NCLEX-RN clinical judgment practice questions, set 66
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 66
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 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
Show answer and rationale
Correct answer: B — Kussmaul respirations
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.
Question 2
An infant weighed 7 pounds 8 ounces at birth. If growth occurs at a normal rate, what would be the expected weight at 6 months of age?
A. Double the birth weight
B. Triple the birth weight
C. Gain 6 ounces each week
D. Add 2 pounds each month
Show answer and rationale
Correct answer: A — Double the birth weight
Infants typically double their birth weight by 6 months of age as part of normal growth and development. This doubling of weight is a common milestone used by healthcare providers to assess a baby's growth progress. Tripling the birth weight or adding 2 pounds each month would result in excessive weight gain, which is not typical or healthy for an infant. Similarly, gaining 6 ounces each week would also lead to rapid and abnormal weight gain, making it an incorrect choice.
Question 3
A nurse frequently treats patients in the 72-hour period after a stroke has occurred. The nurse would be most concerned about which of these assessment findings?
A. INR is 3 seconds long
B. Heart rate is 110 beats per minute
C. Intracranial Pressure is 22 mmHg
D. Blood pressure is 140/80
Show answer and rationale
Correct answer: C — Intracranial Pressure is 22 mmHg
The nurse would be most concerned about the assessment finding of an Intracranial Pressure (ICP) reading of 22 mmHg in a patient 72 hours post-stroke. Elevated ICP can indicate increased risk of edema and further brain damage. A target ICP should ideally be maintained at less than or equal to 15-20 mmHg. While the other options may also be important to monitor, an elevated ICP poses a more immediate threat to the patient's neurological status and requires prompt attention.
Question 4
A client with a new prescription for lithium carbonate for bipolar disorder is being educated by a nurse on early indications of toxicity. The nurse should include which of the following manifestations in the teachings?
A. Constipation
B. Polyuria
C. Rash
D. Tinnitus
Show answer and rationale
Correct answer: B — Polyuria
Polyuria is a crucial early indication of lithium toxicity. It results from the drug's effect on the kidneys, leading to increased urine output. This is a significant symptom to monitor as it can indicate potential toxicity. Constipation, rash, and tinnitus are not typically associated with early indications of lithium toxicity. Constipation is more commonly seen as a side effect of some medications, while rash and tinnitus are not specific indicators of lithium toxicity.
Question 5
Which food should the assistive personnel be instructed to remove from the child's food tray based on the prescribed treatment for nephrotic syndrome?
A. Pickle
B. Wheat toast
C. Baked chicken
D. Steamed vegetables
Show answer and rationale
Correct answer: A — Pickle
In nephrotic syndrome, a no-added-salt diet is recommended to manage the condition. High-sodium foods like pickles should be avoided as they can exacerbate fluid retention and swelling. Wheat toast, baked chicken, and steamed vegetables are generally suitable for individuals with nephrotic syndrome as they are low in sodium and protein, which are important considerations for this condition. Therefore, the correct choice is to remove the pickles from the child's food tray.
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Question 6
In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school-age child for evaluation?
A. Polyphagia
B. Dehydration
C. Bedwetting
D. Weight loss
Correct answer:
The correct answer is 'Bedwetting.' One of the initial symptoms of type 1 diabetes in children is bedwetting. Parents are likely to notice bedwetting in a school-age child, prompting them to seek evaluation. Polyphagia (excessive hunger) and weight loss are also common symptoms of diabetes but may not be as readily noticeable to parents compared to bedwetting. Dehydration is a consequence of diabetes rather than an early symptom that would prompt parents for evaluation.
When reviewing the demographics of ethnic groups in the United States, which group does the nurse recall as the largest and fastest-growing population?
A. Asian
B. Hispanic
C. American Indian
D. African American/Black
Correct answer:
The correct answer is 'Hispanic.' Hispanics are the largest and fastest-growing population in the United States. While African Americans/Blacks, Asians, American Indians, and other groups are significant, Hispanics currently represent the largest demographic group. African American/Black, Asian, and American Indian populations are substantial but not as large or fast-growing as the Hispanic population. Therefore, Hispanic is the most appropriate choice in this scenario.
After performing an assessment of an infant with bladder exstrophy, the nurse prepares a plan of care. The nurse identifies which problem as the priority for the infant?
A. Urinary incontinence
B. Impaired tissue integrity
C. Inability to suck and swallow
D. Lack of knowledge about the disease (parents)
Correct answer:
In bladder exstrophy, the bladder is exposed and external to the body, leading to impaired tissue integrity related to the exposed bladder mucosa as the priority problem. Urinary incontinence is not a concern as the infant is not yet toilet trained. Inability to suck and swallow is unrelated to the disorder. While educating the parents about the condition is important, it is not the priority over addressing the immediate risk of impaired tissue integrity in the infant.
The client often sighs and says in a monotone voice, 'I'm never going to get over this.' When encouraged to participate in care, the client says, 'I don't have the energy.' These cues are suggestive of which nursing diagnoses? Select all that apply.
A. Hopelessness
B. Power
C. Interrupted sleep pattern
D. Disturbed self-esteem
Correct answer:
A nursing diagnosis involves clinical judgment about a response to a health problem. In this scenario, the client's expressions of feeling overwhelmed and lacking energy indicate feelings of hopelessness and powerlessness. While fatigue is mentioned, there is no direct evidence to support an interrupted sleep pattern, making option C incorrect. Similarly, disturbed self-esteem and self-care deficit are not evident from the given cues, making options D and E incorrect.
The nurse is planning care for a 48-year-old woman with acute severe pancreatitis. The highest priority patient outcome is
A. maintaining normal respiratory function.
B. expressing satisfaction with pain control.
C. developing no ongoing pancreatic disease.
D. having adequate fluid and electrolyte balance.
Correct answer:
In acute severe pancreatitis, there is a risk of respiratory failure as a complication, making the maintenance of normal respiratory function the priority outcome. This patient may develop respiratory issues due to the inflammatory process affecting the diaphragm. While pain control, absence of ongoing pancreatic disease, and fluid/electrolyte balance are crucial, they are secondary to ensuring adequate oxygenation and ventilation to prevent respiratory compromise.
Which of the following is the most common type of malignant brain tumor in the United States?
A. Meningioma
B. Glioblastoma multiforme
C. Acoustic neuroma
D. Pituitary adenoma
Correct answer:
Glioblastoma multiforme is the most common malignant brain tumor in the United States, accounting for a significant portion of cases. It is known for its aggressive nature and poor prognosis. Surgical resection, followed by radiation and chemotherapy, is the standard treatment approach for glioblastoma multiforme. Meningioma, acoustic neuroma, and pituitary adenoma are also types of brain tumors but are not as common as glioblastoma multiforme in the United States.
A client had a closed reduction of a fractured right wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires immediate attention?
A. Capillary refill of fingers on right hand is 3 seconds
B. Skin warm to touch and normally colored
C. Client reports prickling sensation in the right hand
D. Slight swelling of fingers of right hand
Correct answer:
A prickling sensation in the right hand is indicative of compartment syndrome, a serious condition that can lead to tissue damage and impaired circulation. Immediate attention is required to prevent complications. Capillary refill of 3 seconds, warm and normally colored skin, and slight swelling of fingers are expected findings after a closed reduction and casting. These findings do not typically indicate a critical issue and can be managed with routine monitoring.
The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate?
A. Unequal leg length
B. Limited adduction
C. Diminished femoral pulses
D. Symmetrical gluteal folds
Correct answer:
The correct answer is 'Unequal leg length.' Shortening of a leg is a common sign of developmental dysplasia of the hip. Limited adduction (Choice B) may be present but is less specific to developmental dysplasia of the hip. Diminished femoral pulses (Choice C) are not typically associated with developmental dysplasia of the hip. Symmetrical gluteal folds (Choice D) are a normal finding and would not be expected in a patient with developmental dysplasia of the hip.
A patient is asked to abduct her arms. Which of the following accurately describes her arm movement?
A. She moves her arms away from her trunk
B. She moves her arms toward her trunk
C. She rotates her arms at the wrists while holding them away from her body
D. She crosses her arms over her abdomen
Correct answer:
Abduction refers to moving a body part away from the midline of the body. In this case, when the patient abducts her arms, she is moving them away from her trunk. Choice A is correct. Choices B, C, and D are incorrect. Choice B describes adduction, which is the movement of a body part toward the midline. Choice C describes wrist rotation, not arm abduction. Choice D describes crossing the arms over the abdomen, which is not the movement associated with abduction.
After change-of-shift report, which patient should the nurse assess first?
A. 72-year-old with cor pulmonale who has 4+ bilateral edema in his legs and feet
B. 28-year-old with a history of a lung transplant and a temperature of 101 F (38.3 C)
C. 40-year-old with a pleural effusion who is complaining of severe stabbing chest pain
D. 64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion
Correct answer:
The patient with lung cancer and tracheal deviation after a subclavian catheter insertion should be assessed first. Tracheal deviation can indicate tension pneumothorax, a life-threatening condition that requires immediate intervention to prevent inadequate cardiac output or hypoxemia. While the other patients also need assessment, the potential for tension pneumothorax in the patient with tracheal deviation necessitates urgent attention to prevent complications.
NCLEX-RN clinical judgment practice questions, set 66 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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