NCLEX-RN clinical judgment practice questions, set 60
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 60
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
The nurse is planning care for a patient with a wrist restraint. How often should a restraint be removed, the area massaged, and the joints moved through their full range?
A. Once a shift
B. Once an hour
C. Every 2 hours
D. Every 4 hours
Show answer and rationale
Correct answer: C — Every 2 hours
Restraints should be removed every 2 hours to prevent complications. Moving the joints through their full range of motion helps prevent muscle shortening and contractures. Massaging the area promotes circulation and reduces the risk of pressure injuries. Removing restraints less frequently could lead to complications like decreased circulation and skin breakdown. Options A, B, and D are incorrect because they do not align with the standard practice of removing restraints every 2 hours to ensure patient safety and well-being.
Question 2
The nursing diagnosis is Risk for impaired skin integrity related to immobility and pressure secondary to pain and presence of a cast. Which of the following desired outcomes should the nurse include in the care plan?
A. Client will be able to turn self by day 3
B. Skin will remain intact and without redness during hospital stay
C. Client will state pain relieved within 30 minutes after medication
D. Pressure will be prevented by repositioning client every 2 hours
Show answer and rationale
Correct answer: B — Skin will remain intact and without redness during hospital stay
The correct desired outcome for a nursing diagnosis of 'Risk for impaired skin integrity' is to ensure that the skin remains intact and without redness during the hospital stay. This outcome directly addresses the risk identified in the diagnosis. Option A focuses on addressing immobility, which is not the priority for this diagnosis. Option C deals with pain relief, which is a separate concern. Option D is an intervention involving pressure prevention through repositioning, rather than an outcome related to skin integrity.
Question 3
The nurse has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis?
A. Nutrition
B. Elimination
C. Activity
D. Safety
Show answer and rationale
Correct answer: D — Safety
In caring for a client with severe depression, safety is a critical priority. The nurse must address precautions to prevent suicide as part of the care plan. While nutrition, elimination, and activity are important aspects of care, safety takes precedence due to the immediate risk of harm associated with depression. Ensuring the client's safety by implementing measures to prevent self-harm or suicide is the priority intervention. Addressing nutrition, elimination, and activity can follow once the client's safety is assured.
Question 4
Which patient poses the least infection risk to an immunosuppressed patient who had a liver transplant?
A. The patient with chronic pancreatitis
B. The patient currently infected with a respiratory virus
C. The patient with a healing leg wound
D. The patient with a urinary tract infection
Show answer and rationale
Correct answer: C — The patient with a healing leg wound
The patient with a healing leg wound poses the least infection risk to an immunosuppressed patient who had a liver transplant. Chronic pancreatitis can lead to complications such as infections that can pose a risk to immunosuppressed individuals. Patients infected with respiratory viruses or urinary tract infections are actively infectious, which can put immunosuppressed patients at a higher risk of acquiring infections. Therefore, the patient with a healing leg wound is the least likely to pose an immediate infection risk.
Question 5
To prepare a 56-year-old male patient with ascites for paracentesis, the nurse should?
A. place the patient on NPO status.
B. assist the patient to lie flat in bed.
C. ask the patient to empty the bladder.
D. position the patient on the right side.
Show answer and rationale
Correct answer: C — ask the patient to empty the bladder.
To prepare a patient with ascites for paracentesis, the nurse should ask the patient to empty the bladder. This is important to decrease the risk of bladder perforation during the procedure. The patient should be positioned in Fowler's position to facilitate the procedure, not lie flat in bed, which can compromise breathing. Placing the patient on NPO status is unnecessary as sedation is not typically required for paracentesis. Positioning the patient on the right side is not a standard preparatory measure for paracentesis.
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Question 6
While auscultating heart sounds, the nurse hears a murmur. Which of these instruments would be used to assess this murmur?
A. Electrocardiogram
B. Bell of the stethoscope
C. Diaphragm of the stethoscope
D. Palpation with the nurse's palm of the hand
Correct answer:
The correct instrument to assess a murmur while auscultating heart sounds is the bell of the stethoscope. An electrocardiogram is used to measure the heart's electrical activity, not to assess murmurs. Palpation with the nurse's palm of the hand is a method to assess pulses or textures, not heart murmurs. The diaphragm of the stethoscope is typically used for high-pitched sounds like breath, bowel, and normal heart sounds, whereas the bell is more suitable for soft, low-pitched sounds such as murmurs or extra heart sounds.
Which term best describes changes such as retirement, grandparenting, and increased dependence on others?
A. Moral
B. Psychosocial
C. Self-esteem
D. Psychomotor
Correct answer:
The correct answer is 'Psychosocial.' Retirement, grandparenting, and increased dependence on others are examples of psychosocial changes because they involve social interactions, relationships, and psychological aspects. 'Moral' (Choice A) does not directly relate to the changes mentioned. 'Self-esteem' (Choice C) is more about self-perception and confidence, not the social changes mentioned. 'Psychomotor' (Choice D) refers to physical movements and skills, which are not the focus of the changes described in the question.
Efforts by healthcare facilities to reduce the incidence of hospital-acquired infections (HAIs) include an awareness of which of the following?
A. The CDC requires all states to report HAI rates from each hospital.
B. Ensure that the restraints are tied to the side rails.
C. The gastrointestinal tract is a common site for HAIs.
D. Joint Commission considers death or serious injury from HAIs a sentinel event.
Correct answer:
Efforts to reduce hospital-acquired infections (HAIs) involve being aware that the Joint Commission considers death or serious injury resulting from HAIs a sentinel event, which must be reported. While more than 20 states require reporting of HAI rates to the CDC, it is not a nationwide CDC requirement. The gastrointestinal tract is not a specific common site for HAIs; rather, bacteria are the primary cause. Ensuring restraints are properly secured is important for patient safety but not directly related to reducing HAIs.
A home care nurse instructs the mother of a 5-year-old child with lactose intolerance about dietary measures for her child. The nurse should tell the mother that it is necessary to provide which dietary supplement in the child's diet?
A. Fats
B. Zinc
C. Protein
D. Calcium
Correct answer:
In lactose intolerance, the inability to digest lactose, the sugar in dairy products, can lead to calcium deficiency if dairy products are removed from the diet. Calcium is crucial for bone health and other bodily functions, so alternative calcium sources like fortified non-dairy milks or leafy greens must be included to prevent deficiency. While fats and proteins are important nutrients, they are not typically deficient in lactose intolerance. Zinc, although an essential mineral, is not the primary concern in this case.
A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection?
A. Trichomoniasis
B. Chlamydia
C. Staphylococcus
D. Streptococcus
Correct answer:
Chlamydial infections are one of the most common causes of salpingitis or pelvic inflammatory disease. Chlamydia can ascend from the vagina or cervix to the reproductive organs, leading to inflammation and infection. Trichomoniasis, caused by a parasite, typically presents with different symptoms than pelvic inflammatory disease and is not the primary cause. Staphylococcus and Streptococcus are bacteria that can cause other types of infections but are not the primary culprits in most cases of pelvic inflammatory disease.
The healthcare professional calculates the IV flow rate for a patient receiving an antibiotic. The patient is to receive 100mL of the antibiotic over 30 minutes. The IV infusion set has a drop factor of 10 drops per milliliter. How many drops per minute should the healthcare professional set the IV to deliver?
A. 11
B. 19
C. 26
D. 33
Correct answer:
To determine the drops per minute for the IV flow rate, you can use the formula: Drops Per Minute = (Milliliters to be infused x Drop Factor) / Time in Minutes. Substituting the given values, you get 100 mL x 10 drops/mL / 30 minutes = 33 drops per minute. Therefore, the correct answer is 33, as the healthcare professional should set the IV to deliver 33 drops per minute to infuse the antibiotic correctly. Choices A, B, and C are incorrect as they do not match the calculated drops per minute based on the provided values.
Which assessment information will be most important for the nurse to report to the healthcare provider about a patient with acute cholecystitis?
A. The patient's urine is bright yellow
B. The patient's stools are tan colored
C. The patient has increased pain after eating
D. The patient complains of chronic heartburn
Correct answer:
The correct answer is that the patient's stools are tan colored. Tan or grey stools indicate biliary obstruction, which requires rapid intervention to resolve in a patient with acute cholecystitis. This change in stool color is a critical sign that the healthcare provider needs to be informed about promptly. The other choices are less concerning and may be common symptoms in patients with acute cholecystitis, but tan-colored stools specifically indicate a potential serious complication that warrants immediate attention.
When checking for proper blood pressure cuff size, which guideline is correct?
A. The standard cuff size is appropriate for all sizes.
B. The length of the rubber bladder should equal 80% of the arm circumference.
C. The width of the rubber bladder should equal 80% of the arm circumference.
D. The width of the rubber bladder should equal 40% of the arm circumference.
Correct answer:
When selecting the correct blood pressure cuff size, it is essential to ensure that the width of the rubber bladder equals 40% of the circumference of the person's arm. This ensures proper fitting and accurate readings. The length of the bladder should actually equal 80% of the arm circumference, not 80% of the width, making choices B and C incorrect. Choice A stating that the standard cuff size is appropriate for all sizes is inaccurate, as using an incorrectly sized cuff can lead to inaccurate blood pressure readings.
The nurse has provided dietary instructions to the mother of a child with celiac disease. The nurse determines that further instruction is needed if the mother states that she will include which food item in the child's nutritional plan?
A. Corn
B. Chicken
C. Oatmeal
D. Vitamin supplements
Correct answer:
In celiac disease, individuals need to avoid gluten-containing foods like wheat, rye, barley, and oats. Oatmeal contains gluten unless it is specifically labeled as gluten-free. Corn and rice are safe alternatives for individuals with celiac disease as they do not contain gluten. Chicken is a naturally gluten-free protein source. While vitamin supplements may be necessary to address deficiencies due to malabsorption, oatmeal poses a risk of gluten exposure, making it an incorrect choice for a child with celiac disease.
Which assessment finding is of most concern for a 46-year-old woman with acute pancreatitis?
A. Absent bowel sounds
B. Abdominal tenderness
C. Left upper quadrant pain
D. Palpable abdominal mass
Correct answer:
The correct answer is a palpable abdominal mass. In a 46-year-old woman with acute pancreatitis, a palpable abdominal mass may indicate the presence of a pancreatic abscess, which requires rapid surgical drainage to prevent sepsis. Absent bowel sounds, abdominal tenderness, and left upper quadrant pain are common symptoms in acute pancreatitis but do not necessarily indicate an immediate need for surgical intervention. Therefore, the presence of a palpable abdominal mass is the most concerning finding in this scenario.
NCLEX-RN clinical judgment practice questions, set 60 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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