NCLEX-RN clinical judgment practice questions, set 48
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 48
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 client is refusing to undergo any more treatments in the hospital and wants to leave against medical advice. When the nurse requests the client to sign an AMA order, the client refuses and leaves. What is the next action of the nurse?
A. Call security to hold the client until he signs the order
B. Notify the physician to convince the client to stay
C. Speak with the client's spouse to persuade him to stay
D. Allow the client to leave and document the refusal in his chart
Show answer and rationale
Correct answer: D — Allow the client to leave and document the refusal in his chart
The nurse cannot force the client to stay in the hospital to receive treatment or to sign an AMA order. It is essential to respect the client's autonomy and decision-making capacity. While involving security or pressuring the client through the physician or spouse may seem like options, they are not appropriate in this situation. The nurse should allow the client to leave if they are competent to make that decision, document the refusal in the client's chart to ensure all actions are appropriately documented, and follow institutional policies for patients leaving against medical advice.
Question 2
A 7-year-old child is seen in a clinic, and the pediatrician documents a diagnosis of nighttime (nocturnal) enuresis. What information should the nurse provide to the parents?
A. Nighttime (nocturnal) enuresis does not respond to treatment.
B. Nighttime (nocturnal) enuresis is caused by a psychiatric problem.
C. Nighttime (nocturnal) enuresis requires surgical intervention to improve the problem.
D. Nighttime (nocturnal) enuresis is usually outgrown without therapeutic intervention.
Show answer and rationale
Correct answer: D — Nighttime (nocturnal) enuresis is usually outgrown without therapeutic intervention.
Nighttime (nocturnal) enuresis is common in children and is characterized by a child who has never been dry at night for extended periods. Most children eventually outgrow bedwetting without therapeutic intervention. This condition is due to the child being unable to sense a full bladder and not awakening to void, often related to delayed maturation of the central nervous system. It is important for parents to understand that nighttime (nocturnal) enuresis is not caused by a psychiatric problem, does not typically require surgical intervention, and usually resolves on its own over time.
Question 3
Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia? (Select one that does not apply)
A. Age
B. Blood pressure
C. Respiratory rate
D. Oxygen saturation
Show answer and rationale
Correct answer: D — Oxygen saturation
The correct answer is 'Oxygen saturation.' When calculating the CURB-65 score for a patient with pneumonia, the factors considered include mental status (confusion), BUN (elevated), blood pressure (decreased), respiratory rate (increased), and age (65 and older). Oxygen saturation is not used in the CURB-65 scoring system. While blood pressure, respiratory rate, and age are factors that are used in the calculation of the CURB-65 score, oxygen saturation is not part of the scoring criteria. Therefore, oxygen saturation is the factor that does not apply when calculating the CURB-65 score.
Question 4
A client is being assessed for risks of a pressure ulcer by a healthcare professional. What is the best description of what may be found with an early pressure ulcer in an African American client?
A. Skin has a purple/bluish color
B. Capillary refill is 1 second
C. Skin appears blanched at the pressure site
D. Tenting appears when checking skin turgor
Show answer and rationale
Correct answer: A — Skin has a purple/bluish color
When assessing for signs of developing pressure ulcers in a client with dark skin, traditional signs like blanching may not be evident. In individuals with darker skin tones, the skin of an early pressure ulcer may present with a purple or bluish hue. This discoloration can be a crucial indicator of compromised circulation and tissue damage. Capillary refill, blanching, and tenting are more commonly used in the assessment of skin integrity and hydration levels but may not be as reliable in individuals with darker skin tones, making the purple/bluish color a key finding in this context.
Question 5
A client is found lying on the floor near the bathroom door, stating, 'I thought I could get up on my own.' What information must the nurse document in this situation?
A. A statement explaining the condition the client was found in, quoting the client's words about the situation
B. An explanation of how the fall happened and when the physician was notified
C. An account of the conditions of the room that contributed to the client's fall
D. A summary of the client's medical history and current medications
Show answer and rationale
Correct answer: A — A statement explaining the condition the client was found in, quoting the client's words about the situation
When a fall or injury occurs while under nursing care, it is crucial to document the known aspects of the situation and the response to the injury. In this scenario, the nurse should document the client's condition as found and quote the client's own words about the situation. This helps provide a clear account of the event without implying blame. Options B, C, and D are incorrect because detailing how the fall happened, listing room conditions, or summarizing medical history are not directly relevant to documenting the immediate situation and the client's own words following the fall.
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Question 6
A client with schizophrenia seems to stop focusing during a conversation with a nurse and begins looking at the ceiling and talking to themselves. Which of the following actions should the nurse take?
A. Stop the interview at this point and resume later when the client is better able to concentrate
B. Ask the client, 'Are you seeing something on the ceiling?'
C. Tell the client, 'You seem to be looking at something on the ceiling. I see something there, too.'
D. Continue the interview without commenting on the client's behavior
Correct answer:
When a client with schizophrenia experiences a break in reality like staring at the ceiling and talking to themselves, the nurse should ask directly about the hallucination, as stated in choice B. By doing so, the nurse can assess the situation, identify the client's needs, and evaluate any potential risk for injury. Choices A, C, and D are incorrect. Stopping the interview (choice A) may not address the immediate concern of the hallucination. Providing false reassurance (choice C) or ignoring the behavior (choice D) does not actively address the client's altered perception of reality.
A patient is undergoing a stress test on a treadmill and turns to talk to the nurse. Which of these statements would require the most immediate intervention?
A. I'm feeling extremely thirsty and will get some water after this.
B. I can feel my heart racing.
C. My shoulder and arm are hurting.
D. My blood pressure reading is 158/80
Correct answer:
The correct answer is 'C: My shoulder and arm are hurting.' Unilateral arm and shoulder pain are classic symptoms of myocardial ischemia, indicating possible heart issues. In this scenario, immediate intervention is required, and the stress test should be halted. Choice A about feeling thirsty does not indicate an acute medical issue. Choice B mentioning heart racing is expected during a stress test. Choice D, a blood pressure reading of 158/80, while slightly elevated, does not present an immediate concern compared to the symptoms of arm and shoulder pain suggesting cardiac distress.
The patient with migraine headaches has a seizure. After the seizure, which action can you delegate to the nursing assistant?
A. Document the seizure
B. Perform neurologic checks
C. Take the patient's vital signs
D. Restrain the patient for protection
Correct answer:
After a patient with migraine headaches has a seizure, it is important to assess their vital signs to monitor their condition. This task can be safely delegated to a nursing assistant as it falls within their scope of practice. Documenting the seizure and performing neurologic checks require a higher level of training and should be done by a nurse or healthcare provider. Restraint should never be used as a first-line intervention after a seizure unless there is an immediate threat to the patient's safety, and it should be done following proper protocols and with appropriate training.
Which finding would necessitate an immediate change in the therapeutic plan for a patient with grade 2 hepatic encephalopathy?
A. Weight loss of 2 lb (1 kg)
B. Positive urine pregnancy test
C. Hemoglobin level of 10.4 g/dL
D. Complaints of nausea and anorexia
Correct answer:
A positive urine pregnancy test would require an immediate change in the therapeutic plan for a patient with grade 2 hepatic encephalopathy due to the teratogenic effects of ribavirin. Ribavirin needs to be discontinued immediately to prevent harm to the fetus. The other options, weight loss, hemoglobin level, and complaints of nausea and anorexia, are common adverse effects of the prescribed regimen and may necessitate interventions such as patient education or supportive care, but they would not mandate an immediate cessation of therapy as in the case of a positive pregnancy test.
The nurse is conducting a health fair for older adults. Which statement is true regarding vital sign measurements in aging adults?
A. The pulse is easier to palpate due to the rigidity of the blood vessels.
B. An increased respiratory rate and a shallower inspiratory phase are expected findings.
C. A widened pulse pressure occurs from changes in the systolic and diastolic blood pressures.
D. Changes in the body's temperature regulatory mechanism decrease the older adult's likelihood of developing a fever.
Correct answer:
Aging causes a decrease in vital capacity and decreased inspiratory reserve volume. As a result, the examiner may observe a shallower inspiratory phase and an increased respiratory rate in older adults. Contrary to common belief, the increased rigidity of arterial walls actually makes the pulse easier to palpate in aging adults. Pulse pressure is widened, not decreased, due to changes in systolic and diastolic blood pressures. Furthermore, changes in the body's temperature regulatory mechanism make older individuals less likely to develop a fever but more susceptible to hypothermia.
Elderly patients are more prone to dehydration than younger people because the elderly ___________.
A. drink more coffee and tea
B. have more stomach mucus production
C. have more saliva
D. have less sense of thirst
Correct answer:
Elderly patients are prone to dehydration because they have a lower and diminished sense of thirst. This reduced sensation of thirst makes them less likely to drink an adequate amount of fluids, leading to dehydration. While it is true that elderly individuals may also have changes such as decreased stomach mucus production and saliva production, these factors do not directly contribute to dehydration. Drinking more coffee and tea, as mentioned in choice A, is not a consistent behavior among all elderly individuals and is not a primary reason for their increased risk of dehydration.
Your patient had a stroke, or CVA, five years ago. The resident still has right-sided weakness. You are ready to transfer the resident from the bed to the wheelchair. The wheelchair should be positioned at the _____________.
A. head of the bed on the patient's right side
B. head of the bed on the patient's left side
C. bottom of the bed on the patient's right side
D. bottom of the bed on the patient's left side
Correct answer:
The wheelchair should be positioned at the head of the bed on the resident's left side. This positioning allows the resident to use their stronger left side to assist with the transfer, compensating for the right-sided weakness. Placing the wheelchair at the head of the bed on the patient's right side (Choice A) would not utilize the stronger left side, which is crucial for the transfer. Similarly, positioning the wheelchair at the bottom of the bed on either side (Choices C and D) would not facilitate optimal assistance from the resident's stronger side during the transfer process.
A client has fallen asleep in his bed in the hospital. His heart rate is 65 bpm, his muscles are relaxed, and he is difficult to arouse. Which stage of the sleep cycle is this client experiencing?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
Correct answer:
The client in this scenario is experiencing stage 3 of the sleep cycle. In stage 3, the individual has moved into deeper stages of sleep, making it difficult to arouse. Characteristics of stage 3 include relaxed muscles, a decrease in vital signs, and being very still. Stage 3 is a phase of non-REM sleep where the client progresses towards REM sleep and vivid dreams. Choices A, B, and D are incorrect. Stage 1 is characterized by light sleep, stage 2 is a slightly deeper sleep with sleep spindles and K-complexes, and stage 4 is the deepest stage of sleep with the slowest brain waves.
The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which sign of this disorder documented?
A. Watery diarrhea
B. Ribbon-like stools
C. Profuse projectile vomiting
D. Bright red blood and mucus in the stools
Correct answer:
Intussusception is a condition where a part of the bowel slides into the next section, causing an obstruction. The classic presentation includes severe abdominal pain that is crampy, intermittent, and may cause the child to draw knees to the chest. While vomiting can occur, it is not typically projectile in nature. A key hallmark of intussusception is the passage of bright red blood and mucus in the stools, often described as currant jelly-like. Watery diarrhea and ribbon-like stools are not typical signs of intussusception and should not be expected in a child with this condition.
Which of the following descriptions best describes the function of the thyroid gland?
A. The thyroid gland converts glucose into glycogen
B. The thyroid gland secretes cortisol during times of stress
C. The thyroid gland regulates body metabolism
D. The thyroid gland affects skin pigmentation
Correct answer:
The thyroid gland is responsible for secreting thyroxine (T4) and triiodothyronine (T3), which work to regulate the metabolism of the body's cells. The primary function of the thyroid gland is to control the body's metabolic rate, affecting processes such as heart rate, temperature regulation, and energy levels. Choices A, B, and D are incorrect because the thyroid gland is not involved in converting glucose into glycogen, secreting cortisol, or affecting skin pigmentation. Instead, the primary role of the thyroid gland is to regulate the metabolism and energy balance in the body.
NCLEX-RN clinical judgment practice questions, set 48 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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