NCLEX-RN clinical judgment practice questions, set 54
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 54
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
Following surgery to correct cryptorchidism, what is the priority action that the nurse should include in the plan of care?
A. Prevent tension on the suture.
B. Monitor urine for glucose and acetone.
C. Encourage oral fluids, and monitor intake and output.
D. Encourage coughing and deep breathing every hour.
Show answer and rationale
Correct answer: A — Prevent tension on the suture.
The correct answer is to prevent tension on the suture. After surgery for cryptorchidism, the testicle is held in position by an internal suture that should not be dislodged. Immobilization of the area for a week is crucial to prevent complications like bleeding and infection. Monitoring urine for glucose and acetone is unrelated to this surgery. While maintaining hydration is important, forcing fluids is not necessary. Encouraging coughing and deep breathing every hour may be a postoperative consideration, but it is not the priority for this specific surgery.
Question 2
A patient in a clinic has been diagnosed with hepatitis A. What is the most likely route of transmission?
A. Sexual contact with an infected partner
B. Contaminated food
C. Blood transfusion
D. Illegal drug use
Show answer and rationale
Correct answer: B — Contaminated food
The correct answer is contaminated food. Hepatitis A is primarily transmitted through the fecal-oral route, often through the ingestion of contaminated food or water. It is caused by the Hepatitis A virus (HAV), which is a single-stranded, positive-sense RNA virus. Sexual contact with an infected partner is more commonly associated with hepatitis B and C. Blood transfusion is a potential route for hepatitis B and C transmission due to bloodborne pathogens. Illegal drug use, particularly involving shared needles, is a common route for hepatitis C transmission.
Question 3
What is a priority problem for a child with severe edema caused by nephrotic syndrome?
A. Risk for constipation
B. Risk for skin breakdown
C. Inability to regulate body temperature
D. Consuming more calories or nutrients than the body requires
Show answer and rationale
Correct answer: B — Risk for skin breakdown
In nephrotic syndrome, characterized by massive proteinuria, hypoalbuminemia, and edema, a child with severe edema is at high risk for skin breakdown. The priority concern is to prevent skin breakdown by cleaning skin surfaces and ensuring adequate separation with clothing to avoid irritation. The child with nephrotic syndrome is typically anorexic, making consuming more calories or nutrients than necessary not a concern. Risk for constipation and inability to regulate body temperature are not primary issues associated with edema caused by nephrotic syndrome.
Question 4
While assisting a client from bed to chair, the nurse observes that the client looks pale and is beginning to perspire heavily. The nurse would then do which of the following activities as a reassessment?
A. Help client into the chair more quickly
B. Document client's vital signs taken just prior to moving the client
C. Help client back to bed immediately
D. Observe client's skin color and take another set of vital signs
Show answer and rationale
Correct answer: D — Observe client's skin color and take another set of vital signs
In this scenario, the nurse has observed concerning signs in the client during the transfer process. The appropriate action for reassessment would be to observe the client's skin color and take another set of vital signs. This will provide essential data to evaluate the client's condition more accurately. Options A, B, and C are interventions that do not address the need for reassessment. Moving the client more quickly, documenting previous vital signs, or returning the client to bed do not directly address the need to reassess the client's current condition.
Question 5
Which of these specific measurements is the best index of a child's general health?
A. Body mass index
B. Height and weight
C. Head circumference
D. Chest circumference
Show answer and rationale
Correct answer: B — Height and weight
Height and weight are the most accurate measurements to assess a child's general health. These measurements reflect the physical growth and development of the child, indicating overall health status. Choices C and D, head circumference and chest circumference, are important measurements for specific assessments but do not provide as comprehensive an overview of general health as height and weight. Body mass index (BMI) is a calculation based on height and weight, making height and weight more direct and primary indicators of a child's health compared to BMI.
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Question 6
A client is in her third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby's father. Which of the following nursing interventions is a priority?
A. Counsel the woman to consent to HIV screening.
B. Perform tests for sexually transmitted diseases.
C. Discuss her high risk for cervical cancer.
D. Refer the client to a family planning clinic.
Correct answer:
In this scenario, the client's disclosure of having multiple sex partners and uncertainty about the baby's father indicates a potential high risk for HIV. Therefore, the priority nursing intervention is to counsel the woman to consent to HIV screening. Early detection of HIV is crucial for initiating timely treatment and improving outcomes. Choices B, C, and D are not the priority in this situation as HIV screening takes precedence over testing for other sexually transmitted diseases, discussing cervical cancer risk, or referring to a family planning clinic.
During a heritage assessment, which question is most appropriate for the nurse to ask?
A. "Do you smoke?"?
B. "What is your religion?"?
C. "Do you have a history of heart disease?"?
D. "How many years have you lived in the United States?"?
Correct answer:
During a heritage assessment, it is crucial for the nurse to ask questions related to a person's country of ancestry, years in the United States, cultural practices, beliefs, and values. By asking about the number of years lived in the United States, the nurse can gain insights into the individual's cultural background and heritage. Options B, C, and A are not directly related to assessing heritage. Asking about religion only addresses one aspect of heritage, while smoking history and health history do not provide a comprehensive view of a person's heritage.
Which of the following is a function of risk management?
A. To consider the problems that arise if errors happen and their effects on the healthcare environment
B. To identify how nursing care responds to specific client problems
C. To view clients as customers and decide what actions will provide a satisfying healthcare experience
D. To analyze physician-nurse relationships and determine where collaboration efforts can improve
Correct answer:
The function of risk management in healthcare is to assess and address potential risks that could lead to errors and their effects on the healthcare environment. This involves identifying, evaluating, and prioritizing risks to minimize their impact and prevent adverse outcomes. Choice A is correct because it aligns with the core purpose of risk management in healthcare. Choices B, C, and D are incorrect as they do not directly relate to the primary focus of risk management, which is the proactive management of risks to ensure patient safety and quality care.
A 36-year-old male patient in the outpatient clinic is diagnosed with acute hepatitis C (HCV) infection. Which action by the nurse is appropriate?
A. Schedule the patient for HCV genotype testing.
B. Administer the HCV vaccine and immune globulin.
C. Teach the patient about ribavirin (Rebetol) treatment.
D. Explain that the infection will resolve over a few months.
Correct answer:
The correct action by the nurse is to schedule the patient for HCV genotype testing. Genotyping of HCV is crucial in determining the appropriate treatment regimen and guiding therapy decisions. Most patients with acute HCV infection progress to the chronic stage, so it is incorrect to inform the patient that the infection will resolve in a few months. There is no vaccine or immune globulin available for HCV, and ribavirin (Rebetol) is typically used for chronic HCV infection. Therefore, the nurse should prioritize genotyping to assist in treatment planning.
During an examination of a patient's abdomen, the nurse notes that the abdomen is rounded and firm to the touch. During percussion, the nurse notes a drum-like quality of the sounds across the quadrants. How would the nurse interpret this type of sound?
A. Constipation
B. Air-filled areas
C. Presence of a tumor
D. Presence of dense organs
Correct answer:
A musical or drum-like sound (tympany) is heard when percussion occurs over an air-filled viscus, such as the stomach or intestines. This indicates the presence of air-filled areas. Constipation, choice A, does not produce specific percussion sounds and is related to bowel movements rather than the sound produced during percussion. The presence of a tumor, choice C, would not typically produce a drum-like sound but might result in dullness or decreased resonance. Dense organs, choice D, would produce a dull thud sound rather than a drum-like tympanic sound.
A client is being assisted to lie in the Sims' position. In what position does the nurse arrange the client?
A. The client lies on his side with the upper leg flexed
B. The client lies on his back with his head lower than his feet
C. The client lies on his abdomen with a pillow supporting his head
D. The client is sitting up at a 90-degree angle
Correct answer:
The Sims' position is a side-lying position used for examinations or comfort. In the Sims' position, the client lies on their side with the upper leg flexed. The abdomen is slightly downward, and the lower arm is positioned behind the body. A pillow can be used to support the leg. Choice B is incorrect as it describes a position with the client lying on their back with the head lower than the feet. Choice C is incorrect as it describes a prone position, not the Sims' position. Choice D is incorrect as it describes a sitting position, not the Sims' position.
Mr. Thomas is a well-groomed 68-year-old male patient who had prostate surgery two days ago. He has an indwelling catheter and a urinary drainage bag. You have weighed him at 9 am each morning for 3 mornings in a row. Today, on the 4th day, his morning weight is 3 pounds more than it was the day before. Why could he have gained these 3 pounds in one day, on a 1000 calorie diet?
A. It is obvious that his visitors have been sneaking him junk food from the local fast-food restaurant.
B. It may be that his urinary drainage bag was not emptied today and it was emptied on previous days.
C. It is obvious that the scale is broken and it should be replaced immediately to prevent these false weights.
D. A 3-pound weight gain is not significant enough to question and should just be noted.
Correct answer:
The correct answer is that the weight gain may be due to the urinary drainage bag not being emptied today, while it was emptied on previous days. This scenario is common and can lead to an increase in weight that is not related to food intake. Choice A is incorrect because assuming visitors are sneaking junk food is speculative and not based on facts. Choice C is incorrect as there is no evidence to suggest the scale is broken. Choice D is incorrect because any unexplained weight gain should be investigated further, even if it seems insignificant at first.
A healthcare provider is assessing vital signs in pediatric patients. Which of the following vital signs is abnormal?
A. 11-year-old male: 90 BPM, 22 RPM, 100/70 mmHg
B. 13-year-old female: 105 BPM, 22 RPM, 105/50 mmHg
C. 5-year-old male: 102 BPM, 24 RPM, 90/65 mmHg
D. 6-year-old female: 100 BPM, 26 RPM, 90/70 mmHg
Correct answer:
The normal range of vital signs for pediatric patients varies with age. For 11 to 14-year-olds, the normal vital sign ranges are: Heart rate: 60-105 BPM; Respiratory rate: 12-20 RPM; Blood pressure: Systolic 85-120 mmHg, Diastolic 55-80 mmHg. The 13-year-old female in choice B has a diastolic blood pressure below the normal range, indicating hypotension. Additionally, her heart rate is at the upper limit of normal, and her respiratory rate is within normal limits. Choices A, C, and D all fall within the normal ranges for vital signs in pediatric patients.
A clinic nurse interviews a parent who is suspected of abusing her child. Which of the
following characteristics is the nurse least likely to find in an abusing parent?
A. Low self-esteem
B. Unemployment
C. Self-blame for the injury to the child
D. Single status
Correct answer:
The profile of a parent at risk of abusive behavior includes a tendency to blame the child
or others for the injury sustained. Abusers typically blame others, especially their partners,
for the mistakes in their lives. This is related to hypersensitivity, but they are not
necessarily alike. This occurs because most abusive people don't hold themselves as being
accountable for the actions they commit. Instead, they'll try to shift the blame to the
person that they have abused and somehow say they "deserved it"? or that they were
forced into a corner.
The nurse is preparing to perform a physical assessment. The correct action by the nurse is reflected by which statement?
A. Performs the examination from both sides of the bed.
B. Examines tender or painful areas last to help relieve the patient's anxiety.
C. Follows a flexible examination sequence, considering the patient's age and condition.
D. Organizes the assessment to ensure that the patient does not change positions too often.
Correct answer:
The nurse should organize the assessment to minimize the patient's need to change positions frequently, ensuring efficiency and comfort. It is essential to perform the examination from both sides of the bed to facilitate a comprehensive assessment. Examining tender or painful areas last can help reduce patient discomfort and anxiety. The examination sequence should be flexible, taking into account the patient's age, condition, and specific needs. This approach allows for a tailored and patient-centered assessment, optimizing the quality of care provided.
NCLEX-RN clinical judgment practice questions, set 54 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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