NCLEX-RN clinical judgment practice questions, set 5
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 5
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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
Which finding is most important for the nurse to communicate to the health care provider about a patient who received a liver transplant 1 week ago?
A. Dry palpebral and oral mucosa
B. Crackles at bilateral lung bases
C. Temperature 100.8?F (38.2?C)
D. No bowel movement for 4 days
Show answer and rationale
Correct answer: C — Temperature 100.8?F (38.2?C)
The correct answer is the patient's temperature of 100.8°F (38.2°C). In a patient who received a liver transplant 1 week ago, a fever is a significant finding that should be promptly communicated to the health care provider. Post-transplant patients are at high risk of infections, and fever can often be the initial indicator of an underlying infectious process. The other findings listed in choices A, B, and D are important and should be addressed, but they do not take precedence over a potential infection post-liver transplant. Dry palpebral and oral mucosa may indicate dehydration, crackles at bilateral lung bases may suggest fluid overload or infection, and no bowel movement for 4 days could indicate a bowel obstruction or ileus. However, in the context of a recent liver transplant, an elevated temperature is the most concerning and requires immediate attention to rule out infection.
Question 2
You are caring for an infant who is just about 12 months old. Which assessment data is normal for the infant at this age?
A. The infant had doubled their birth weight at twelve months.
B. The infant had tripled their birth weight at twelve months.
C. The mother reports that the infant is drinking 60 mLs per kilogram of its body weight.
D. The infant had grown ¼ inch since last month.
Show answer and rationale
Correct answer: A — The infant had doubled their birth weight at twelve months.
The normal assessment data for the infant at 12 months of age is that the infant has doubled their birth weight at 12 months of age.
The mother's reports that the infant is drinking 60 mLs per kilogram of its body weight and the fact that the infant had grown ¼ inch since last month are not normal assessment data. Infants are fed breast milk or formula every two to four hours with a total daily intake of 80 to 100 mLs per kilogram of body weight.
As the neonate grows, they gain five to seven ounces during the first six months and then they double their birth weight during the first year; the head circumference increases a half inch each month for six months and then two tenths of an inch until the infant is one year of age. Similarly, the height or length of the newborn increases an inch a month for the first 6 months and then 1/2 inch a month until the infant is 1 year of age.
Question 3
The nurse is reviewing the hot/cold theory of health and illness. Which statement best describes the basic tenets of this theory?
A. The causation of illness is based on supernatural forces that influence the humors of the body.
B. Herbs and medicines are classified based on their physical characteristics of hot and cold and the humors of the body.
C. The four humors of the body consist of blood, yellow bile, black bile, and phlegm.
D. The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors of the body.
Show answer and rationale
Correct answer: D — The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors of the body.
The hot/cold theory of health and illness is based on the four humors of the body: blood, phlegm, black bile, and yellow bile. These humors regulate the basic bodily functions, described in terms of temperature, dryness, and moisture. The treatment of disease in this theory involves adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors. Choice A is incorrect as the theory is not based on supernatural forces but on the balance of bodily humors. Choice B is incorrect as herbs and medicines are not classified solely based on their physical characteristics of hot and cold in this theory. Choice C is incorrect as the four humors are blood, phlegm, black bile, and yellow bile, not spiritual connectedness or social aspects. Therefore, the correct choice is D, as it accurately reflects a foundational tenet of the hot/cold theory of health and illness.
Question 4
What action by the nurse will be most effective in decreasing the spread of pertussis in a community setting?
A. Providing supportive care to patients diagnosed with pertussis
B. Teaching family members about the importance of careful handwashing
C. Teaching patients about the necessity of adult pertussis immunizations
D. Encouraging patients to complete the prescribed course of antibiotics
Show answer and rationale
Correct answer: C — Teaching patients about the necessity of adult pertussis immunizations
The most effective action by the nurse to decrease the spread of pertussis in a community setting is to teach patients about the necessity of adult pertussis immunizations. The increased rate of pertussis in adults is often attributed to waning immunity after childhood immunization. Immunization is highly effective in protecting communities from infectious diseases. While teaching about handwashing is important for overall infection control, pertussis is primarily spread through respiratory droplets and contact with secretions. Providing supportive care does not significantly impact the disease course or transmission risk. Encouraging completion of antibiotics may help reduce transmission, but patients likely have already spread the disease by the time the diagnosis is made. Therefore, the emphasis should be on prevention through immunization to reduce the spread of pertussis.
Question 5
The nurse recognizes that teaching a 44-year-old woman following a laparoscopic cholecystectomy has been effective when the patient states which of the following?
A. I can expect yellow-green drainage from the incision for a few days.
B. I can remove the bandages on my incisions tomorrow and take a shower.
C. I should plan to limit my activities and not return to work for 4 to 6 weeks.
D. I will always need to maintain a low-fat diet since I no longer have a gallbladder.
Show answer and rationale
Correct answer: B — I can remove the bandages on my incisions tomorrow and take a shower.
The correct answer is, 'I can remove the bandages on my incisions tomorrow and take a shower.' After a laparoscopic cholecystectomy, patients have Band-Aids over the incisions and can typically remove the bandages the next day. Patients are usually discharged the same or next day and have minimal restrictions on their daily activities. Yellow-green drainage from the incision would be abnormal, requiring the patient to contact their healthcare provider. While a low-fat diet may be recommended initially after surgery, it is not a lifelong requirement, as the body can adjust to the absence of the gallbladder over time. Choice A is incorrect as abnormal drainage should be reported. Choice C is incorrect as most patients can resume normal activities within a few days to a week. Choice D is incorrect as maintaining a low-fat diet is not a lifelong necessity after a cholecystectomy.
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Question 6
A 33-year-old male client with heart failure has been taking furosemide for the past week. Which of the following assessment cues below may indicate the client is experiencing a negative side effect from the medication?
A. Weight gain of 5 pounds
B. Edema of the ankles
C. Gastric irritability
D. Decreased appetite
Correct answer:
The correct answer is 'Decreased appetite.' Furosemide is a loop diuretic used for conditions like heart failure, where it helps reduce fluid retention. One common side effect of furosemide is hypokalemia, which can lead to decreased appetite among other symptoms. Hypokalemia is a low level of potassium in the blood, and its signs and symptoms include anorexia, fatigue, nausea, decreased GI motility, muscle weakness, dysrhythmias, reduced urine osmolality, and altered level of consciousness. Weight gain and ankle edema are actually expected outcomes of furosemide therapy due to its diuretic effect, which helps reduce edema and fluid overload. Gastric irritability is a nonspecific symptom that is not typically associated with furosemide use. Therefore, a decreased appetite is a key indicator of a potential negative side effect when assessing a client on furosemide therapy.
A patient's urine tests positive for glucose. The doctor asks you to confirm this finding. Which of the following would BEST confirm this finding?
A. Run the urine on the hand-held glucometer.
B. Have another MA perform a repeat dipstick test.
C. Run a Clinitest.
D. Run an Acetest.
Correct answer:
To confirm glucosuria, the most appropriate method is to run a Clinitest. Clinitest tablets are specifically designed to detect glucose in urine samples. This test is particularly useful when the urine is discolored, making it challenging to accurately assess the color change.\n
Choice A, using a hand-held glucometer, is not the standard method for confirming glucose in urine; these devices are primarily used for blood glucose monitoring.\n
Choice B, having another Medical Assistant perform a repeat dipstick test, may not provide a more definitive confirmation as dipstick tests can sometimes yield false positives or be less accurate compared to other methods like the Clinitest.\n
Choice D, running an Acetest, is used to detect ketones in the urine, not glucose. Ketones are typically associated with conditions like diabetic ketoacidosis, which is different from glucosuria.
Which of the following statements is true regarding non-profit organizations?
A. They are located in various areas, not specifically poor or rural ones.
B. They are mandated to care for people, even if clients are unable to pay for services.
C. The money they receive for services is reinvested back into their own business to further develop services.
D. They are not referred to as proprietary organizations.
Correct answer:
Non-profit organizations are entities that operate for a social cause or public benefit, and they do not distribute profits to owners or shareholders. They are not limited to being located in poor or rural areas; they can be found in various locations. One key characteristic of non-profits is that they are obligated to provide services, regardless of a client's ability to pay. This ensures that essential services are accessible to all individuals in need. The statement 'The money they receive for services is reinvested back into their own business to further develop services' is correct. Non-profit organizations reinvest any surplus funds back into their operations to enhance the services they provide. The statement 'They are not referred to as proprietary organizations' is correct because proprietary organizations are typically for-profit entities, not non-profit ones.
Mr. B is recovering from a surgical procedure that was performed four days ago. The nurse's assessment finds this client coughing up rust-colored sputum; his respiratory rate is 28/minute with expiratory grunting, and his lung sounds have coarse crackles on auscultation. Which of the following conditions is the most likely cause of these symptoms?
A. Tuberculosis
B. Pulmonary edema
C. Pneumonia
D. Histoplasmosis
Correct answer:
In this scenario, the client's presentation of coughing up rust-colored sputum, increased respiratory rate, expiratory grunting, and coarse crackles on lung auscultation suggests the development of pneumonia. Pneumonia is characterized by lung tissue inflammation or infection, often caused by various organisms. Symptoms may include productive cough, dyspnea, and abnormal breath sounds. Tuberculosis (Choice A) typically presents with a chronic cough, weight loss, and night sweats and is less likely in this acute post-operative setting. Pulmonary edema (Choice B) is characterized by pink, frothy sputum, crackles throughout the lungs, and typically occurs in the context of heart failure. Histoplasmosis (Choice D) is a fungal infection that usually presents with flu-like symptoms and is less likely to manifest with the specific respiratory findings described in this case.
When performing a physical examination, safety must be considered to protect the examiner and the patient against the spread of infection. Which of these statements describes the most appropriate action the nurse would take when performing a physical examination?
A. Washing one's hands after removing gloves is necessary, even if the gloves are still intact
B. Hands are washed before and after every physical patient encounter
C. Hands are washed before the examination of each body system to prevent the spread of bacteria from one part of the body to another
D. Gloves are worn throughout the entire examination to demonstrate concern regarding the spread of infectious diseases
Correct answer:
The most appropriate action for the nurse to take when performing a physical examination is to wash their hands before and after every physical patient encounter. This practice helps prevent the spread of infection. Hands should also be washed after contact with blood, body fluids, secretions, and excretions, and after contact with any equipment contaminated with body fluids. It is crucial to wash hands after removing gloves, even if the gloves appear intact. Choice A is incorrect because washing hands after removing gloves is necessary to ensure thorough hygiene. Choice C is incorrect because hands should be washed before and after every patient encounter, not just before examining each body system. Choice D is incorrect because gloves should be worn when there is potential contact with body fluids, but they do not need to be worn throughout the entire examination.
When taking blood pressures on a variety of people at a health fair, what should the nurse keep in mind?
A. After menopause, blood pressure readings in women are usually higher than those taken in men.
B. The blood pressure of an African-American adult is usually higher than that of a non-Hispanic White adult of the same age.
C. Blood pressure measurements in people who are overweight are usually higher than those of people who are at a normal weight.
D. A teenager's blood pressure reading may be lower than that of an adult.
Correct answer:
When assessing blood pressures, it is important to consider that the blood pressure of African-American adults is typically higher than that of non-Hispanic White adults of the same age. This is significant as Black individuals in the United States have a higher prevalence of hypertension compared to other groups. Blood pressure readings in women are generally higher than in men after menopause. Additionally, blood pressure measurements in overweight individuals are typically higher than those in individuals of normal weight. While teenagers may have lower blood pressure readings than adults, it is crucial to recognize the trend of a gradual rise in blood pressure throughout childhood and into adulthood. Therefore, the correct choice is B. Choices A, C, and D are incorrect as they do not reflect the typical blood pressure differences observed in various populations.
What is the most appropriate suggestion regarding the diet for an 18-month-old child experiencing mild diarrhea and 'mushy' stools, but tolerating fluids and solid foods?
A. Applesauce, bananas, wheat toast
B. Mashed potatoes with baked chicken
C. Gelatin, strained cabbage, and custard
D. Fluids only until the 'mushy' stools stop
Correct answer:
For a child with mild diarrhea who is tolerating fluids and solid foods, the most appropriate diet suggestion would be to continue feeding a normal diet to prevent dehydration, reduce stool frequency and volume, and hasten recovery. Foods that are well tolerated during diarrhea include bland but nutritional options like complex carbohydrates (rice, wheat, potatoes, cereals), yogurt with live cultures, cooked vegetables, and lean meats. Mashed potatoes with baked chicken provide a balance of nutrients and are easy on the digestive system. Options A and C contain foods that may worsen diarrhea; applesauce and gelatin can be high in sugars which can exacerbate diarrhea, and cabbage may be hard to digest for some individuals. Option D of offering fluids only can affect the child's nutritional status by not providing enough essential nutrients during the recovery period.
During an examination, the nurse notices that a female patient has a round "moon"? face, central trunk obesity, and a cervical hump. Her skin is fragile with bruises. The nurse determines that the patient likely has which condition?
A. Gigantism
B. Acromegaly
C. Cushing syndrome
D. Marfan syndrome
Correct answer:
Cushing syndrome is characterized by weight gain and edema with central trunk and cervical obesity (buffalo hump) and a round, plethoric face (moon face). Excessive catabolism in Cushing syndrome causes muscle wasting, weakness, thin arms and legs, reduced height, and thin, fragile skin with purple abdominal striae, bruising, and acne. Gigantism is characterized by increased height and weight and delayed sexual development, which are not present in the patient. Acromegaly results from excessive growth hormone secretion in adulthood, leading to bone overgrowth in specific areas like the face, head, hands, and feet. Marfan syndrome is an inherited connective tissue disorder characterized by a tall, thin stature and distinct features not seen in this patient. The combination of signs described in the question aligns with the clinical presentation of Cushing syndrome.
Which of the following tasks may be delegated to unlicensed assistive personnel?
A. Cleansing a wound with peroxide
B. Irrigating a colostomy
C. Assisting with performing incentive spirometry
D. Removing a saline-lock IV
Correct answer:
Certain tasks can be safely delegated to unlicensed assistive personnel to assist nurses in their workload. Tasks that involve routine activities like incentive spirometry can be delegated. Unlicensed assistive personnel can assist clients with incentive spirometry, helping in promoting lung expansion and preventing respiratory complications. Cleansing a wound with peroxide (Choice A) and irrigating a colostomy (Choice B) involve more complex procedures that should be performed by licensed healthcare providers due to the risk of infection and potential complications. Removing a saline-lock IV (Choice D) requires specialized training and should only be performed by licensed personnel to prevent complications and ensure patient safety. The nurse remains responsible for delegating tasks appropriately and overseeing the care provided by unlicensed assistive personnel.
A second-year nursing student has just suffered a needlestick while working with a patient that is positive for AIDS. Which of the following is the most significant action that the nursing student should take?
A. Immediately see a social worker
B. Start prophylactic AZT treatment
C. Start prophylactic Pentamidine treatment
D. Seek counseling
Correct answer:
Starting prophylactic AZT treatment is the most critical intervention in this scenario. Azidothymidine (AZT) is an antiretroviral medication used to prevent and treat HIV/AIDS by reducing the replication of the virus. Post-exposure prophylaxis (PEP) for HIV involves taking medication to suppress the virus and prevent infection after exposure. PEP should be initiated within 72 hours of potential HIV exposure to be effective. Seeking treatment quickly is crucial to enhance its effectiveness. Seeing a social worker (Choice A) may be helpful for emotional support but is not the immediate priority. Pentamidine treatment (Choice C) is not indicated for post-exposure prophylaxis for HIV. Seeking counseling (Choice D) is important for the nursing student's emotional well-being but does not address the urgent need for post-exposure prophylaxis to prevent HIV transmission.
NCLEX-RN clinical judgment practice questions, set 5 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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