NCLEX-RN clinical judgment practice questions, set 67
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 67
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 patient asks the nurse why they must have a heparin injection. What is the nurse's best response?
A. Heparin will dissolve clots that you have.
B. Heparin will reduce the platelets that make your blood clot.
C. Heparin will work better than warfarin.
D. Heparin will prevent new clots from developing.
Show answer and rationale
Correct answer: D — Heparin will prevent new clots from developing.
The correct answer is D: 'Heparin will prevent new clots from developing.' Heparin is an anticoagulant medication that helps prevent the formation of new blood clots. It does not dissolve existing clots (choice A), reduce platelets (choice B), or necessarily work 'better' than warfarin (choice C) but rather functions differently. The primary action of heparin is to prevent the development of new clots, especially in conditions where clot formation is a concern.
Question 2
What is the flap of tissue that covers the trachea upon swallowing called?
A. Epidermis
B. Endocardium
C. Epiglottis
D. Epistaxis
Show answer and rationale
Correct answer: C — Epiglottis
The correct answer is C: Epiglottis. The epiglottis is a flap of tissue that covers the trachea when swallowing to prevent food or liquid from entering the airway. Choice A, Epidermis, is the outer layer of the skin and is not related to the trachea. Choice B, Endocardium, is the inner lining of the heart chambers and is also unrelated to the trachea. Choice D, Epistaxis, refers to a nosebleed and is not the correct term for the tissue covering the trachea.
Question 3
A patient has come to the office for a blood draw. The patient starts to sweat and is very anxious. Which of the following would be the BEST way to proceed?
A. Do not perform the procedure. Notify the physician of the reason why.
B. Perform the procedure but pay close attention for signs of potential syncope.
C. Allow the patient to reschedule for a time when he isn't as anxious.
D. Have the physician draw the blood.
Show answer and rationale
Correct answer: B — Perform the procedure but pay close attention for signs of potential syncope.
In the scenario where a patient is sweating and anxious, it is important to assess for signs of potential syncope (fainting) while proceeding with the blood draw. If the patient does not exhibit signs of fainting, the phlebotomy procedure can be performed safely. Postponing the procedure may not address the patient's anxiety and inconvenience them. Having the physician draw the blood is not necessary if the phlebotomist can handle the situation effectively.
Question 4
Which of the following activities would the nurse perform during the diagnosing phase of the nursing process? Select all that apply.
A. Collect and organize client information
B. Analyze data
C. Identify problems, risks, and client strengths
D. Develop nursing diagnoses
Show answer and rationale
Correct answer: B — Analyze data
During the diagnosing phase of the nursing process, the nurse analyzes the collected data to identify problems, risks, and client strengths, which then leads to developing nursing diagnoses. Collecting and organizing client information is part of the assessment phase, where data is gathered. Developing nursing diagnoses comes after data analysis in the diagnosing phase. Goal setting is a component of the planning phase, which follows the diagnosing phase.
Question 5
After surgery for an imperforate anus, an infant returns with a red and edematous colostomy stoma. What action should the nurse take based on this finding?
A. Elevate the buttocks.
B. Document the findings.
C. Apply ice immediately.
D. Call the primary health care provider.
Show answer and rationale
Correct answer: B — Document the findings.
A red and edematous colostomy stoma is a common finding immediately after surgery, and these changes are expected to decrease over time. As the stoma heals, it usually becomes pink without signs of abnormal drainage, swelling, or skin breakdown. Therefore, the appropriate action for the nurse is to document these normal findings. Elevating the buttocks, applying ice, or calling the primary health care provider are unnecessary interventions at this stage.
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.
Stems and choices stay public so you can still reason. Correct answers and full rationales unlock with the rest of the bank.
Question 6
Which of the following is an example of low health literacy skills?
A. A nurse is unable to explain the dose, indications, side effects, and structural formula of carbamazepine
B. A client cannot read an admission form to sign it
C. A nurse cannot calculate the correct IV rate for Ringer's lactate
D. A nurse is unable to explain the dose, indications, side effects, and structural formula of carbamazepine
Correct answer:
Low health literacy skills are exemplified by an individual's inability to comprehend health-related information. In this scenario, a client's inability to read an admission form to sign it indicates low health literacy. This lack of understanding can hinder their ability to make informed decisions about their healthcare. The other choices involve healthcare professionals and their knowledge or skills, not the health literacy of individuals seeking care.
When a sequence of repeated weights is necessary, the healthcare provider should aim to weigh the patient at the same time of day and with consistent clothing. Using a standardized balance or electronic standing scale is recommended for accurate measurements. The patient should remove shoes and heavy outer clothing. It is not required for the patient to always be weighed in undergarments. What is the most appropriate indicator of the patient's overall well-being?
A. General health
B. Genetic makeup
C. Nutritional status
D. Activity and exercise patterns
Correct answer:
Weight measurements are essential to assess general health, particularly in monitoring growth patterns. Height and weight recordings are crucial indicators of overall well-being, reflecting the individual's health status. Genetic makeup does not change with weight fluctuations, making it an inappropriate indicator. Nutritional status and activity levels can influence weight but are not as comprehensive as general health in reflecting overall well-being.
The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which finding would the nurse expect?
A. Confusion
B. Loss of half of the visual field
C. Shallow respirations
D. Tonic-clonic seizures
Correct answer:
In the late stages of Amyotrophic Lateral Sclerosis (A.L.S.), respiratory muscles are affected, leading to shallow respirations. Confusion is not typically associated with A.L.S. Loss of half of the visual field suggests a neurological issue unrelated to A.L.S., while tonic-clonic seizures are not commonly seen in A.L.S. patients. Shallow respirations are a hallmark sign of respiratory muscle weakness in A.L.S. due to the degeneration of motor neurons.
What is the likely cause of pericarditis in a young patient?
A. Heart failure
B. Acute MI
C. Hypertension
D. Infectious processes
Correct answer:
In younger patients, pericarditis is typically caused by an infection commonly triggered by viruses like the Coxsackie virus, streptococcus, staphylococcus, or Haemophilus influenzae. Infectious processes are the leading cause of pericarditis in younger individuals. Heart failure, Acute MI, and Hypertension are not common causes of pericarditis in young patients. In older adults, acute myocardial infarction (MI) is a more common cause of pericarditis.
Which of the following medical terms means 'surgical fixation of the stomach'?
A. Abdominorrhaphy
B. Gastroplasty
C. Gastropexy
D. Abdominorrhexis
Correct answer:
The correct answer is 'Gastropexy,' which means 'surgical fixation of the stomach.' This procedure involves surgically fixing the stomach in place. 'Abdominorrhaphy' refers to suturing or repairing the abdomen, not related to fixing the stomach. 'Gastroplasty' is a surgical reconstruction of the abdomen, not specifically related to fixing the stomach. 'Abdominorrhexis' refers to the rupture or tearing of the abdomen, not a surgical fixation procedure.
A client with asthma has low-pitched wheezes present in the final half of exhalation. One hour later, the client has high-pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client:
A. Has increased airway obstruction.
B. Has improved airway obstruction.
C. Needs to be suctioned.
D. Exhibits hyperventilation.
Correct answer:
The change from low-pitched wheezes to high-pitched wheezes indicates a shift from larger to smaller airway obstruction, suggesting increased narrowing of the airways. This change signifies a progression or worsening of the airway obstruction. The absence of evidence of secretions does not support the need for suctioning. Hyperventilation is characterized by rapid and deep breathing, which is not indicated by the information provided in the question.
A 3-year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse should
A. Expose the cast to air and turn the child frequently
B. Use a heat lamp to reduce the drying time
C. Handle the cast with the abductor bar
D. Turn the child as little as possible
Correct answer:
After applying a hip spica cast, it is important to facilitate drying by exposing the cast to air and turning the child frequently. This helps promote even drying and prevents complications such as skin breakdown. Using a heat lamp can cause burns and is not recommended. Handling the cast with the abductor bar does not aid in drying the cast. Turning the child as little as possible is incorrect as regular turning is crucial to prevent complications.
The healthcare provider calculates the IV flow rate for a patient receiving lactated Ringer's solution. The patient needs to receive 2000mL of Lactated Ringer's over 36 hours. The IV infusion set has a drop factor of 15 drops per milliliter. How many drops per minute should the healthcare provider set the IV to deliver?
A. 8
B. 10
C. 14
D. 18
Correct answer:
To determine the drops per minute, we use the formula Drops Per Minute = (Milliliters x Drop Factor) / Time in Minutes. In this case, Drops Per Minute = (2000mL x 15 drops/mL) / (36 hours x 60 minutes/hour) = 30000 / 2160 = 13.89 (approximately 14). Therefore, the correct answer is 14 drops per minute. Choice A (8), Choice B (10), and Choice D (18) are incorrect as they do not correctly calculate the drops per minute based on the given information.
A patient suffering from hyperglycemia would be experiencing:
A. Low blood sugar
B. High blood sugar
C. Normal blood sugar
D. None of the above
Correct answer:
Hyperglycemia is a condition characterized by high blood sugar levels. In this state, there is an excess of glucose in the bloodstream. Patients with hyperglycemia are often diagnosed with diabetes. The term 'hyperglycemia' specifically refers to elevated blood sugar levels. Therefore, the correct answer is 'High blood sugar.' Choices A, C, and D are incorrect because hyperglycemia indicates elevated blood sugar levels and not low or normal levels.
During an office visit, the healthcare provider is assessing a patient's skin. What part of the hand and technique would be used to best assess the patient's skin temperature?
A. Fingertips
B. Dorsal surface of the hand
C. Ulnar portion of the hand
D. Palmar surface of the hand
Correct answer:
The correct answer is the dorsal surface of the hand. The dorsa (backs) of the hands and fingers are best for determining temperature because the skin is thinner on the dorsal surfaces than on the palms. Fingertips are best for fine, tactile discrimination and not for assessing skin temperature. The ulnar and palmar surfaces of the hands are not as effective for assessing skin temperature as the dorsal surface because they have thicker skin layers.
NCLEX-RN clinical judgment practice questions, set 67 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
No. Nursier is independent practice. Register through the official path named on the NCLEX-RN exam guide.
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.
