NCLEX-RN clinical judgment practice questions, set 62
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 62
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
In a 68-year-old man, a gradual loss of hearing is known as _____________.
A. presbycusis
B. xerostomia
C. myopia
D. presbyopia
Show answer and rationale
Correct answer: A — presbycusis
The correct answer is 'presbycusis.' Presbycusis is the age-related gradual loss of hearing ability, commonly seen in the elderly population. Xerostomia refers to dry mouth, myopia is nearsightedness, and presbyopia is the age-related loss of the eye's ability to focus on close objects. Given Mr. Roberts' age and symptom of gradual hearing loss, presbycusis is the most likely diagnosis. Xerostomia, myopia, and presbyopia do not match the sensory change described in the question, making them incorrect choices.
Question 2
A healthcare professional is reviewing a patient's chart and notices that the patient suffers from Lyme disease. Which of the following microorganisms is related to this condition?
A. Borrelia burgdorferi
B. Streptococcus pyogenes
C. Bacillus anthracis
D. Enterococcus faecalis
Show answer and rationale
Correct answer: A — Borrelia burgdorferi
Lyme disease, the most common vector-borne disease in the United States, is caused by the bacterium Borrelia burgdorferi. Borrelia burgdorferi is transmitted to humans through the bite of infected black-legged ticks. Streptococcus pyogenes is associated with strep throat and other infections, not Lyme disease. Bacillus anthracis causes anthrax, a separate infectious disease. Enterococcus faecalis is more commonly linked to urinary tract infections and other healthcare-associated infections, not Lyme disease.
Question 3
Which topic is most important to include in patient teaching for a 41-year-old patient diagnosed with early alcoholic cirrhosis?
A. Maintaining good nutrition
B. Avoiding alcohol ingestion
C. Taking lactulose (Cephulac)
D. Using vitamin B supplements
Show answer and rationale
Correct answer: B — Avoiding alcohol ingestion
The most important topic to include in patient teaching for a 41-year-old patient diagnosed with early alcoholic cirrhosis is avoiding alcohol ingestion. Alcohol abstinence is crucial in stopping or reversing the progression of the disease. While maintaining good nutrition, taking lactulose (Cephulac), and using vitamin B supplements are important interventions in managing cirrhosis, abstaining from alcohol is the priority for this patient to prevent further damage to the liver and halt disease progression.
Question 4
A 51-year-old woman had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to
A. choose low-fat foods from the menu
B. perform leg exercises hourly while awake
C. ambulate the evening of the operative day
D. turn, cough, and deep breathe every 2 hours
Show answer and rationale
Correct answer: D — turn, cough, and deep breathe every 2 hours
Postoperative nursing care after a cholecystectomy focuses on preventing respiratory complications due to the surgical incision being high in the abdomen, which impairs coughing and deep breathing. Turning, coughing, and deep breathing every 2 hours help prevent respiratory complications, such as pneumonia. While choices A, B, and C are also important aspects of postoperative care, they are not as high a priority as ensuring proper ventilation and respiratory function in the immediate postoperative period.
Question 5
Which of the following is an example of emotional abuse?
A. A slap to the person's hand
B. Threatening the person
C. Ignoring and isolating a person
D. Leaving a patient soiled for hours
Show answer and rationale
Correct answer: C — Ignoring and isolating a person
Emotional abuse involves behaviors that harm an individual's self-worth and emotional well-being. Threatening someone instills fear and causes psychological distress, making it a clear example of emotional abuse. Choices A, C, and D involve physical abuse, neglect, and neglect of care, respectively, rather than emotional abuse. A slap to the person's hand constitutes physical abuse, ignoring and isolating a person is neglectful behavior, and leaving a patient soiled for hours falls under neglect of care.
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Question 6
A woman presents with bruises on her face and back in various stages of healing. She states, 'sometimes he just gets so angry.' Which of the following statements is most appropriate as a response from the nurse?
A. Do you mean your boyfriend?
B. Do you mean your boyfriend?
C. No one will ever hurt you again.
D. Tell me more about what happens when he gets angry.
Correct answer:
The most appropriate response from the nurse is to gather more information by asking the client to elaborate on what occurs when the individual in question gets angry. It is essential for the nurse to understand the situation better before taking any action or making assumptions. Option A and B are repetitive and do not encourage further exploration of the situation. Option C offers a false promise and reassurance that the nurse cannot guarantee, which may not be helpful in addressing the client's needs.
In the Gram Stain procedure, which component acts as the mordant?
A. Crystal violet
B. Methyl alcohol
C. Iodine
D. Safranin
Correct answer:
In the Gram Stain procedure, the mordant is Gram's Iodine. The purpose of the mordant is to form a complex with the crystal violet, enhancing its ability to bind to the cell wall. Crystal violet is actually the primary stain used in the Gram Stain procedure to initially color all cells. Methyl alcohol is the decolorizer that removes the crystal violet from certain cell types. Safranin is the counterstain used to stain those cells that did not retain the crystal violet stain after the decolorization step.
A client using an intraaural hearing aid experiences whistling after placement. What is the nurse's next action?
A. Try to reposition the hearing aid
B. Change the batteries
C. Remove the device and have it cleaned
D. Notify the physician that the hearing aid is not working
Correct answer:
An intraaural hearing aid, also known as an in-the-ear hearing aid, is placed in the ear canal. Whistling after placement indicates improper positioning of the device. The correct action for the nurse is to try repositioning the hearing aid to eliminate the whistling. Changing the batteries is not necessary for addressing whistling. Removing the device to clean it is not the immediate action needed for whistling. Notifying the physician is premature without attempting to reposition the hearing aid first.
Which of the following complaints is characteristic of a patient with Bell's Palsy?
A. Paralysis of the right or left arm
B. Malfunction of a certain cranial nerve
C. A sub-condition of Cerebral Palsy
D. A side effect of a stroke
Correct answer:
Bell's Palsy is characterized by the dysfunction of the Facial nerve, which is cranial nerve VII. This dysfunction leads to facial muscle weakness or paralysis, not affecting the arms. Choice A is incorrect as Bell's Palsy specifically involves facial muscles, not the arms. Choice C is incorrect as it incorrectly associates Bell's Palsy with a different condition, Cerebral Palsy. Choice D is incorrect as Bell's Palsy is not a side effect of a stroke but rather a distinct condition with its own etiology.
The patient's symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms suggest toxic hepatitis, which can be caused by commonly used over-the-counter drugs such as acetaminophen (Tylenol). Travel to a foreign country and a history of IV drug use are risk factors for viral hepatitis. Corticosteroid use does not cause the symptoms listed.
A. Hemoglobin
B. Temperature
C. Activity level
D. Albumin level
Correct answer:
The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of edema. In this case, monitoring the albumin level is crucial to assess the patient's fluid balance and potential for edema. While hemoglobin, temperature, and activity level are important parameters to monitor in a patient's assessment, they are not directly associated with the patient's current symptoms of toxic hepatitis and edema development. Therefore, the correct choice is the albumin level.
A client is diagnosed with ariboflavinosis. Which of the following foods should the nurse serve this client?
A. Citrus fruits
B. Milk
C. Fish
D. Potatoes
Correct answer:
Ariboflavinosis is a vitamin B-2 deficiency. Symptoms may include cracks around the mouth, inflammation of the tongue, or light sensitivity. Foods rich in vitamin B-2, like milk, liver, green vegetables, or whole grains, are recommended. Citrus fruits (choice A) are good sources of vitamin C, not B-2. Fish (choice C) is a source of protein and omega-3 fatty acids but not a significant source of vitamin B-2. Potatoes (choice D) are a source of carbohydrates but do not provide high levels of vitamin B-2.
The mother of a newborn infant with hypospadias asks the nurse why circumcision cannot be performed. Which is the most appropriate response by the nurse?
A. Circumcision will cause an infection.
B. Circumcision is not performed in a newborn.
C. Circumcision will cause difficulty with urination.
D. Circumcision has been delayed to save tissue for surgical repair.
Correct answer:
The reason circumcision is not performed in a newborn with hypospadias is that the dorsal foreskin tissue will be needed for the surgical repair of hypospadias. Delaying circumcision allows for the preservation of tissue that will be crucial for the corrective surgery. This surgical repair is typically done within the first year of life to minimize the psychological impact on the child. Choices A, B, and C are incorrect as they do not address the specific reason for delaying circumcision in this case.
The healthcare professional is preparing to use a stethoscope for auscultation. Which statement is true regarding the diaphragm of the stethoscope?
A. Used to listen for high-pitched sounds
B. Used to listen for low-pitched sounds
C. Should be firmly held against the person's skin to block out low-pitched sounds
D. Should be lightly held against the person's skin to listen for extra heart sounds and murmurs
Correct answer:
The diaphragm of the stethoscope is designed for listening to high-pitched sounds like breath, bowel, and normal heart sounds. It should be firmly held against the person's skin to ensure optimal sound transmission, leaving a ring after use. On the other hand, the bell of the stethoscope is ideal for detecting soft, low-pitched sounds such as extra heart sounds or murmurs. Therefore, the diaphragm is not used to block out low-pitched sounds but rather to enhance the detection of high-frequency sounds.
A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to
A. A social worker from the local hospital
B. An occupational therapist from the community center
C. A physical therapist from the rehabilitation agency
D. Another client with diabetes mellitus who takes insulin
Correct answer:
An occupational therapist from the community center would be the most appropriate referral for this client. Occupational therapists specialize in helping individuals improve fine motor skills, which are essential for tasks like drawing up insulin injections. A social worker typically focuses on psychosocial aspects, a physical therapist on physical mobility, and another client with diabetes would not have the professional expertise to address the client's specific needs related to insulin preparation.
A client on an acute mental health unit reports hearing voices that are stating, "kill your doctor"?. Which of the following actions should the nurse take first?
A. Encourage the client to participate in group therapy on the unit.
B. Initiate one-to-one observation of the client.
C. Focus the client on reality.
D. Notify the provider of the client's statement.
Correct answer:
When a client experiences command hallucinations, such as being told to harm someone, the priority is ensuring the safety of the client and others. Initiating one-to-one observation allows for close monitoring and intervention to prevent harm. Encouraging participation in group therapy may not be appropriate or safe at this time. Focusing the client on reality may not be effective when experiencing hallucinations, and notifying the provider should come after immediate safety measures have been taken.
NCLEX-RN clinical judgment practice questions, set 62 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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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.
