NCLEX-RN clinical judgment practice questions, set 45
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 45
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 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
Show answer and rationale
Correct answer: C — A young woman
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.
Question 2
Which gland of the endocrine system secretes a hormone that assists with the sleep/wake cycle?
A. Pituitary
B. Pineal
C. Pancreas
D. Hypothalamus
Show answer and rationale
Correct answer: B — Pineal
The correct answer is the Pineal gland. The Pineal gland, located in the brain, secretes melatonin, which plays a crucial role in regulating the sleep/wake cycle in response to exposure to light. The Pituitary gland (Choice A) secretes various hormones but not specifically related to the sleep/wake cycle. The Pancreas (Choice C) secretes insulin and digestive enzymes, not hormones related to the sleep/wake cycle. The Hypothalamus (Choice D) is involved in regulating many bodily functions, including hormone secretion, but it does not directly secrete the hormone that regulates the sleep/wake cycle.
Question 3
A patient is on bedrest 24 hours after a hip fracture. Which regular assessment or intervention is essential for detecting or preventing the complication of Fat Embolism Syndrome?
A. Performing passive, light range-of-motion exercises on the hip as tolerated.
B. Assess the patient's mental status for drowsiness or sleepiness.
C. Assess the pedal pulse and capillary refill in the toes.
D. Administer a stool softener as ordered.
Show answer and rationale
Correct answer: B — Assess the patient's mental status for drowsiness or sleepiness.
In detecting or preventing Fat Embolism Syndrome (FES), assessing the patient's mental status for drowsiness or sleepiness is crucial. Decreased level of consciousness is an early sign of FES due to decreased oxygen levels. Performing passive, light range-of-motion exercises on the hip may not directly relate to FES. Assessing pedal pulse and capillary refill in the toes is essential for assessing circulation but not specific to detecting FES. Administering a stool softener, while important for preventing constipation in immobilized patients, is not directly related to detecting or preventing FES.
Question 4
A patient with newly diagnosed lung cancer tells the nurse, 'I don't think I'm going to live to see my next birthday.' Which response by the nurse is best?
A. Would you like to talk to the hospital chaplain about your feelings?
B. Can you tell me what it is that makes you think you will die so soon?
C. Are you afraid that the treatment for your cancer will not be effective?
D. Do you think that taking an antidepressant medication would be helpful?
Show answer and rationale
Correct answer: B — Can you tell me what it is that makes you think you will die so soon?
The nurse's initial response should be to collect more assessment data about the patient's statement. The answer beginning 'Can you tell me what it is' is the most open-ended question and will offer the best opportunity for obtaining more data. The answer beginning 'Are you afraid' implies that the patient thinks that the cancer will be immediately fatal, although the patient's statement may not be related to the cancer diagnosis. The remaining two answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate.
Question 5
The infant has a diagnosis of bladder exstrophy. To protect the exposed bladder tissue, what intervention should the nurse plan?
A. Cover the bladder with petroleum jelly gauze.
B. Cover the bladder with a non-adhering plastic wrap.
C. Apply sterile distilled water dressings over the bladder mucosa.
D. Keep the bladder tissue dry by covering it with dry sterile gauze.
Show answer and rationale
Correct answer: C — Apply sterile distilled water dressings over the bladder mucosa.
Bladder exstrophy is a condition where the bladder is exposed and external to the body. To protect the exposed bladder tissue from drying out while allowing urine drainage, it is best to cover the bladder with a non-adhering plastic wrap. Using petroleum jelly gauze should be avoided as it can dry out, adhere to the mucosa, and damage delicate tissue upon removal. Applying sterile distilled water dressings can also dry out and cause damage when removed. Keeping the bladder tissue dry with sterile gauze is not ideal as maintaining a moist environment is important for tissue protection in this case.
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Question 6
A patient's body temperature has varied over the last 24 hours from 97.6 degrees F in the morning to 99 degrees F in the evening. The patient is worried that this change in temperature may indicate the beginning of a fever. Which of the following BEST explains this phenomenon?
A. The patient definitely has a fever in the evening and should be seen by a doctor.
B. The patient is experiencing changes related to a diurnal rhythm.
C. The patient is more than likely taking their temperature incorrectly.
D. The patient is experiencing changes related to fluctuating daily hormones.
Correct answer:
The patient is experiencing changes related to a diurnal rhythm. Diurnal rhythm is the phenomenon of body temperature fluctuating depending on the time of day. Temperatures taken in the morning are typically lower than those taken throughout the rest of the day. Choice A is incorrect because a single elevated temperature reading in the evening does not definitively indicate a fever. Choice C is incorrect as there is no indication of incorrect temperature measurement. Choice D is incorrect as the temperature changes are not related to monthly hormones but rather to the body's natural daily rhythm.
What information should be collected when assessing the health status of a community?
A. Air pollution levels
B. Number of health food stores
C. Most common causes of death
D. Education level of the individuals
Correct answer:
When assessing the health status of a community, it is crucial to gather data on various health measures such as the most common causes of death. This information helps in understanding the prevalent health issues within the community. Factors like air pollution levels, the number of health food stores, and the education level of individuals are important community aspects but do not directly reflect the health status of the community. Therefore, the correct answer is to collect data on the most common causes of death as it provides insights into the major health concerns affecting the community.
Which of the following puts the layers of skin in the correct order from right to left?
A. Dermis, epidermis, hypodermis
B. Hypodermis, epidermis, dermis
C. Epidermis, dermis, hypodermis
D. None of the above
Correct answer:
The correct order of the layers of skin from outermost to innermost is the epidermis, dermis, and then the hypodermis. The epidermis is the outermost layer of the skin, followed by the dermis, which is the middle layer containing connective tissue, hair follicles, and sweat glands. The hypodermis, also known as the subcutaneous tissue, lies beneath the dermis and consists of fat and connective tissue. Choice A is incorrect as it lists the layers in the reverse order. Choice B is incorrect as it reverses the order of the layers. Choice D is incorrect as there is a correct answer among the choices.
You have measured the urinary output of your resident at the end of your 8-hour shift. The output is 25 ounces. What should you do next?
A. Convert the number of ounces into cc.
B. Convert the number of ounces into cm.
C. Immediately report this poor output to the nurse.
D. Know that 25 ounces of urine is too much in 8 hours.
Correct answer:
You should convert the number of ounces into cc because cc is the unit of measurement used to record intake and output accurately. This urinary output falls within normal limits, so there is no need to report it immediately to the nurse. It is essential to report urinary outputs of less than 30 cc per hour to detect potential issues early. Converting ounces into centimeters (cm) is not appropriate in this context as cm is a unit of length, not volume. Knowing that 25 ounces of urine is too much in 8 hours is inaccurate as it depends on various factors like fluid intake and individual differences.
A 4-year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first?
A. Place the child in the nearest bed
B. Administer IV medication to slow down the seizure
C. Place a padded tongue blade in the child's mouth
D. Remove the child's toys from the immediate area
Correct answer:
During a seizure, the priority nursing actions are to ensure the safety of the child and maintain airway patency. Placing objects in the child's mouth, like a padded tongue blade, is not recommended as it can lead to injury or obstruction of the airway. Moving the child to a bed is also not the immediate priority during a seizure. Administering IV medication to slow down the seizure is not typically done as the initial action. Therefore, the correct first nursing action is to remove any potential hazards, such as the hard plastic toys, from the immediate area to prevent injury during the seizure.
A client with Multiple Sclerosis reports a constant, burning, tingling pain in the shoulders. The nurse anticipates that the physician will order which medication for this type of pain?
A. alprazolam (Xanax)
B. Corticosteroid injection
C. gabapentin (Neurontin)
D. hydrocodone/acetaminophen (Norco)
Correct answer:
For neuropathic pain associated with conditions like Multiple Sclerosis, medications like gabapentin, an anticonvulsant, are commonly used. Gabapentin helps in managing nerve pain by stabilizing electrical activity in the brain and nervous system. Alprazolam is a benzodiazepine used for anxiety and not primarily indicated for neuropathic pain. Corticosteroid injections are more suitable for inflammatory conditions like arthritis, not for neuropathic pain. Hydrocodone/acetaminophen is an opioid combination used for moderate to severe pain, but it is not the first-line choice for neuropathic pain.
A client in the emergency room enters the care area to start an IV. He finds a man sitting on the table, hunched over, and attempting to take deep breaths. He states, 'my chest hurts so much!' His wife is sitting on a chair in the corner, crying. Which of the following is the first action of the client?
A. Bring the IV kit and quickly start an IV
B. Assess his breathing and provide oxygen, if necessary
C. Administer medication to control chest pain
D. Talk with his wife and find out why she is crying
Correct answer:
In the above scenario, the first action of the nurse should be to assess the client's airway and breathing. It is crucial to address respiratory status first, as the client appears to be experiencing difficulty breathing. Providing oxygen if necessary can help support oxygenation and alleviate potential respiratory distress. Administering medication for chest pain or starting an IV can come after ensuring adequate oxygenation. Talking with the client's wife, though important for emotional support, is not the priority when the client's respiratory status needs to be assessed and managed promptly.
The nurse is teaching a student nurse about the different types of thermometers. When teaching the student about the advantages of the tympanic membrane thermometer (TMT), which statement would the nurse include?
A. "Measuring temperature using the TMT is cost-effective."?
B. "The rapid measurement of the TMT is beneficial for uncooperative younger children."?
C. "TMT is not recommended for measuring core body temperature in newborn infants."?
D. "TMT is not the preferred method for measuring body temperature in patients with otitis media."?
Correct answer:
The correct answer is "The rapid measurement of the TMT is beneficial for uncooperative younger children." TMT is ideal for young children who may not cooperate for oral temperatures or fear rectal temperatures. However, using TMT for newborn infants is not recommended due to inconsistencies in results. Measuring temperature with TMT is not necessarily cost-effective. The most accurate method for measuring core temperature is through rectal temperatures. TMT may not be the preferred method for patients with otitis media due to potential inaccuracies caused by fluid behind the tympanic membrane.
Tommy R., your 68-year-old patient, is at risk for falls. He has fallen 3 times in the last month. You should keep Tommy's ______________ in order to prevent him from falling again.
A. bedside rails up at all times
B. bed in the low position
C. call bell within reach
D. family members in the room at all times
Correct answer:
To prevent falls, it is essential to keep the patient's call bell within reach so they can easily call for help when needed. This allows for timely assistance and can prevent falls. While low beds can reduce the severity of injuries in case of a fall, they do not prevent falls from happening. Having family members in the room at all times is not a realistic or practical solution. Side rails can actually increase the severity of falls as patients may attempt to climb over them, and using side rails as fall prevention is considered a restraint practice that can lead to entrapment and other risks.
Which entry in the medical record best meets the requirement for problem-oriented charting?
A. "A: Pacing and muttering to self. P: Sensory perceptual alteration, related to internal auditory stimulation. I: Given fluphenazine (Prolixin) 2.5 mg at 0900, and went to room to lie down. E: Calmer by 0930. Returned to lounge to watch TV."?
B. "S: States, 'I feel like I'm ready to blow up.' O: Pacing hall, mumbling to self. A: Auditory hallucinations. P: Offer haloperidol (Haldol) 2 mg . I: (Haldol) 2 mg at 0900. E: Returned to lounge at 0930 and quietly watched TV."?
C. "Agitated behavior. D: Patient muttering to self as though answering an unseen person. A: Given haloperidol (Haldol) 2 mg and went to room to lie down. E: Patient calmer. Returned to lounge to watch TV."?
D. "Pacing hall and muttering to self as though answering an unseen person. haloperidol (Haldol) 2 mg administered at 0900 with calming effect in 30 minutes. Stated, 'I'm no longer bothered by the voices.'"?
Correct answer:
Problem-oriented documentation uses the first letter of key words to organize data: S for subjective data, O for objective data, A for assessment, P for plan, I for intervention, and E for evaluation. The correct answer demonstrates problem-oriented charting by following this structure. Choice A, C, and D do not follow the problem-oriented charting format and instead offer examples of different documentation styles such as PIE charting, focus documentation, and narrative documentation, respectively. Therefore, choice B is the best example of problem-oriented charting among the options provided.
NCLEX-RN clinical judgment practice questions, set 45 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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