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NCLEX-RN clinical judgment practice questions, set 53

NCLEX-RN · clinical judgment

NCLEX-RN clinical judgment practice questions set 53

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

While auscultating a patient's lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding?

  1. A. Inspiratory crackles at the bases
  2. B. Expiratory wheezes in both lungs
  3. C. Abnormal lung sounds in the apices of both lungs
  4. D. Pleural friction rub in the right and left lower lobes
Show answer and rationale

Correct answer: A — Inspiratory crackles at the bases

The correct answer is 'Inspiratory crackles at the bases.' Crackles are low-pitched, bubbling sounds typically heard during inspiration, which aligns with the nurse's finding. Expiratory wheezes are high-pitched sounds and are not consistent with the described auscultation findings. The lower third of both lungs refers to the bases, not the apices, so option C is incorrect. Pleural friction rubs are grating sounds heard during both inspiration and expiration, unlike the described finding of only hearing the sounds during inhalation in the lower third of both lungs.

Question 2

While auscultating a patient's lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding?

  1. A. Inspiratory crackles at the bases
  2. B. Expiratory wheezes in both lungs
  3. C. Abnormal lung sounds in the apices of both lungs
  4. D. Pleural friction rub in the right and left lower lobes
Show answer and rationale

Correct answer: A — Inspiratory crackles at the bases

The correct answer is 'Inspiratory crackles at the bases.' Crackles are low-pitched, bubbling sounds typically heard during inspiration, which aligns with the nurse's finding. Expiratory wheezes are high-pitched sounds and are not consistent with the described auscultation findings. The lower third of both lungs refers to the bases, not the apices, so option C is incorrect. Pleural friction rubs are grating sounds heard during both inspiration and expiration, unlike the described finding of only hearing the sounds during inhalation in the lower third of both lungs.

Question 3

After an unimmunized individual is exposed to hepatitis B through a needle-stick injury, which actions will the nurse plan to take (select one that does not apply)?

  1. A. Administer hepatitis B vaccine.
  2. B. Test for antibodies to hepatitis B.
  3. C. Teach about alpha-interferon therapy.
  4. D. Give hepatitis B immune globulin.
Show answer and rationale

Correct answer: C — Teach about alpha-interferon therapy.

In the case of exposure to hepatitis B, the nurse should plan to administer hepatitis B vaccine to provide active immunity. Testing for antibodies to hepatitis B is essential to determine the individual's immune status. Giving hepatitis B immune globulin is necessary for passive immunity in cases of exposure. However, teaching about alpha-interferon therapy is not part of the standard management for hepatitis B exposure. Interferon therapy and oral antivirals are typically used in the treatment of chronic hepatitis B infections, not for prophylaxis after exposure.

Question 4

The nurse is caring for a 73-year-old man with cirrhosis. Which data obtained by the nurse during the assessment will be of most concern?

  1. A. The patient complains of right upper-quadrant pain upon palpation.
  2. B. The patient's hands flap back and forth when the arms are extended.
  3. C. The patient has ascites and a 2-kg weight gain from the previous day.
  4. D. The patient's skin has multiple spider-shaped blood vessels on the abdomen.
Show answer and rationale

Correct answer: B — The patient's hands flap back and forth when the arms are extended.

The most concerning data obtained by the nurse is the patient's hands flapping back and forth when the arms are extended, indicating asterixis, which is associated with hepatic encephalopathy. This condition can progress to hepatic coma and requires immediate attention. The presence of spider angiomas and right upper-quadrant abdominal pain are common findings in cirrhosis and do not warrant urgent intervention. Although ascites and weight gain suggest the need for treatment, they are not as alarming as the neurologic manifestations seen in hepatic encephalopathy.

Question 5

A client with a new colostomy is being taught how to care for the colostomy bag. Which statement from the client indicates the need for more education?

  1. A. I can clean the skin around the ostomy site with soap and water when I change the bag.
  2. B. I should irrigate the stoma regularly to avoid buildup of gas and odor.
  3. C. I need to wait 30 minutes after I irrigate to replace the colostomy bag.
  4. D. I should change the bag when it is one-third to one-fourth full.
Show answer and rationale

Correct answer: C — I need to wait 30 minutes after I irrigate to replace the colostomy bag.

A client with a new colostomy requires education on proper colostomy care. Waiting 30 minutes after irrigating to replace the colostomy bag is unnecessary. The client may reapply the bag once the skin is dry. Cleaning the skin around the ostomy site with soap and water, irrigating the stoma regularly to prevent gas and odor buildup, and changing the bag when it is one-third to one-fourth full are appropriate actions. Therefore, the statement indicating the need for more education is the one suggesting a specific time interval for bag replacement after irrigation.

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Question 6

Which laboratory test result should the nurse monitor to evaluate the effects of therapy for a 62-year-old female patient with acute pancreatitis?

  1. A. Calcium
  2. B. Bilirubin
  3. C. Amylase
  4. D. Potassium
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Question 7

The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient?

  1. A. Supine with the head of the bed elevated 30 degrees
  2. B. In a high-Fowler's position with the left arm extended
  3. C. On the right side with the left arm extended above the head
  4. D. Sitting upright with the arms supported on an overbed table
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Question 8

The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient?

  1. A. Supine with the head of the bed elevated 30 degrees
  2. B. In a high-Fowler's position with the left arm extended
  3. C. On the right side with the left arm extended above the head
  4. D. Sitting upright with the arms supported on an overbed table
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Question 9

The healthcare provider is educating a parent about side effects of routine immunizations. Which of the following must be reported immediately?

  1. A. Irritability
  2. B. Slight edema at the injection site
  3. C. Local tenderness
  4. D. Temperature of 102.5?F
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Question 10

Which brain structure serves as the heat-regulating center?

  1. A. Hypothalamus
  2. B. Pituitary Gland
  3. C. Pons
  4. D. Medulla Oblongata
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Question 11

A client has died approximately one hour ago. The nurse notes that the client's temperature has decreased in the last hour since their death. Which of the following processes explains this phenomenon?

  1. A. Rigor mortis
  2. B. Postmortem decomposition
  3. C. Algor mortis
  4. D. Livor mortis
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Question 12

A systolic blood pressure of 145 mm Hg is classified as:

  1. A. Normotensive
  2. B. Prehypertension
  3. C. Stage I hypertension
  4. D. Stage II hypertension
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Question 13

What is the priority nursing diagnosis for a patient experiencing a migraine headache?

  1. A. Acute pain related to biologic and chemical factors
  2. B. Anxiety related to change in or threat to health status
  3. C. Hopelessness related to deteriorating physiological condition
  4. D. Risk for side effects related to medical therapy
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Question 14

You see a patient lying on the floor of the bathroom. You are NOT assigned to this patient. What is the first thing that you should do?

  1. A. Get the nurse who is caring for the patient.
  2. B. Tell the nurse that the patient has had another seizure.
  3. C. Observe the patient for any injuries and call out for help.
  4. D. Nothing. This patient is not one of your assignments.
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Question 15

The nurse is caring for a 7-year-old child with glomerulonephritis and is preparing to discuss the plan of care with the parents. In anticipating this encounter, the nurse recognizes that which is a common reaction of parents to the diagnosis of glomerulonephritis?

  1. A. Fear of the complicated treatment regimen
  2. B. Anger at the child for requiring hospitalization
  3. C. Guilt that they did not seek treatment more quickly
  4. D. Depression that the child may not be able to play sports
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About these NCLEX-RN clinical judgment questions

NCLEX-RN clinical judgment practice questions, set 53 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.

No. Nursier is independent practice. Register through the official path named on the NCLEX-RN exam guide.

The first five questions already include the rationale. Start full practice to unlock the remaining keys, missed-question review, and the rest of the bank.

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