NCLEX-RN clinical judgment practice questions, set 55
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 55
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
Which patient is at risk for developing oral candidiasis, a type of stomatitis?
A. A 77-year-old woman in a long-term care facility taking an antibiotic
B. A 35-year-old man who has had HIV for 6 years
C. A 40-year-old man who is undergoing chemotherapy
D. An 80-year-old woman with dentures
Show answer and rationale
Correct answer: A — A 77-year-old woman in a long-term care facility taking an antibiotic
The correct answer is a 77-year-old woman in a long-term care facility taking an antibiotic. This patient has multiple risk factors for developing oral candidiasis, including older age, being in a long-term care facility, and taking antibiotics. Candidiasis can be caused by long-term antibiotic therapy, immunosuppressive therapy (such as chemotherapy), older age, living in a long-term care facility, diabetes, having dentures, and poor oral hygiene. Choices B, C, and D are less likely to be at high risk for oral candidiasis compared to the correct answer.
Question 2
When teaching a patient to use the three-point gait technique of crutch use:
A. The injured leg moves ahead at the same time as both crutches.
B. One crutch moves at a time and is then followed by the injured leg.
C. Both crutches move ahead at the same time followed by both legs at the same time.
D. None of the above are correct.
Show answer and rationale
Correct answer: A — The injured leg moves ahead at the same time as both crutches.
The correct technique for a three-point gait involves the injured leg moving simultaneously with both crutches, followed by the uninjured leg. This gait pattern is utilized when the patient is unable to bear full weight on one of their legs. Choice A accurately describes the appropriate sequence of movements for the three-point gait technique. Choices B and C do not accurately reflect the correct pattern of movement during the three-point gait technique, making them incorrect. Choice D is incorrect as there is a correct option among the choices provided.
Question 3
What is the most frequent cause for suicide in adolescents?
A. Progressive failure to adapt
B. Feelings of anger or hostility
C. Reunion wish or fantasy
D. Feelings of alienation or isolation
Show answer and rationale
Correct answer: D — Feelings of alienation or isolation
Feelings of alienation or isolation are the most frequent cause for suicide in adolescents. Adolescents may experience a gradual isolation leading to a loss of meaningful social contacts, which can be self-imposed or result from an inability to express feelings. During this developmental stage, achieving a sense of identity and peer acceptance is crucial. Choices A, B, and C are incorrect: Progressive failure to adapt, feelings of anger or hostility, and reunion wish or fantasy are not typically identified as the primary cause of suicide in adolescents.
Question 4
When is cleft palate repair usually performed in children?
A. A cleft palate cannot be repaired in children.
B. Repair is usually performed by age 8 weeks.
C. Repair is usually performed by 2 months of age.
D. Repair is usually performed between 6 months and 2 years.
Show answer and rationale
Correct answer: D — Repair is usually performed between 6 months and 2 years.
Cleft palate repair timing is individualized based on the severity of the deformity and the child's size. Typically, cleft palate repair is performed between 6 months and 2 years of age. This age range allows for optimal outcomes and is often done before 12 months to promote normal speech development. Early closure of the cleft palate helps to facilitate speech development. Options A, B, and C are incorrect because a cleft palate can be repaired in children, and repair is usually performed between 6 months and 2 years of age, not at 8 weeks or 2 months.
Question 5
Which individual is at greatest risk for developing hypertension?
A. 45-year-old African-American attorney
B. 60-year-old Asian-American shop owner
C. 40-year-old Caucasian nurse
D. 55-year-old Hispanic teacher
Show answer and rationale
Correct answer: A — 45-year-old African-American attorney
African-Americans have a higher risk of developing hypertension compared to other ethnic groups. They tend to develop high blood pressure at younger ages and are more sensitive to salt, which increases their risk of hypertension. Additionally, studies have shown that African-Americans may respond differently to hypertensive drugs. Therefore, the 45-year-old African-American attorney is at the greatest risk for developing hypertension. The other choices do not specify factors that put them at a higher risk for hypertension compared to African-Americans.
Keep going past these 15 questions
Missed-question review, longer banks, and the rest of 20,000+ nursing practice questions open when you start studying.
Stems and choices stay public so you can still reason. Correct answers and full rationales unlock with the rest of the bank.
Question 6
While planning care for a 2-year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior?
A. Strange bed and surroundings
B. Separation from parents
C. Presence of other toddlers
D. Unfamiliar toys and games
Correct answer:
The correct answer is 'Separation from parents.' Separation anxiety is most evident from 6 months to 30 months of age and is the greatest stress imposed on a toddler by hospitalization. If separation is avoided, young children have a tremendous capacity to withstand other stress. The other choices, such as 'Strange bed and surroundings,' 'Presence of other toddlers,' and 'Unfamiliar toys and games,' may also have an impact on the child, but separation from parents is typically the most significant factor affecting behavior in a hospitalized 2-year-old.
A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6°F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first?
A. Codeine
B. Guaifenesin (Robitussin)
C. Acetaminophen (Tylenol)
D. Piperacillin/tazobactam (Zosyn)
Correct answer:
The correct answer is Piperacillin/tazobactam (Zosyn). Early initiation of antibiotic therapy is crucial in cases of community-acquired pneumococcal pneumonia to reduce mortality. While providing symptomatic relief with medications like Codeine for cough, Guaifenesin for mucus clearance, and Acetaminophen for fever and pain is important, the priority should be to start antibiotic therapy to target the underlying infection. Piperacillin/tazobactam is an appropriate choice for treating severe community-acquired pneumonia caused by pneumococcal organisms.
When administering a shot of Vitamin K to a 30-day-old infant, which of the following target areas is the most appropriate?
A. Gluteus maximus
B. Gluteus minimus
C. Vastus lateralis
D. Vastus medialis
Correct answer:
When administering medications to infants, it is common to use the vastus lateralis muscle in the thigh for injections. The preferred site is the junction of the upper and middle thirds of the vastus lateralis muscle. This area provides a good muscle mass for the injection and minimizes the risk of hitting nerves or blood vessels. The gluteus maximus and gluteus minimus are not typically used for infant injections due to the risk of injury to the sciatic nerve. The vastus medialis is not as commonly used as the vastus lateralis for infant injections.
The nurse is caring for a 10-year-old upon admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is
A. Urinary output of 30 ml per hour
B. No complaints of thirst
C. Increased hematocrit
D. Good skin turgor around burn
Correct answer:
The correct answer is urinary output of 30 ml per hour. In a 10-year-old child, this level of urinary output is indicative of adequate fluid replacement without suggesting overload. Monitoring urinary output is crucial in assessing fluid balance. Choices B, C, and D are incorrect. No complaints of thirst do not provide a direct assessment of fluid status. Increased hematocrit is a sign of dehydration, not adequate fluid replacement. Good skin turgor around the burn is a general assessment but may not directly reflect the child's overall fluid status.
During an intake screening for a patient with hypertension who has been taking ramipril for 4 weeks, which statement made by the patient would be most important for the nurse to pass on to the physician?
A. ''I get dizzy when I get out of bed.''
B. ''I'm urinating much more than I used to.''
C. ''I've been running on the treadmill for 10 minutes each day.''
D. ''I can't get rid of this cough.''
Correct answer:
The correct answer is ''I can't get rid of this cough.'' Ramipril, an ACE inhibitor, commonly causes a persistent, dry cough as an adverse effect. This symptom can be indicative of bradykinin accumulation caused by ACE inhibitors. It is important for the nurse to inform the physician about this side effect so that a medication change to another class of antihypertensives, such as an ARB, may be considered. Choices A, B, and C are not directly related to the common adverse effects of ramipril and are not as concerning for a patient on this medication.
After repair of an inguinal hernia, the infant is being cared for. Which assessment finding indicates that the surgical repair was effective?
A. A clean, dry incision
B. Abdominal distension
C. An adequate flow of urine
D. Absence of inguinal swelling with crying
Correct answer:
The absence of inguinal swelling when the infant cries or strains indicates that the surgical repair of the inguinal hernia was effective. Inguinal swelling typically occurs with crying or straining in cases of this condition. A clean, dry incision signifies the absence of wound infection post-surgery but does not directly indicate the effectiveness of the hernia repair. Abdominal distension suggests a gastrointestinal issue unrelated to the hernia repair. An adequate flow of urine is not specific to evaluating the success of inguinal hernia repair.
While suctioning the endotracheal tube of an adult client, what level of pressure should the nurse apply?
A. 70-80 mmHg
B. 100-120 mmHg
C. 150-170 mmHg
D. 200 mmHg
Correct answer:
When suctioning the endotracheal tube of an adult client, the nurse should set the suction apparatus at a level no higher than 150 mmHg, with a preferable level between 100 and 120 mmHg. Suction pressure that is too high can contribute to the client's hypoxia. Alternatively, too low suction pressure may not clear adequate amounts of secretions. Choice A (70-80 mmHg) is too low and may not effectively clear secretions. Choices C (150-170 mmHg) and D (200 mmHg) are too high and can potentially harm the client by causing hypoxia or damaging the airway.
Which of the following organs would be described as being located retroperitoneally?
A. Kidneys
B. Thymus
C. Small Intestines
D. Spleen
Correct answer:
The term 'retroperitoneal' refers to organs positioned behind the peritoneum. The kidneys are retroperitoneal organs, located outside the peritoneal cavity, against the posterior abdominal wall. This positioning provides them with additional protection from external forces due to the surrounding structures. The thymus, small intestines, and spleen are not retroperitoneal organs. The thymus is located in the mediastinum, the small intestines are intraperitoneal, and the spleen is intraperitoneal and located in the left upper quadrant of the abdomen.
When taking a patient’s history, she mentions being depressed and dealing with an anxiety disorder. Which of the following medications would the patient most likely be taking?
A. Amitriptyline (Elavil)
B. Calcitonin
C. Pergolide mesylate (Permax)
D. Verapamil (Calan)
Correct answer:
The correct answer is Amitriptyline (Elavil) as it is a tricyclic antidepressant commonly used to treat symptoms of depression and anxiety disorders. Amitriptyline works by increasing the levels of certain neurotransmitters in the brain to improve mood. Choices B, C, and D are incorrect. Calcitonin is a hormone used in the treatment of osteoporosis; Pergolide mesylate is a dopamine agonist used in Parkinson's disease; Verapamil is a calcium channel blocker used to treat high blood pressure and certain heart conditions, not mental health disorders.
A client is complaining of pain that starts in the shoulder and travels down the length of his arm. This type of pain is referred to as:
A. Referred pain
B. Superficial pain
C. Radiating pain
D. Precipitating pain
Correct answer:
Radiating pain is the correct term for pain that originates in one part of the body and extends to other related areas. In this scenario, the pain starting in the shoulder and traveling down the arm describes radiating pain. Referred pain (Choice A) is pain felt at a site different from the actual origin of the pain. Superficial pain (Choice B) is pain that arises from the skin or tissues just beneath it. Precipitating pain (Choice D) refers to pain that is triggered by specific actions or events, not the characteristic described in the question.
NCLEX-RN clinical judgment practice questions, set 55 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.
Keep going past these 15 questions
Missed-question review, longer banks, and the rest of 20,000+ nursing practice questions open when you start studying.
