NCLEX-RN clinical judgment practice questions, set 64
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 64
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
A client is in the post-anesthesia care unit (PACU) shivering despite being covered with several layers of blankets. What is the nurse's next action?
A. Turn the client to the prone position
B. Assist the client in breathing deeply
C. Administer meperidine as ordered
D. None of the above
Show answer and rationale
Correct answer: C — Administer meperidine as ordered
In the post-anesthesia care unit, clients may experience shivering or chills due to a drop in body temperature after surgery. Meperidine (Demerol) can be prescribed to alleviate shivering in cold clients. The prone position (lying face down) and deep breathing exercises are not interventions specifically indicated for addressing shivering due to low body temperature. Therefore, administering meperidine as ordered is the most appropriate action to manage the client's shivering in this scenario.
Question 2
What is the highest priority for post ECT care?
A. Observe for confusion
B. Monitor respiratory status
C. Reorient to time, place, and person
D. Document the client's response to the treatment
Show answer and rationale
Correct answer: B — Monitor respiratory status
The highest priority for post ECT care is to monitor respiratory status. This is crucial because a life-threatening side effect of ECT is respiratory arrest. While observing for confusion and reorienting the client are important aspects of post ECT care, they are not as critical as ensuring the client's respiratory status is stable. Documenting the client's response to treatment is also important for maintaining accurate medical records, but it is not the highest priority immediately post ECT.
Question 3
The nurse is comparing the concepts of religion and spirituality. Which statement describes an appropriate component of one's spirituality?
A. Belief in and worship of God or gods
B. Being closely tied to one's ethnic background
C. Attendance at a specific church or place of worship
D. A connection with something larger than oneself and belief in transcendence
Show answer and rationale
Correct answer: D — A connection with something larger than oneself and belief in transcendence
Spirituality refers to a connection with something larger than oneself and a belief in transcendence. The other responses do not apply to spirituality. Choice A, 'Belief in and worship of God or gods,' and choice C, 'Attendance at a specific church or place of worship,' are more aligned with religious practices. Choice B, 'Being closely tied to one's ethnic background,' is not a defining aspect of spirituality or religion as it pertains more to cultural identity rather than spiritual beliefs.
Question 4
The nurse informs the physical therapy department that the client is too weak to use a walker and needs to be transported by wheelchair. Which step of the nursing process is the nurse engaged in at this time?
A. Assessment
B. Planning
C. Implementation
D. Evaluation
Show answer and rationale
Correct answer: C — Implementation
The nurse is responsible for coordinating the plan of care with other disciplines to ensure the client's safety. This action represents the implementation phase of the nursing process. During the implementation phase, the nurse puts the care plan into action, which includes coordinating with other healthcare team members like the physical therapy department. Assessment involves data gathering, planning involves goal setting, and evaluation involves determining the attainment of client goals.
Question 5
Before allowing the client's infant granddaughter to visit before the client's scheduled heart transplant, the nurse decides it would be beneficial to collaborate with which of the following? Select all that apply.
A. Client and Family
B. Other nursing staff on the unit
C. Security department
D. Hospital administration
Show answer and rationale
Correct answer: B — Other nursing staff on the unit
Collaborating with the client and family is crucial as it fosters a sense of autonomy and active involvement in the healthcare process for the client. Involving other nursing staff ensures the successful implementation of the planned intervention and provides support for the client's needs. Collaboration with the security department or hospital administration is not necessary in this situation, as the focus should be on the client's well-being and family involvement during a sensitive time.
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Question 6
After hydrostatic reduction for intussusception, what client response should the nurse expect to observe?
A. Abdominal distension
B. Currant jelly-like stools
C. Severe, colicky-type pain with vomiting
D. Passage of barium or water-soluble contrast with stools
Correct answer:
After hydrostatic reduction for intussusception, the nurse should observe the passage of barium or water-soluble contrast with stools. This indicates a successful reduction of the telescoped bowel segment. Abdominal distension and currant jelly-like stools are clinical manifestations of intussusception, not expected outcomes following hydrostatic reduction. Severe, colicky-type pain with vomiting suggests an unresolved gastrointestinal issue, not a successful reduction of intussusception.
Which is a physical, integumentary risk among the elderly population?
A. Skin tears
B. Thickened skin
C. Thinning toe nails
D. Less nasal hair
Correct answer:
Skin tears are a physical integumentary risk among the elderly population. As individuals age, their skin becomes thinner and more fragile, making them susceptible to skin tears. Thickened skin, thinning toenails, and reduced nasal hair are common age-related changes but do not pose the same level of risk as skin tears. Thickened skin may provide some protection, thinning toenails are primarily a cosmetic concern, and reduced nasal hair does not typically lead to significant health risks.
A patient's chart indicates a history of ketoacidosis. Which of the following would you not expect to see with this patient if this condition were acute?
A. Vomiting
B. Extreme Thirst
C. Weight gain
D. Acetone breath smell
Correct answer:
In acute ketoacidosis, a patient typically experiences rapid weight loss due to the body burning fat and muscle for energy in the absence of sufficient insulin. Therefore, weight gain would not be expected. Vomiting may occur due to the metabolic disturbances associated with ketoacidosis. Extreme thirst is a common symptom as the body tries to compensate for dehydration. Acetone breath smell is a classic sign of ketoacidosis as acetone is one of the ketones produced during this condition.
A mother brings her 5-week-old infant to the health care clinic and tells the nurse that the child has been vomiting after meals. The mother reports that the vomiting is becoming more frequent and forceful. The nurse suspects pyloric stenosis and asks the mother which assessment question to elicit data specific to this condition?
A. Are the stools ribbon-like, and is the infant eating poorly?
B. Does the infant suddenly become pale, begin to cry, and draw the legs up to the chest?
C. Does the vomit contain sour, undigested food without bile, and is the infant constipated?
D. Does the infant cry loudly and continuously during the evening hours but nurses or takes formula well?
Correct answer:
Vomiting undigested food that is not bile stained and constipation are classic symptoms of pyloric stenosis. Stools that are ribbon-like and a child who is eating poorly are signs of congenital megacolon (Hirschsprung's disease). An infant who suddenly becomes pale, cries out, and draws the legs up to the chest is demonstrating physical signs of intussusception. Crying during the evening hours, appearing to be in pain, eating well, and gaining weight are clinical manifestations of colic.
The nursing care plan for a toddler diagnosed with Kawasaki Disease (mucocutaneous lymph node syndrome) should be based on the high risk for development of which problem?
A. Chronic vessel plaque formation
B. Pulmonary embolism
C. Occlusions at the vessel bifurcations
D. Coronary artery aneurysms
Correct answer:
The correct answer is chronic vessel plaque formation. Kawasaki Disease affects small and medium-sized blood vessels, leading to progressive inflammation and potential damage to the walls of medium-sized muscular arteries, which can result in coronary artery aneurysms. While other complications such as pulmonary embolism and occlusions at vessel bifurcations can occur in different conditions, for Kawasaki Disease, the primary concern is the development of chronic vessel plaque formation.
When auscultating the blood pressure of a 25-year-old patient, the nurse notices that the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg, the Korotkoff sounds muffle. At 92 mm Hg, the Korotkoff sounds disappear. How should the nurse record this patient's blood pressure?
A. 200/92
B. 200/100
C. 100/200/92
D. 200/100/92
Correct answer:
When auscultating blood pressure, it is crucial to note the points at which Korotkoff sounds change. In adults, the last audible sound indicates the diastolic pressure. In this case, the Korotkoff sounds muffle at 100 mm Hg and disappear at 92 mm Hg. Therefore, the blood pressure should be recorded as systolic/diastolic, which is 200/92. Choices B, C, and D are incorrect because they do not reflect the correct points where the Korotkoff sounds change during blood pressure measurement.
During a client interview, which of the following leading questions should the nurse avoid asking?
A. What medication do you take at home?
B. You are really excited about the plastic surgery, aren't you?
C. Were you aware I've had this same type of surgery?
D. What would you like to talk about?
Correct answer:
The nurse should avoid asking leading questions during a client interview as they can influence the client's response. Option B is a leading question as it suggests an expected response from the client, potentially biasing the information provided. This can lead to inaccurate data collection and subsequent errors in diagnostic reasoning. Choices A, C, and D are open-ended questions that encourage the client to provide unbiased information and allow for a more comprehensive assessment.
A 64-year-old patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care?
A. Assist with active range of motion (ROM).
B. Observe for agitation and paranoia.
C. Give muscle relaxants as needed to reduce spasms.
D. Use simple words and phrases to explain procedures.
Correct answer:
In a patient with ALS, progressive muscle weakness is a significant issue. Assisting with active range of motion (ROM) exercises will help maintain muscle strength for as long as possible. Agitation and paranoia are not typically associated with ALS, making choice B incorrect. Giving muscle relaxants can further weaken muscles and depress respirations, worsening the condition, so choice C is inappropriate. Choice D is not directly related to the patient's physical condition and needs.
A 64-year-old patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care?
A. Assist with active range of motion (ROM).
B. Observe for agitation and paranoia.
C. Give muscle relaxants as needed to reduce spasms.
D. Use simple words and phrases to explain procedures.
Correct answer:
In a patient with ALS, progressive muscle weakness is a significant issue. Assisting with active range of motion (ROM) exercises will help maintain muscle strength for as long as possible. Agitation and paranoia are not typically associated with ALS, making choice B incorrect. Giving muscle relaxants can further weaken muscles and depress respirations, worsening the condition, so choice C is inappropriate. Choice D is not directly related to the patient's physical condition and needs.
Which of the following signs is NOT indicative of increased intracranial pressure?
A. Decreased level of consciousness
B. Projectile vomiting
C. Sluggish pupil dilation
D. Increased heart rate
Correct answer:
Increased intracranial pressure can lead to serious complications if not promptly addressed. Common signs of increased intracranial pressure include decreased level of consciousness, sluggish pupil dilation, abnormal respirations, and projectile vomiting. However, an increased heart rate is not a typical sign associated with increased intracranial pressure. It is important for healthcare providers to recognize these signs early to prevent severe consequences such as brain herniation.
NCLEX-RN clinical judgment practice questions, set 64 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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