners, and recent history of strokes or head trauma, as these are more directly related to the decision-making process for administering TPA in this emergency situation.
Which of the following is an example of client handling equipment?
A. Wheelchair
B. Height-adjustable bed
C. Shower chair
D. Call light
Correct answer:
Client handling equipment is designed to reduce stress and workload on healthcare professionals who assist, turn, or lift clients, aiming to decrease the risk of injuries from improper lifting techniques. A height-adjustable bed is a prime example of client handling equipment as it allows healthcare providers to raise the client to a suitable working height, facilitating care provision. Choices A, C, and D are not examples of client handling equipment. While a wheelchair, shower chair, and call light are essential in client care settings, they are not intended to aid in handling and lifting clients.
The nurse is counting a client's respiratory rate. During a 30-second interval, the nurse counts six respirations, and the client coughs three times. In repeating the count for a second 30-second interval, the nurse counts eight respirations. Which respiratory rate should the nurse document?
A. 14
B. 16
C. 17
D. 28
Correct answer:
The most accurate respiratory rate is the second count obtained by the nurse, which was not interrupted by coughing. The nurse counted eight respirations over 30 seconds, so doubling this count gives a respiratory rate of 16 breaths per minute. This calculation is based on the assumption that the client's breathing pattern remained relatively stable during the two 30-second intervals. Options A, C, and D are incorrect because they do not reflect the accurate count obtained without interruptions. Choice B (16) is the correct answer as it reflects the uninterrupted count of respirations by the nurse.
Which of the following items of subjective client data would be documented in the medical record by the nurse?
A. Client's face is pale
B. Cervical lymph nodes are palpable
C. Nursing assistant reports client refused lunch
D. Client feels nauseated
Correct answer:
The correct answer is 'Client feels nauseated.' Subjective data refers to the client's sensations, feelings, and perception of their health status. It can only be reported by the client as it is based on their personal experiences. The feeling of nausea is a subjective symptom that the client experiences and can provide insight into their health condition. Choices A and B represent objective data, as they describe observable or measurable findings that can be detected by the nurse. Choice C involves information reported by someone other than the client, making it indirect and not purely subjective.
You are working the 8 am to 4 pm shift. You begin to vomit at 3 pm and you do not think that you are able to continue working. You decide to immediately go home without notifying your RN supervisor. You have ________________.
A. enough sick time, so this is not a problem.
B. finished all your work, so this is not a problem.
C. seriously abandoned the patients.
D. seriously abused and neglected the patients.
Correct answer:
Patient abandonment is a serious violation that can lead to disciplinary action and immediate termination of employment. It is defined as leaving patients without proper consent from the supervisor. In this scenario, leaving work without notifying the RN supervisor and potentially leaving patients unattended is considered patient abandonment, as it compromises patient safety and care. Choices A and B are incorrect because having sick time or finishing work does not justify leaving without proper protocol. Choice D is incorrect as the scenario does not indicate abuse or neglect towards the patients.
When planning care for an uninsured diabetic patient, which strategy should be a priority?
A. Obtain less expensive medications
B. Follow evidence-based practice guidelines
C. Assist with dietary changes as the first action
D. Teach about the impact of exercise on diabetes
Correct answer:
The priority when planning care for an uninsured diabetic patient should be to follow evidence-based practice guidelines. By adhering to standardized evidence-based guidelines, the nurse can help reduce healthcare disparities among different socioeconomic groups. While obtaining less expensive medications and assisting with dietary changes are important, the primary concern should be providing care that aligns with established standards of practice. Teaching about the impact of exercise is also valuable but may not be the priority when immediate care planning for an uninsured patient is considered.
When planning care for an uninsured diabetic patient, which strategy should be a priority?
A. Obtain less expensive medications
B. Follow evidence-based practice guidelines
C. Assist with dietary changes as the first action
D. Teach about the impact of exercise on diabetes
Correct answer:
The priority when planning care for an uninsured diabetic patient should be to follow evidence-based practice guidelines. By adhering to standardized evidence-based guidelines, the nurse can help reduce healthcare disparities among different socioeconomic groups. While obtaining less expensive medications and assisting with dietary changes are important, the primary concern should be providing care that aligns with established standards of practice. Teaching about the impact of exercise is also valuable but may not be the priority when immediate care planning for an uninsured patient is considered.
A patient who has been diagnosed with vasospastic disorder (Raynaud's disease) complains of cold and stiffness in the fingers. Which of the following descriptions is most likely to fit the patient?
A. An adolescent male
B. An elderly woman
C. A young woman
D. An elderly man
Correct answer:
The correct answer is 'A young woman.' Raynaud's disease is most common in young women and is often associated with rheumatologic disorders like lupus and rheumatoid arthritis. This disorder involves vasospasm of the arteries, leading to reduced blood flow to the fingers and toes. Typically, Raynaud's affects the fingers, and in some cases, it can affect the toes. Only rarely does it involve other body parts such as the nose, ears, nipples, and lips. Choices B, C, and D are less likely as Raynaud's disease predominantly affects young women, although it can occur in other demographic groups as well.
NCLEX-RN clinical judgment practice questions, set 44 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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