NCLEX-RN clinical judgment practice questions, set 46
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 46
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 child with hemolytic-uremic syndrome is anuric and will undergo peritoneal dialysis. Which measure should the nurse implement?
A. Restrict fluids as prescribed.
B. Care for the arteriovenous fistula.
C. Encourage foods high in potassium.
D. Administer analgesics as prescribed.
Show answer and rationale
Correct answer: A — Restrict fluids as prescribed.
In hemolytic-uremic syndrome, often associated with bacterial toxins and viruses, acute kidney injury occurs in children, leading to symptoms like anemia, thrombocytopenia, renal injury, and CNS symptoms. For an anuric child with hemolytic-uremic syndrome undergoing peritoneal dialysis, fluid restriction is vital to prevent fluid overload. Pain management is not directly related to hemolytic-uremic syndrome. Foods high in potassium should be limited, not encouraged, due to impaired kidney function. Peritoneal dialysis does not involve an arteriovenous fistula, which is specific to hemodialysis.
Question 2
A mother brings her child to the well-child clinic and expresses concern to the nurse because the child has been playing with another child diagnosed with hepatitis. The nurse prepares to perform an assessment on the child, knowing that which finding would be of least concern for hepatitis?
A. Jaundice
B. Hepatomegaly
C. Dark-colored, frothy urine
D. Left upper abdominal quadrant pain
Show answer and rationale
Correct answer: D — Left upper abdominal quadrant pain
Assessment findings in a child with hepatitis typically include right upper quadrant tenderness and hepatomegaly. The child may also present with pale, clay-colored stools and dark, frothy urine. Jaundice, which can be observed in the sclerae, nail beds, and mucous membranes, is a common sign of hepatitis. Left upper abdominal quadrant pain is not a typical finding associated with hepatitis; therefore, it would be of least concern in this scenario. The other options are more commonly associated with hepatitis and are important signs to monitor for in a child with possible exposure to the virus.
Question 3
The nurse is preparing to assess a hospitalized patient who is experiencing significant shortness of breath. How should the nurse proceed with the assessment?
A. Have the patient lie down to obtain an accurate cardiac, respiratory, and abdominal assessment.
B. Obtain a thorough history and physical assessment from the patient's family member.
C. Immediately perform a complete history and physical assessment to obtain baseline information.
D. Examine the body areas relevant to the problem and complete the rest of the assessment after the problem has resolved.
Show answer and rationale
Correct answer: D — Examine the body areas relevant to the problem and complete the rest of the assessment after the problem has resolved.
When assessing a patient experiencing significant shortness of breath, it is crucial to prioritize the evaluation of areas directly related to the problem. Having the patient lie down may exacerbate the breathing difficulty. Therefore, the nurse should focus on examining the body areas pertinent to the issue, such as the respiratory and cardiac systems. Completing the rest of the assessment can be deferred until after addressing the immediate problem. Obtaining a complete history or involving family members should come after addressing the acute issue to ensure the patient's safety and comfort.
Question 4
A patient with Glaucoma is verbalizing his daily medication routine to the nurse. He states he has two different eye drop medications, both every twelve hours. He washes his hands, instills the drops, closes his eyes gently, and presses his finger to the corner of his eye nearest his nose. After waiting 1 minute with his eyes closed, he instills the other medication in the same way. What is the nurse's best response?
A. ''You should wait more than 1 minute between different medications.''
B. ''Your routine is very good! Can you demonstrate it for me?''
C. ''It is actually not the best practice to close your eyes after instilling eye drops.''
D. ''You should actually be pressing your finger in the other corner of the eye.''
Show answer and rationale
Correct answer: A — ''You should wait more than 1 minute between different medications.''
It is recommended to wait 10-15 minutes between different eye drop medications to give them time to absorb and avoid one medication washing another one out. Choice A is the correct response as the patient should wait more than 1 minute between administering different eye drop medications. Choice B is incorrect as the routine described by the patient needs improvement. Choice C is inaccurate as closing the eyes after instilling eye drops is a best practice to ensure proper absorption. Choice D is incorrect as pressing the finger to the corner of the eye nearest the nose is the correct technique.
Question 5
A client is receiving digoxin (Lanoxin) 0.25 mg daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider?
A. Blood pressure 94/60 mm Hg
B. Heart rate 76 bpm
C. Urine output 50 ml/hour
D. Respiratory rate 16 bpm
Show answer and rationale
Correct answer: A — Blood pressure 94/60 mm Hg
The correct answer is 'Blood pressure 94/60 mm Hg.' Both digoxin and metoprolol decrease the heart rate. Metoprolol specifically affects blood pressure. Therefore, the heart rate and blood pressure need to be within normal range (HR 60-100 bpm; systolic BP above 100 mm Hg) to safely administer both medications. A blood pressure of 94/60 mm Hg indicates hypotension, which could be exacerbated by metoprolol, necessitating immediate reporting to the healthcare provider. Choices B, C, and D are within normal limits and do not pose immediate risks related to the administration of these medications.
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Question 6
The parents of a newborn with hypospadias are reviewing the treatment plan with the nurse. Which statement by the parents indicates their understanding of the plan?
A. Caution should be used when straddling my infant on a hip.
B. Vital signs should be taken daily to check for bladder infection.
C. Catheterization will be necessary when my infant does not void.
D. Circumcision has been delayed to save tissue for surgical repair.
Correct answer:
Hypospadias is a congenital defect involving abnormal placement of the urethral orifice of the penis. In hypospadias, the urethral orifice is located below the glans penis along the ventral surface. It's important not to circumcise the infant, as the dorsal foreskin tissue will be required for surgical repair of the hypospadias. Option A is unrelated to the treatment plan for hypospadias. Option B is not directly related to the surgical repair of hypospadias. Option C is not a routine part of the treatment plan for hypospadias, as catheterization is usually managed by healthcare professionals.
When obtaining a health history and physical assessment for a 36-year-old female patient with possible multiple sclerosis (MS), the nurse should
A. assess for the presence of chest pain.
B. inquire about urinary tract problems.
C. inspect the skin for rashes or discoloration.
D. ask the patient about any increase in libido.
Correct answer:
When assessing a patient for possible multiple sclerosis (MS), it is important to inquire about urinary tract problems as they are common symptoms of the condition, such as incontinence or retention. Chest pain is not typically associated with MS, so assessing for its presence is not a priority. Inspecting the skin for rashes or discoloration is not a typical manifestation of MS. Additionally, a decrease in libido, rather than an increase, is more commonly seen in patients with MS. Therefore, the most appropriate action for the nurse in this scenario is to inquire about urinary tract problems.
When obtaining a health history and physical assessment for a 36-year-old female patient with possible multiple sclerosis (MS), the nurse should
A. assess for the presence of chest pain.
B. inquire about urinary tract problems.
C. inspect the skin for rashes or discoloration.
D. ask the patient about any increase in libido.
Correct answer:
When assessing a patient for possible multiple sclerosis (MS), it is important to inquire about urinary tract problems as they are common symptoms of the condition, such as incontinence or retention. Chest pain is not typically associated with MS, so assessing for its presence is not a priority. Inspecting the skin for rashes or discoloration is not a typical manifestation of MS. Additionally, a decrease in libido, rather than an increase, is more commonly seen in patients with MS. Therefore, the most appropriate action for the nurse in this scenario is to inquire about urinary tract problems.
When evaluating the temperature of older adults, what aspect should the healthcare provider remember about an older adult's body temperature?
A. The body temperature of the older adult is lower than that of a younger adult.
B. An older adult's body temperature is approximately the same as that of a young child.
C. Body temperature varies based on the type of thermometer used.
D. In older adults, body temperature can fluctuate widely due to less effective heat control mechanisms.
Correct answer:
When evaluating the temperature of older adults, it is important to note that their body temperature is usually lower than that of younger adults, with a mean temperature of 36.2°C. Choice B is incorrect because an older adult's body temperature is not approximately the same as that of a young child. Choice C is incorrect because body temperature is a physiological parameter and does not vary based on the type of thermometer used. Choice D is incorrect because while older adults may have less effective heat control mechanisms, their body temperature is typically lower, not widely fluctuating.
What type of blood pressure measurement error is most likely to occur if the nurse does not check for the presence of an auscultatory gap?
A. Diastolic blood pressure may not be heard.
B. Diastolic blood pressure may be falsely low.
C. Systolic blood pressure may be falsely low.
D. Systolic blood pressure may be falsely high.
Correct answer:
If an auscultatory gap is undetected, a falsely low systolic reading may occur. This gap can lead to an underestimation of the systolic blood pressure, causing potential misinterpretation of the patient's condition. The diastolic blood pressure may not be heard due to the gap, but the critical issue in this scenario is the risk of underestimating systolic blood pressure, which can impact clinical decision-making. Choices B, C, and D are incorrect because the key concern in this context is the potential for a falsely low systolic blood pressure reading when an auscultatory gap is not assessed.
The nurse is caring for a 10-year-old on admission to the burn unit. One assessment
parameter that will indicate that the child has adequate fluid replacement is:
A. Urinary output of 30 ml per hour
B. No complaints of thirst
C. Increased hematocrit
D. Good skin turgor around burn
Correct answer:
For a child of this age, this is adequate output, yet does not suggest overload. Disruption
of sodium-ATPase activity presumably causes an intracellular sodium shift which
contributes to hypovolemia and cellular edema. Heat injury also initiates the release of
inflammatory and vasoactive mediators. These mediators are responsible for local
vasoconstriction, systemic vasodilation, and increased transcapillary permeability. Increase
in transcapillary permeability results in a rapid transfer of water, inorganic solutes, and
plasma proteins between the intravascular and interstitial spaces.
The nurse is collecting data on a child recently diagnosed with glomerulonephritis. Which question to the mother should elicit data associated with the cause of this disease?
A. ''Has your child had any nausea or diarrhea?''
B. ''Have you noticed any rashes on your child?''
C. ''Did your child recently complain of a sore throat?''
D. ''Did your child sustain any injuries to the kidney area?''
Correct answer:
The correct answer is 'Did your child recently complain of a sore throat?' Group A beta-hemolytic streptococcal infection is a known cause of glomerulonephritis. In this condition, the child typically becomes ill with streptococcal infection of the upper respiratory tract, and then after 1 to 2 weeks, symptoms of acute poststreptococcal glomerulonephritis can develop. This question aims to gather crucial information related to a potential trigger for glomerulonephritis. Choices A, B, and D are incorrect because they do not pertain to a common cause or associated symptom of glomerulonephritis.
Which of the following is classified as a prerenal condition that affects urinary elimination?
A. Nephrotoxic medications
B. Pericardial tamponade
C. Neurogenic bladder
D. Polycystic kidney disease
Correct answer:
A prerenal condition is one that causes reduced urinary elimination by affecting the blood flow to the kidneys. Pericardial tamponade is a condition that impacts the heart's ability to pump sufficient blood, leading to decreased blood flow to vital organs such as the kidneys. This reduction in blood flow to the kidneys can result in decreased urine production. The other choices, such as nephrotoxic medications, neurogenic bladder, and polycystic kidney disease, do not primarily affect the blood flow to the kidneys and are not classified as prerenal conditions that impact urinary elimination.
The nurse is assessing a 3-year-old child for symptoms of autism spectrum disorder (ASD). Which assessment finding should lead the nurse to question the diagnosis?
A. Inability to react appropriately to social cues
B. Engages in repetitive behaviors
C. Comprehends language well beyond the complexity expected for age
D. Displays self-destructive behavior
Correct answer:
The correct answer is 'Comprehends language well beyond the complexity expected for age.' Children with autism spectrum disorder typically struggle with language and communication skills, so comprehending language well beyond their age level would not align with the diagnosis of ASD. This finding could indicate other developmental strengths or delays. Choices A, B, and D are more commonly associated with ASD - the inability to react appropriately to social cues, engaging in repetitive behaviors, and displaying self-destructive behavior are typical manifestations of autism spectrum disorder.
To palpate the liver during a head-to-toe physical assessment, the nurse should
A. put pressure on the biopsy site using a sandbag
B. elevate the head of the bed to facilitate breathing
C. place the patient on the right side with the bed flat
D. check the patient's post-biopsy coagulation studies
Correct answer:
To palpate the liver effectively during a head-to-toe physical assessment, the patient should be positioned on the right side with the bed flat. This position helps to splint the biopsy site and allows for proper palpation of the liver. Elevating the head of the bed has no direct relevance to palpating the liver. Checking coagulation studies is done before the biopsy and is unrelated to palpation. Putting pressure on the biopsy site using a sandbag is not an appropriate way to facilitate liver palpation as it does not provide the necessary support and stabilization needed for the procedure.
NCLEX-RN clinical judgment practice questions, set 46 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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