NCLEX-RN clinical judgment practice questions, set 58
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 58
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
You are ready to give your resident a complete bed bath. The temperature of this bath water should be which of the following?
A. Cooler than a tub bath.
B. Hotter than a tub bath.
C. About 106 degrees.
D. Over 120 degrees.
Show answer and rationale
Correct answer: C — About 106 degrees.
The correct temperature for a bed bath water should be about 106 degrees. This temperature is considered safe and comfortable for residents. Using a bath thermometer is essential to ensure the water is not too hot, as hot water can cause burns. On the other hand, water that is too cool can lead to discomfort, shivering, and chilling. Options A, B, and D are incorrect because cooler water may cause discomfort and shivering, hotter water can lead to burns, and water over 120 degrees is considered too hot and risky for a resident's skin.
Question 2
A patient in the cardiac unit is concerned about the risk factors associated with atherosclerosis. Which of the following are hereditary risk factors for developing atherosclerosis?
A. Family history of heart disease
B. Overweight
C. Smoking
D. Age
Show answer and rationale
Correct answer: A — Family history of heart disease
A family history of heart disease is an inherited risk factor for developing atherosclerosis. This factor is not modifiable through lifestyle changes. Studies have shown that having a first-degree relative with heart disease significantly increases the individual's risk of developing atherosclerosis. Overweight, smoking, and age are not hereditary risk factors for atherosclerosis. Overweight and smoking are lifestyle-related risk factors, while age is a non-modifiable risk factor that increases with time but is not directly inherited.
Question 3
A patient in the cardiac unit is concerned about the risk factors associated with atherosclerosis. Which of the following are hereditary risk factors for developing atherosclerosis?
A. Family history of heart disease
B. Overweight
C. Smoking
D. Age
Show answer and rationale
Correct answer: A — Family history of heart disease
A family history of heart disease is an inherited risk factor for developing atherosclerosis. This factor is not modifiable through lifestyle changes. Studies have shown that having a first-degree relative with heart disease significantly increases the individual's risk of developing atherosclerosis. Overweight, smoking, and age are not hereditary risk factors for atherosclerosis. Overweight and smoking are lifestyle-related risk factors, while age is a non-modifiable risk factor that increases with time but is not directly inherited.
Question 4
A 3-year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse should:
A. Expose the cast to air and turn the child frequently.
B. Use a heat lamp to reduce the drying time.
C. Handle the cast with the abductor bar.
D. Turn the child as little as possible.
Show answer and rationale
Correct answer: A — Expose the cast to air and turn the child frequently.
After a hip spica cast is applied, it is important to facilitate drying by exposing the cast to air and turning the child frequently, approximately every 2 hours. This helps ensure even drying and prevents skin breakdown. Using a heat lamp can cause burns and should be avoided. Handling the cast with the abductor bar is not necessary for the drying process and may cause discomfort to the child. Turning the child as little as possible is not recommended as regular turning helps prevent complications like pressure ulcers and stiffness.
Question 5
The nurse assesses a patient suspected of having meningitis. Which of the following is a common clinical manifestation of this condition?
A. A high WBC count and decreased level of consciousness
B. A high WBC count and manic activity
C. A low WBC count and manic activity
D. A low WBC count and decreased level of consciousness
Show answer and rationale
Correct answer: A — A high WBC count and decreased level of consciousness
The correct answer is 'A high WBC count and decreased level of consciousness.' Meningitis is often caused by an infectious organism, leading to an increase in Intracranial Pressure (ICP), which can result in decreased level of consciousness. While meningitis can trigger an inflammatory response, it typically presents with an elevated white blood cell (WBC) count rather than a low WBC count. Manic activity is not a common clinical manifestation of meningitis; instead, patients may exhibit altered mental status, confusion, or lethargy.
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Question 6
In the term 'Hemoglobin,' the suffix '-globin' means:
A. Protein
B. Iron
C. Metal
D. Blood
Correct answer:
The suffix '-globin' in the term 'Hemoglobin' specifically refers to a protein. Hemoglobin is a protein found in red blood cells that carries oxygen. Choice B, 'Iron,' is incorrect as iron is a mineral component of hemoglobin but not the meaning of the suffix. Choice C, 'Metal,' is too broad and not specific to the meaning of the suffix in this context. Choice D, 'Blood,' is incorrect as it refers to the overall term 'Hemoglobin' rather than the specific meaning of the suffix '-globin.' Therefore, the correct answer is A: 'Protein.'
Albert B. is incontinent of urine. He also wears glasses and hearing aids. His ____________lead(s) to his risk for falls.
A. incontinence and loss of vision
B. loss of vision
C. incontinence
D. loss of hearing
Correct answer:
Albert B. is at risk for falls due to two factors: his incontinence and his loss of vision. Loss of vision significantly impairs one's ability to navigate and avoid obstacles, thereby increasing the risk of falls. While incontinence is a risk factor for falls, the primary concern in this case is the loss of vision since it directly affects balance and safety. Therefore, the correct answer is 'loss of vision.' Choices A, C, and D are incorrect because they do not address the key factor of impaired vision leading to the risk of falls.
Which of the following is an example of whistle-blowing?
A. A nurse contacts administration about a colleague who takes supplies to use for a mission trip
B. A client sues a nurse because she failed to call the physician about his wound infection
C. A nursing assistant calls for help when a client falls out of bed
D. A client developed a sacral pressure ulcer when he was not turned in bed for over four hours
Correct answer:
Whistle-blowing involves notifying administration or a supervisor about unethical or illegal activities. In this scenario, the nurse reporting a colleague taking supplies for personal use is an example of whistle-blowing as it involves reporting behavior that is dishonest and potentially harmful. Choices B, C, and D do not represent whistle-blowing. Choice B involves a legal action by a client against a nurse, choice C is a situation where immediate care is provided, and choice D is a case of neglect that should have been prevented.
During which part of the client interview would it be best for the nurse to ask, 'What's the weather forecast for today?'
A. Introduction
B. Body
C. Closing
D. Orientation
Correct answer:
Asking about the weather initiates the social or introductory phase of the interview, allowing the nurse to establish rapport with the client at the beginning. This question can help assess the client's mental status and set a friendly tone. In the body phase, the client responds to the nurse's inquiries, while during the closing phase, either the nurse or the client concludes the interview. Therefore, the best time to ask about the weather forecast is during the introduction phase to facilitate a positive start to the interaction.
The nurse is reviewing the lab results of a patient taking lithium for schizoaffective disorder. The lab results show that the blood lithium value is 1.7 mcg/L. What would the nurse take as the priority action?
A. Induce vomiting
B. Hold the next dose of Lithium
C. Administer an antiemetic
D. Give the next dose of Lithium
Correct answer:
The correct answer is to hold the next dose of Lithium. The blood lithium value of 1.7 mcg/L exceeds the therapeutic range of 0.5-1.5 mcg/L, indicating potential toxicity. Holding the next dose is crucial to prevent further accumulation of lithium in the bloodstream. Inducing vomiting is not appropriate in this situation as the priority is to prevent further absorption of lithium. Administering an antiemetic is not the priority in lithium toxicity. Giving the next dose of lithium would exacerbate the toxicity and should be avoided.
A patient asks a nurse, "My doctor recommended I increase my intake of folic acid. What type of foods contain the highest concentration of folic acid?'
A. Green vegetables and liver
B. Yellow vegetables and red meat
C. Carrots
D. Milk
Correct answer:
Green vegetables and liver are rich sources of folic acid. Green vegetables like spinach, asparagus, and broccoli are high in folic acid content. Liver, especially from chicken or beef, is also a good source of folic acid. Yellow vegetables and red meat (choice B) do not contain as high a concentration of folic acid as green vegetables and liver. Carrots (choice C) are nutritious but do not have the highest concentration of folic acid. Milk (choice D) is not a significant source of folic acid compared to green vegetables and liver.
Many Asians believe in the yin/yang theory, which is rooted in the ancient Chinese philosophy of Tao. Which statement most accurately reflects this philosophy's view of "health"??
A. A person is able to work and produce.
B. A person is happy, stable, and feels good.
C. All aspects of the person are in perfect balance.
D. A person is able to care for others and function socially.
Correct answer:
In the yin/yang theory rooted in ancient Chinese philosophy, health is believed to exist when all aspects of a person are in perfect balance. This includes physical, mental, emotional, and spiritual well-being. Choice C accurately reflects this philosophy's view of health. Choices A, B, and D do not capture the essence of the yin/yang theory. Being able to work and produce, being happy and stable, or caring for others and functioning socially, while important, do not encompass the holistic balance emphasized in the yin/yang theory.
Based on the information given, which patient would be an appropriate candidate for a closed MRI without contrast?
A. A 20-year-old woman with unexplained joint pain and a low BMI.
B. A 35-year-old woman with Multiple Sclerosis who is trying to conceive.
C. A 67-year-old man who had open-heart surgery 4 years ago.
D. A 40-year-old woman in a hypomanic state for the last 2 days.
Correct answer:
The correct answer is the 20-year-old woman with unexplained joint pain and a low BMI. MRI can be used to diagnose musculoskeletal disorders, and this patient has no contraindications to an MRI. Choice B is incorrect because using MRI without contrast may not be ideal for a patient trying to conceive. Choice C is incorrect as the patient's past open-heart surgery may pose risks for an MRI without contrast. Choice D is incorrect since the patient's hypomanic state does not indicate a need for an MRI without contrast for joint pain.
During an initial assessment interview, which statement made by a patient should serve as the priority focus for the plan of care?
A. "I can always trust my family."?
B. "It seems like I always have bad luck."?
C. "You never know who will turn against you."?
D. "I hear evil voices that tell me to do bad things."?
Correct answer:
The statement about hearing evil voices indicates that the patient is experiencing auditory hallucinations, which is a significant symptom that requires immediate attention and intervention. This symptom can be associated with serious mental health conditions like psychosis. Choices A, B, and C are more general statements that do not provide specific information about the patient's mental health status or symptoms, making them less urgent and not as critical for the plan of care compared to the presence of auditory hallucinations.
You are taking care of 7 patients today. One of your residents wants water; another needs help walking to the bathroom; another just stated that they have chest pain; and another is crying because his daughter did not visit him today. Which patient care task is the lowest in terms of priority?
A. The water
B. Help to the bathroom
C. The chest pain
D. The crying person
Correct answer:
The lowest priority patient care task in this scenario is addressing the emotional need of the patient who is crying because his daughter did not visit him today. While emotional support is important, the other needs - providing water, assisting to the bathroom, and addressing chest pain - are physical needs that must take priority as they directly impact the patient's well-being and health. It is crucial to acknowledge and address emotional needs but in this situation, the physical needs of the patients should be addressed first.
NCLEX-RN clinical judgment practice questions, set 58 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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