NCLEX-RN clinical judgment practice questions, set 63
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 63
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 assessing children in a pediatric clinic. Which statement is true regarding the
measurement of blood pressure in children?
A. Blood pressure guidelines for children are based on age.
B. Phase II Korotkoff sounds are the best indicator of systolic blood pressure in
children.
C. Using a Doppler device is recommended for accurate blood pressure measurements
until adolescence.
D. The disappearance of phase V Korotkoff sounds can be used for the diastolic
reading in children.
Show answer and rationale
Correct answer: D — The disappearance of phase V Korotkoff sounds can be used for the diastolic
reading in children.
The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children, as
well as in adults. Blood pressure guidelines for children are based on more than just age, but also sex
and height. Phase I Korotkoff, not Phase II, is the best indicator of systolic blood pressure. The true
statement regarding the measurement of blood pressure in children is that the disappearance of phase
V Korotkoff sounds can be used for the diastolic reading in children, as well as in adults.
Question 2
Which information given by a 70-year-old patient during a health history indicates to the nurse that the patient should be screened for hepatitis C?
A. The patient had a blood transfusion in 2005
B. The patient used IV drugs about 20 years ago
C. The patient frequently eats in fast-food restaurants
D. The patient traveled to a country with poor sanitation
Show answer and rationale
Correct answer: B — The patient used IV drugs about 20 years ago
The correct answer is 'The patient used IV drugs about 20 years ago.' Any patient with a history of IV drug use should be tested for hepatitis C due to the increased risk of transmission through sharing needles. Blood transfusions given after 1992, when an antibody test for hepatitis C became available, do not pose a risk for hepatitis C. Hepatitis C is not spread by the oral-fecal route, so contaminated food or traveling to countries with poor sanitation are not direct risk factors for hepatitis C.
Question 3
The mitral valve is synonymous with the term:
A. Left ventricle
B. Right atrium
C. Bicuspid valve
D. Tricuspid valve
Show answer and rationale
Correct answer: C — Bicuspid valve
The mitral valve, also known as the bicuspid valve, is located between the left atrium and the left ventricle, regulating blood flow from the left atrium into the left ventricle. The term 'bicuspid' refers to the valve's two cusps or leaflets. This distinguishes it from the tricuspid valve (Choice D), which has three cusps, making Choice D incorrect. The left ventricle (Choice A) and right atrium (Choice B) are not synonymous with the mitral valve. Therefore, the correct answer is C: Bicuspid valve.
Question 4
Who is most likely to arrange the discharge of a patient to their own home, a nursing home, or an assisted living facility?
A. A physical therapist
B. A speech therapist
C. A social worker
D. An occupational therapist
Show answer and rationale
Correct answer: C — A social worker
Social workers play a crucial role in arranging patient discharges to suitable facilities. They collaborate with healthcare professionals to ensure that patients are transitioned to the most appropriate setting post-hospitalization. Social workers focus on the holistic needs of patients, including their social and emotional well-being, to facilitate a smooth continuum of care. Choices A, B, and D do not typically have the primary responsibility for arranging patient discharges to various facilities.
Question 5
The clinic nurse is obtaining data about a child with a diagnosis of lactose intolerance. Which data should the nurse expect to obtain on assessment?
A. Reports of frothy stools and diarrhea
B. Reports of foul-smelling ribbon stools
C. Reports of profuse, watery diarrhea and vomiting
D. Reports of diffuse abdominal pain unrelated to meals or activity
Show answer and rationale
Correct answer: A — Reports of frothy stools and diarrhea
Lactose intolerance commonly presents with frothy stools and diarrhea due to the inability to digest lactose. Other symptoms include abdominal distension, crampy abdominal pain, and excessive flatus. Foul-smelling ribbon stools are indicative of Hirschsprung's disease, not lactose intolerance. Profuse, watery diarrhea and vomiting are more characteristic of celiac disease. Diffuse abdominal pain unrelated to meals or activity is a typical symptom of irritable bowel syndrome, not lactose intolerance.
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Question 6
A mother brings her 26-month-old to the well-child clinic. She expresses frustration and anger due to her child's constant saying 'no' and refusal to follow her directions. The nurse explains this is normal for his age, as negativism is attempting to meet which developmental need?
A. Trust
B. Initiative
C. Independence
D. Self-esteem
Correct answer:
In Erikson's theory of development, toddlers struggle to assert independence. They often use the word 'no' even when they mean yes. This stage is called autonomy versus shame and doubt. The child's behavior of saying 'no' and resisting directions reflects the developmental need for independence, not trust (option A), initiative (option B), or self-esteem (option D). Trust is typically associated with early infancy, initiative with preschool age, and self-esteem with later childhood and adolescence.
What would a healthcare professional expect to observe while assessing the growth of children during their school-age years?
A. Decreasing amounts of body fat and muscle mass
B. Little change in body appearance from year to year
C. Progressive height increase of 4 inches each year
D. Yearly weight gain of about 5.5 pounds per year
Correct answer:
During school-age years, children typically gain about 5.5 pounds per year and increase in height by about 2 inches annually. This steady growth pattern is expected between ages 2 to 10 years. Choice A is incorrect as children at this stage are expected to gain weight and grow in height. Choice B is incorrect as there should be noticeable changes in body appearance due to growth. Choice C is incorrect as a progressive height increase of 4 inches each year is not typical during the school-age years.
A patient is found unconscious in their room with rhythmic jerking of all four extremities and heavy foaming at the mouth. The patient was on seizure precautions with bedrails up and padded. What is the priority action for the nurse to take?
A. Administer Lorazepam (Ativan)
B. Turn the patient to his/her side
C. Call the physician
D. Suction the patient
Correct answer:
The nurse's priority action should be to turn the patient to his/her side. This position helps maintain an open airway and prevents aspiration of secretions or vomitus. Administering Lorazepam (Ativan) without ensuring a clear airway could lead to further complications. Calling the physician is important, but immediate interventions to protect the airway take precedence. Suctioning the patient may be necessary but should not be the initial action; positioning for airway protection is the priority.
The nurse is creating a plan of care for a 10-year-old child diagnosed with acute glomerulonephritis. What is the priority nursing intervention?
A. Promoting bed rest
B. Restricting oral fluids
C. Allowing the child to play
D. Encouraging visits from friends
Correct answer:
During the acute phase of glomerulonephritis, promoting bed rest is a priority to reduce stress on the kidneys and promote recovery. As the condition improves, activity can be gradually increased. Restricting oral fluids is not recommended as maintaining adequate hydration is crucial. Allowing the child to play quietly can be beneficial but is not the priority over rest during the acute phase. Encouraging visits from friends may disrupt the rest needed for recovery, so visitors should be limited.
What preparation should be made for a client undergoing a KUB (Kidney, Ureter, Bladder) radiography test?
A. Client must be NPO before the examination
B. Enema should be administered before the examination
C. Medicate the client with furosemide 20 mg IV 30 minutes before the examination
D. No special orders are necessary for this examination
Correct answer:
The correct answer is that no special orders are necessary for a KUB radiography test. It is important to inform the client to remove any clothing, jewelry, or objects that may interfere with the test. Option A is incorrect because there is no need for the client to be NPO before this examination. Option B is incorrect as enemas are not routinely administered prior to a KUB radiography test. Option C is incorrect as there is no need to medicate the client with furosemide before this examination.
A patient is admitted to the same-day surgery unit for a liver biopsy. Which of the following laboratory tests assesses coagulation? Select one that doesn't apply.
A. Partial thromboplastin time
B. Prothrombin time
C. Platelet count
D. Hemoglobin
Correct answer:
The correct answer is 'Hemoglobin.' Hemoglobin levels are not indicative of coagulation status but are important for assessing oxygen-carrying capacity. Choices A, B, and C are all laboratory tests that assess coagulation. Partial thromboplastin time (PTT) and prothrombin time (PT) evaluate different aspects of the coagulation cascade, while platelet count is essential for assessing primary hemostasis. Therefore, in the context of evaluating coagulation, hemoglobin is not the appropriate choice.
When percussing over the lungs of a 4-year-old child, the nurse hears bilateral loud, long, and low tones. How should the nurse proceed?
A. Palpate over the area for increased pain and tenderness.
B. Ask the child to take shallow breaths and percuss over the area again.
C. Refer the child to a specialist because of an increased amount of air in the lungs.
D. Consider this finding as normal for a child this age and proceed with the examination.
Correct answer:
In pediatric patients, loud, long, and low tones heard when percussing over the lungs are normal findings. These percussion notes are characteristic of a child's lung due to its thin chest wall and increased air content. It is unnecessary to palpate for pain and tenderness, ask the child to take shallow breaths and repeat the percussion, or refer the child to a specialist. Therefore, the correct action is to consider these findings as normal for the child's age and continue with the examination.
In which of the following conditions would a healthcare provider not administer erythromycin?
A. Campylobacteriosis infection
B. Legionnaires disease
C. Pneumonia
D. Multiple Sclerosis
Correct answer:
Erythromycin is an antibiotic used to treat bacterial infections. Multiple sclerosis (MS) is an autoimmune disease affecting the central nervous system, involving the brain and spinal cord. Since MS is not caused by bacteria, administering erythromycin would not be appropriate. Campylobacteriosis infection, Legionnaires disease, and pneumonia are bacterial infections that can be treated with erythromycin, making them incorrect choices for conditions where erythromycin would not be administered.
The mother of a child who had a cleft palate repair 4 days ago is receiving home care instructions. Which statement by the mother indicates the need for further instruction?
A. ''I will use a short nipple on the bottle.''
B. ''I should avoid using straws for drinking.''
C. ''I can give my child the pacifier in 2 weeks.''
D. ''I may give my baby food mixed with water.''
Correct answer:
The correct answer is ''I should avoid using straws for drinking.'' After a cleft palate repair, the child should avoid straws, pacifiers, spoons, and fingers near the mouth for 7 to 10 days to prevent injury to the surgical site. Allowing the child to use a straw can create negative pressure in the mouth, potentially disrupting the healing process. The other options are appropriate postoperative instructions for a child who had a cleft palate repair and do not pose a risk to the surgical site.
A healthcare professional is considering which patient to admit to the same room as a patient who had a liver transplant 3 weeks ago and is now hospitalized with acute rejection. Which patient would be the best choice?
A. Patient who is receiving chemotherapy for liver cancer
B. Patient who is receiving chemotherapy for lung cancer
C. Patient who has a wound infection after cholecystectomy
D. Patient who requires pain management for chronic pancreatitis
Correct answer:
The patient with chronic pancreatitis is the best choice to admit to the same room as a patient who had a liver transplant and is experiencing acute rejection. This is because the patient with chronic pancreatitis does not pose an infection risk to the immunosuppressed patient who had a liver transplant. On the other hand, patients receiving chemotherapy for cancer or those with wound infections are at risk for infections, which could endanger the immunosuppressed patient with acute rejection.
NCLEX-RN clinical judgment practice questions, set 63 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.
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