NCLEX-RN clinical judgment practice questions, set 49
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 49
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
When performing an EKG, the patient starts to laugh out of feelings of anxiety. What would you expect the EKG to show? (Choose the BEST answer.)
A. Increased pulse rate, normal EKG
B. Decreased pulse rate, abnormal EKG
C. Tachycardia, poor EKG graph
D. Bradycardia, poor EKG graph
Show answer and rationale
Correct answer: C — Tachycardia, poor EKG graph
When a patient laughs due to anxiety during an EKG, it is likely to cause tachycardia, which is a rapid heart rate. This increased heart rate can lead to poor EKG graph quality as the electrical signals from large moving muscles can interfere with data collection from the chest leads. Therefore, in this scenario, the EKG is expected to show tachycardia with poor graph quality. Choices A, B, and D are incorrect because a patient laughing out of anxiety is more likely to result in an increased pulse rate (tachycardia) rather than a decreased pulse rate (bradycardia) or a normal EKG.
Question 2
Which statement by the client with chronic obstructive lung disease indicates an understanding of the major reason for the use of occasional pursed-lip breathing?
A. ''This action of my lips helps to keep my airway open.''
B. ''I can expel more air when I pucker up my lips to breathe out.''
C. ''My mouth doesn't get as dry when I breathe with pursed lips.''
D. ''By prolonging breathing out with pursed lips, the smaller areas in my lungs don't collapse.''
Show answer and rationale
Correct answer: D — ''By prolonging breathing out with pursed lips, the smaller areas in my lungs don't collapse.''
The correct answer is D. Clients with chronic obstructive pulmonary disease have difficulty exhaling fully due to the weak alveolar walls from the disease process. Pursed-lip breathing helps prevent alveolar collapse by maintaining positive pressure in the airways during exhalation. This is the major reason for using pursed-lip breathing in individuals with chronic obstructive lung disease. Choices A, B, and C are incorrect because they do not directly address the main purpose of pursed-lip breathing, which is to prevent alveolar collapse and improve exhalation in these patients.
Question 3
The nurse is assessing an 8-year-old child whose growth rate measures below the third percentile for
a child his age. He appears significantly younger than his stated age and is chubby with infantile
facial features. Which condition does this child likely have?
A. Acromegaly
B. Marfan syndrome
C. Hypopituitary dwarfism
D. Achondroplastic dwarfism
Show answer and rationale
Correct answer: C — Hypopituitary dwarfism
Hypopituitary dwarfism is caused by a deficiency in growth hormone in childhood and results in a
retardation of growth below the third percentile, delayed puberty, and other problems. The child's
appearance fits this description. Achondroplastic dwarfism is a genetic disorder resulting in
characteristic deformities; Marfan syndrome is an inherited connective tissue disorder characterized
by a tall, thin stature and other features. Acromegaly is the result of excessive secretion of growth
hormone in adulthood which causes overgrowth of bone in the face, head, hands, and feet.
Question 4
The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate?
A. Unequal leg length
B. Limited adduction
C. Diminished femoral pulses
D. Symmetrical gluteal folds
Show answer and rationale
Correct answer: A — Unequal leg length
In developmental dysplasia of the hip (DDH), one of the key findings is unequal leg length. This occurs due to the dislocation of the hip joint, where the ball is loose in the socket. Limited adduction, the inability to bring the hip and knee towards the midline of the body, is also a common finding in DDH. Diminished femoral pulses are not typically associated with DDH, as it primarily affects the skeletal structure rather than vascular supply. Symmetrical gluteal folds are normal in infants and do not indicate DDH, as asymmetry in gluteal folds can be a sign of hip dislocation.
Question 5
After a class on culture and ethnicity, the new graduate nurse reflects a correct understanding of the concept of ethnicity with which statement?
A. "Ethnicity is dynamic and ever-changing."?
B. "Ethnicity is the belief in a higher power."?
C. "Ethnicity pertains to a social group that may possess shared traits such as religion and language."?
D. "Ethnicity is learned from birth through the processes of language acquisition and socialization."?
Show answer and rationale
Correct answer: C — "Ethnicity pertains to a social group that may possess shared traits such as religion and language."?
Ethnicity pertains to a social group that may possess shared traits such as common geographic origin, migratory status, religion, language, values, traditions, or symbols and food preferences. Culture is dynamic, ever-changing, and learned from birth through the processes of language acquisition and socialization. Religion is the belief in a higher power. Ethnicity pertains to a social group within the social system that claims to have variable traits, such as a common geographic origin, migratory status, religion, race, language, values, traditions, symbols, or food preferences.
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Question 6
While eating in the hospital cafeteria, a nurse notices a toddler at a nearby table choking on a piece of food and appearing slightly blue. What is the appropriate initial action to take?
A. Begin mouth-to-mouth resuscitation
B. Give the child water to help with swallowing
C. Perform 5 abdominal thrusts
D. Call for the emergency response team
Correct answer:
When a toddler is choking on a piece of food and appears blue, it indicates airway obstruction. The appropriate initial action should be to perform 5 abdominal thrusts. This technique can help dislodge the obstructing object and clear the airway. Initiating mouth-to-mouth resuscitation is not recommended as the first step in a choking emergency, especially in children. Giving water may not be effective and can worsen the situation by causing further blockage. Calling the emergency response team should be considered if the abdominal thrusts are unsuccessful in clearing the airway.
A nurse is providing discharge instructions for a client who had back surgery. All of the following indicate that the client is ready for discharge EXCEPT:
A. The client still has sutures at the incision site
B. The client is able to take a shower
C. The client must still use an ice pack at the wound site
D. The client has a temperature of 100.8°F
Correct answer:
When determining if a client is ready for discharge after back surgery, it is essential to ensure that there are no signs of complications or emerging issues. A postoperative temperature of 100.8°F may indicate a developing infection, and the client should not be discharged until this is further evaluated by the physician. Choices A, B, and C are indicators that the client is progressing well and ready for discharge, as having sutures, being able to shower, and using an ice pack are typically expected postoperative activities without indicating a need for further hospitalization.
Which goal has the highest priority in the plan of care for a 26-year-old homeless patient admitted with viral hepatitis who has severe anorexia and fatigue?
A. Increase activity level.
B. Maintain adequate nutrition
C. Establish a stable environment
D. Identify sources of hepatitis exposure
Correct answer:
The highest priority outcome is to maintain adequate nutrition because it is essential for hepatocyte regeneration. In viral hepatitis, the liver is affected, and proper nutrition supports the liver's function and regeneration. While increasing activity level and establishing a stable environment are important, they are not as urgent as ensuring the patient receives proper nutrition. Identifying sources of hepatitis exposure can help prevent future infections, but in the acute phase, the immediate focus should be on providing adequate nutrition to support the patient's recovery.
During a work shift, how can a nurse best demonstrate the dynamic nature of the nursing process?
A. Collaborating with the client to establish healthcare goals
B. Reviewing the client's medical record history
C. Explaining the purpose of administered medications to the client
D. Rapidly resetting priorities for client care based on changes in the client's condition
Correct answer:
The nursing process is dynamic as it involves adapting to the changing health status of the client. Rapidly resetting priorities for client care based on changes in the client's condition exemplifies this dynamic nature by responding promptly to evolving circumstances. Collaborating with the client to establish healthcare goals (Option A), reviewing the client's medical record history (Option B), and explaining the purpose of administered medications to the client (Option C) are all essential nursing actions but do not directly showcase the dynamic nature of the nursing process.
The nurse cares for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider?
A. Oxygen saturation is 88%.
B. Blood pressure is 145/90 mm Hg.
C. Respiratory rate is 22 breaths/minute when lying flat.
D. Pain level is 5 (on a 0 to 10 scale) with a deep breath.
Correct answer:
The correct answer is 'Oxygen saturation is 88%.' Following a thoracentesis, oxygen saturation should improve. A saturation of 88% suggests a potential complication like pneumothorax. While the other assessment findings are important, the priority is to address the low oxygen saturation to prevent further complications. High blood pressure and respiratory rate may also need attention, but the immediate concern is the oxygen saturation level. Pain level, though significant for the patient's comfort, takes lower priority compared to the potential life-threatening issue of hypoxia.
You are working the 4 pm to 12 midnight evening shift. You are taking care of a group of patients. The supervising RN identifies 5 patients who get a medication at 'HS'. When will you give this medication?
A. After the dinner meal
B. Whenever requested
C. At the patient's bedtime
D. Before the end of the shift
Correct answer:
The correct answer is to give the medication at the patient's bedtime. 'HS' is a medical abbreviation that stands for 'hora somni,' which translates to 'at bedtime' or 'at the hours of sleep.' This timing ensures that the medication is administered appropriately to align with the patient's sleep schedule and maximize its effectiveness. Choices A, B, and D are incorrect because giving the medication after dinner, whenever requested, or before the end of the shift may not coincide with the intended purpose of the medication, potentially affecting its efficacy and patient outcomes.
At the beginning of her shift in a long-term care facility, which of the following clients should a nurse check on first?
A. A 91-year-old man who needs help eating breakfast
B. An 86-year-old man who has been incontinent in his bed
C. An 82-year-old woman who needs IV antibiotics
D. A 75-year-old man who is recovering from an injury and needs an ice pack
Correct answer:
When prioritizing care in a long-term care facility, the nurse must consider tasks that require their immediate attention and cannot be delegated. Administering IV antibiotics is a critical nursing task that only the nurse can perform, ensuring the timely and correct delivery of medication to the patient. While assisting with breakfast, managing incontinence, and providing an ice pack are important, these tasks can be delegated to other healthcare team members, allowing the nurse to address the client needing IV antibiotics first to ensure effective treatment and patient safety.
A 6-month-old infant has been brought to the well-child clinic for a checkup. The infant is currently sleeping. What would the nurse do first when beginning the examination?
A. Wake the infant before beginning the examination.
B. Examine the infant's hips before the infant wakes up.
C. Auscultate the lungs and heart while the infant is still sleeping.
D. Begin with the assessment of the eye and continue with the remainder of the examination in a head-to-toe approach.
Correct answer:
When the infant is quiet or sleeping, it is an ideal time to assess the cardiac, respiratory, and abdominal systems. It is recommended not to wake the infant unnecessarily. Auscultating the lungs and heart while the infant is still sleeping allows for a comprehensive assessment without disturbing the infant. Examining the infant's hips prematurely may disrupt the infant's sleep. Starting with an assessment of the eye is not appropriate as it is an invasive procedure and should be performed towards the end of the examination after the non-invasive assessments have been completed.
A family member is complaining that the lights are too dim in the middle of the night when she comes in to visit her husband. What is the most objective response?
A. Patients sleep better with the lights dimmed.
B. The nightshift nurses prefer to work with less light.
C. It's time for him to sleep, and you should, too.
D. There's a reason we do that. Let me share a research study with you.
Correct answer:
The most objective response in this situation is to explain to the family member that there is a specific reason for dimming the lights and offer to share a research study to provide evidence-based information. By doing so, it helps the family member understand that the care provided is based on established practices and research, potentially alleviating her concerns and ensuring that her husband receives appropriate care. Choices A, B, and C do not address the family member's concern or provide a rationale backed by evidence, making them less suitable responses in this context.
After taking the vital signs for your patient and finding them to be normal, what should you do next?
A. Report the vital signs to the doctor
B. Write the vital signs on a scrap paper
C. Call the family members
D. Document them on the graphic VS form
Correct answer:
After assessing and finding that the vital signs are normal for the patient, the appropriate action would be to document them on the graphic VS form. This form is used to track and record vital sign measurements accurately and consistently. Reporting the normal vital signs to the doctor is not necessary unless there are concerning trends or deviations. Writing the vital signs on a scrap piece of paper is not recommended as it may not be an official or reliable record. Calling the family members is unrelated to the process of documenting and tracking vital signs for the patient.
NCLEX-RN clinical judgment practice questions, set 49 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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