NCLEX-RN clinical judgment practice questions, set 65
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 65
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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 patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action by the nurse?
A. The oxygen saturation is 94%.
B. The blood pressure is 98/56 mm Hg.
C. The patient's central IV line is disconnected.
D. The international normalized ratio (INR) is prolonged.
Show answer and rationale
Correct answer: C — The patient's central IV line is disconnected.
The most immediate action required by the nurse is to address the disconnected central IV line delivering epoprostenol (Flolan). Epoprostenol has a short half-life of 6 minutes, necessitating immediate reconnection to prevent rapid clinical deterioration. While oxygen saturation, blood pressure, and INR are important parameters requiring monitoring and intervention, the priority lies in ensuring the continuous delivery of the critical medication to stabilize the patient's condition.
Question 2
Which of the following statements best describes postural drainage as part of chest physiotherapy?
A. Tapping on the chest wall to loosen secretions
B. Squeezing the abdomen to increase expansion of the upper chest
C. Using gravity to move secretions in the lung tissue
D. Dilating the trachea to facilitate better release of secretions
Show answer and rationale
Correct answer: C — Using gravity to move secretions in the lung tissue
Postural drainage is a technique used in chest physiotherapy for clients with accumulated lung secretions. It involves positioning the client to utilize gravity in moving secretions from the lungs. Choice A, tapping on the chest wall, describes percussion, not postural drainage. Choice B, squeezing the abdomen, is not a correct description of postural drainage. Choice D, dilating the trachea, is not related to postural drainage but may be associated with airway clearance techniques.
Question 3
What is the most common complication of chest wall injury?
A. Hemothorax
B. Atelectasis
C. Pneumonia
D. Pneumothorax
Show answer and rationale
Correct answer: C — Pneumonia
Pneumonia is the most common complication of chest wall injury. Chest wall trauma can lead to impaired lung function, making patients more susceptible to pneumonia due to reduced ability to clear secretions and impaired breathing. While hemothorax and pneumothorax are potential complications of chest wall injury, pneumonia is more commonly encountered. Atelectasis, although a common pulmonary complication, is not typically the most common complication seen in chest wall injuries.
Question 4
Is it true that Hepatitis C virus (HCV) can be spread through hugging, sneezing, coughing, sharing eating utensils, and other forms of casual contact?
A. True
B. False
Show answer and rationale
Correct answer: B — False
False. HCV is not spread through casual contact such as hugging, sneezing, or sharing eating utensils. The correct modes of transmission for HCV include direct contact with human blood through blood transfusions, improperly sterilized needles and syringes, needle sharing, or occasionally through sexual contact. Therefore, the statement is false, making 'False' the correct answer. Choices A, C, and D are incorrect as they do not accurately reflect the mode of transmission of HCV.
Question 5
You are turning your patient in bed and notice that a confused and lethargic patient had loose car keys and lipstick in the bed and had been lying on them. What is this person at risk for due to all three of these factors: confusion, lethargy, and items in the bed?
A. Falls
B. Skin breakdown
C. Apnea
D. Lack of mobility
Show answer and rationale
Correct answer: B — Skin breakdown
This patient is at great risk for skin breakdown due to the presence of three specific risk factors: confusion, lethargy, and items in the bed. While confusion puts the patient at risk for falls, confusion and lethargy together may lead to a lack of mobility. However, skin breakdown is the primary concern in this scenario as it is associated with all three risk factors - confusion, lethargy, and the presence of items in the bed. Therefore, the correct answer is 'Skin breakdown'.
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Question 6
Which of the following vital signs can be expected in a child that is afebrile?
A. Rectal Temp of 100.9 degrees F.
B. Oral Temp of 38 degrees C.
C. Axillary Temp of 98.6 degrees F.
D. All of the above are incorrect.
Correct answer:
The correct answer is the axillary temperature of 98.6 degrees F. Afebrile means without a fever, and an axillary temperature, which is taken in the armpit, is considered normal at 98.6 degrees F. Choice A is incorrect as a rectal temperature of 100.9 degrees F indicates a fever. Choice B is incorrect as an oral temperature of 38 degrees C is also indicative of a fever. Choice D is incorrect as not all options are wrong; only choices A and B are incorrect for an afebrile child.
A 30-year-old man is being admitted to the hospital for elective knee surgery. Which assessment finding is most important to report to the healthcare provider?
A. Tympany on percussion of the abdomen
B. Liver edge 3 cm below the costal margin
C. Bowel sounds of 20/minute in each quadrant
D. Aortic pulsations visible in the epigastric area
Correct answer:
The correct answer is 'Liver edge 3 cm below the costal margin.' Normally, the lower border of the liver is not palpable below the ribs, so this finding suggests hepatomegaly, which could indicate an underlying health issue. Tympany on percussion of the abdomen, bowel sounds of 20/minute in each quadrant, and aortic pulsations visible in the epigastric area are all within normal limits for a physical assessment and do not require immediate reporting to the healthcare provider.
While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child's developmental needs?
A. "I want to protect my child from any falls."?
B. "I will set limits on exploring the house."?
C. "I understand the need to use those new skills."?
D. "I intend to keep control over our child."?
Correct answer:
The correct answer is: "I understand the need to use those new skills."? This response indicates that the mother recognizes the importance of allowing the toddler to practice and develop new skills, supporting autonomy and exploration. Setting limits, protecting from falls, and intending to keep control go against the toddler's developmental needs. Toddlers at this stage require opportunities to explore, practice new skills, and gain independence to foster healthy development.
A nursing care plan states, 'Assist the patient to the bedside commode PRN.' When will this patient get this assistance to the commode?
A. Whenever needed
B. At bedtime
C. During the night
D. During the day
Correct answer:
The correct answer is 'Whenever needed.' The abbreviation 'PRN' stands for 'pro re nata,' which translates to 'as needed' or 'whenever necessary.' This means that the patient will receive assistance to the commode whenever they require it, based on their individual needs and condition. Choices B, C, and D are incorrect because 'PRN' does not specify a specific time like bedtime, during the night, or during the day; instead, it indicates assistance based on the patient's needs.
Which of the following lists the recommended sequence for removing soiled personal protective equipment when preparing to leave a patient's room?
A. Gown, goggles, mask, gloves, and exit the room.
B. Gloves, wash hands, remove gown, mask, and goggles.
C. Gloves, goggles, gown, mask, and wash hands.
D. Gloves, goggles, gown, mask, and wash hands.
Correct answer:
The correct sequence for removing soiled personal protective equipment is crucial to prevent contamination. Gloves should always be removed first as they are most likely to be contaminated. Following the removal of gloves, goggles, gown, mask, and finally washing hands is recommended. Choice A is incorrect as gloves should be removed first. Choice B is incorrect as the sequence is not in the recommended order. Choice D is incorrect as gloves should be removed before goggles.
A nurse is caring for a patient with peripheral vascular disease (PVD). The patient
complains of burning and tingling of the hands and feet and cannot tolerate touch of any
kind. Which of the following is the most likely explanation for these symptoms?
A. Inadequate tissue perfusion leading to nerve damage.
B. Fluid overload leading to compression of nerve tissue.
C. Sensation distortion due to psychiatric disturbance.
D. Inflammation of the skin on the hands and feet.
Correct answer:
Patients with the peripheral vascular disease often sustain nerve damage as a result of
inadequate tissue perfusion. Ischemic rest pain is more worrisome; it refers to pain in the
extremity that is due to a combination of PVD and inadequate perfusion. Ischemic rest
pain often is exacerbated by poor cardiac output. The condition is often partially or fully
relieved by placing the extremity in a dependent position, so that perfusion is enhanced by
the effects of gravity.
A nurse is caring for a patient with peripheral vascular disease (PVD). The patient
complains of burning and tingling of the hands and feet and cannot tolerate touch of any
kind. Which of the following is the most likely explanation for these symptoms?
A. Inadequate tissue perfusion leading to nerve damage.
B. Fluid overload leading to compression of nerve tissue.
C. Sensation distortion due to psychiatric disturbance.
D. Inflammation of the skin on the hands and feet.
Correct answer:
Patients with the peripheral vascular disease often sustain nerve damage as a result of
inadequate tissue perfusion. Ischemic rest pain is more worrisome; it refers to pain in the
extremity that is due to a combination of PVD and inadequate perfusion. Ischemic rest
pain often is exacerbated by poor cardiac output. The condition is often partially or fully
relieved by placing the extremity in a dependent position, so that perfusion is enhanced by
the effects of gravity.
What term is used to refer to generalized wasting of body tissues and malnutrition?
A. Entropion
B. Confabulation
C. Induration
D. Cachexia
Correct answer:
Cachexia is the correct term used to describe the generalized wasting of body tissues, ill health, and malnutrition associated with some chronic diseases. It involves a loss of fat tissue to protect the bones and joints. Clients with cachexia are at risk of pressure ulcers and other complications due to malnutrition and poor health. Entropion refers to an eyelid condition, confabulation is a memory disturbance, and induration is the abnormal hardening of a part of the body.
A patient is admitted and complains of gastric pain, fever, and diarrhea. Which assessment finding should be reported to the healthcare provider immediately?
A. Abdominal distention
B. A bruit near the epigastric area
C. 3 episodes of vomiting in the last hour
D. Blood pressure of 160/90
Correct answer:
A bruit near the epigastric area may indicate the presence of an aortic aneurysm, which is a life-threatening condition requiring immediate medical attention. Abdominal distention, while concerning, may not be as urgent as a potential aneurysm. Vomiting episodes may suggest underlying issues but do not present an immediate life-threatening situation. A blood pressure of 160/90, though elevated, does not pose the same level of immediate threat as a potential aortic aneurysm.
A diabetic patient's arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg; HCO3 18 mEq/L. The nurse would expect which finding?
A. Intercostal retractions
B. Kussmaul respirations
C. Low oxygen saturation (SpO2)
D. Decreased venous O2 pressure
Correct answer:
Kussmaul respirations (deep and rapid) are a compensatory mechanism for metabolic acidosis. The low pH and low bicarbonate levels indicate metabolic acidosis. Intercostal retractions, low oxygen saturation, and decreased venous O2 pressure are not associated with acidosis. Intercostal retractions typically occur in respiratory distress, while low oxygen saturation and decreased venous O2 pressure are more related to respiratory or circulatory issues, not metabolic acidosis.
NCLEX-RN clinical judgment practice questions, set 65 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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