NCLEX-RN clinical judgment practice questions, set 69
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 69
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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
An experienced healthcare professional instructs a new colleague on caring for a patient with dyspnea due to a pulmonary fungal infection. Which action by the new colleague indicates a need for further teaching?
A. Listening to the patient's lung sounds several times during the shift
B. Placing the patient in droplet precautions and in a private hospital room
C. Increasing the oxygen flow rate to maintain oxygen saturation above 90%
D. Monitoring the patient's serology results to identify the specific infecting organism
Show answer and rationale
Correct answer: B — Placing the patient in droplet precautions and in a private hospital room
The correct answer is placing the patient in droplet precautions and in a private hospital room. Fungal infections are not transmitted from person to person, so isolation procedures like droplet precautions are unnecessary. Listening to the patient's lung sounds, increasing the oxygen flow rate, and monitoring serology results are all appropriate actions in caring for a patient with dyspnea caused by a pulmonary fungal infection.
Question 2
When caring for a single client during one shift, it is appropriate for the nurse to reuse only which of the following personal protective equipment?
A. Goggles
B. Gown
C. Surgical mask
D. Clean gloves
Show answer and rationale
Correct answer: A — Goggles
Goggles may be reused unless they are overly contaminated by material that has splashed in the nurse's face and cannot be effectively rinsed off. Gowns are at high risk for contamination and should be used only once and then discarded or washed. Surgical masks and gloves should never be washed or reused. Goggles provide eye protection from splashes and should be cleaned and disinfected after each use to ensure proper protection.
Question 3
Which of the following diseases is caused by the Bordetella pertussis bacterium?
A. German Measles
B. RSV
C. Meningitis
D. Whooping Cough
Show answer and rationale
Correct answer: D — Whooping Cough
Bordetella pertussis is the bacterium responsible for causing Whooping Cough, also known as pertussis. Meningitis can be caused by various bacteria, but not specifically by Bordetella pertussis. German Measles, also known as Rubella, and RSV (Respiratory Syncytial Virus) are viral infections and are not caused by the Bordetella pertussis bacterium. Therefore, the correct answer is Whooping Cough, caused by Bordetella pertussis.
Question 4
A child is seen in the emergency department for scarlet fever. Which of the following descriptions of scarlet fever is not correct?
A. Scarlet fever is caused by infection with group A Streptococcus bacteria.
B. "Strawberry tongue"? is a characteristic sign.
C. Petechiae occur on the soft palate.
D. The pharynx is red and swollen.
Show answer and rationale
Correct answer: C — Petechiae occur on the soft palate.
Petechiae on the soft palate are not a typical finding in scarlet fever. Scarlet fever is caused by group A Streptococcus bacteria, often presenting with a strawberry tongue, red and swollen pharynx, and a sandpaper-like rash. The presence of petechiae on the soft palate is more commonly associated with conditions like rubella rather than scarlet fever. Therefore, this description is not correct in the context of scarlet fever.
Question 5
A child is seen in the emergency department for scarlet fever. Which of the following descriptions of scarlet fever is not correct?
A. Scarlet fever is caused by infection with group A Streptococcus bacteria.
B. "Strawberry tongue"? is a characteristic sign.
C. Petechiae occur on the soft palate.
D. The pharynx is red and swollen.
Show answer and rationale
Correct answer: C — Petechiae occur on the soft palate.
Petechiae on the soft palate are not a typical finding in scarlet fever. Scarlet fever is caused by group A Streptococcus bacteria, often presenting with a strawberry tongue, red and swollen pharynx, and a sandpaper-like rash. The presence of petechiae on the soft palate is more commonly associated with conditions like rubella rather than scarlet fever. Therefore, this description is not correct in the context of scarlet fever.
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Question 6
The parents of a child with a hernia are instructed by the nurse on measures to reduce the hernia. Which statement indicates the parents understand the care for their child?
A. We will encourage our child to cough every few hours on a daily basis.
B. We will make sure that our child participates in physical activity every day.
C. We will provide comfort measures to reduce any crying periods by our child.
D. We will be sure to give our child a Fleet enema every day to prevent constipation.
Correct answer:
The correct answer is providing comfort measures to reduce any crying periods by the child. This can include offering a warm bath, avoiding upright positioning, and using other comfort measures to reduce crying, which can help reduce a hernia. Encouraging coughing or physical activity can increase strain on the hernia. Giving a Fleet enema daily for constipation is not recommended as it can also increase strain on the hernia.
The nurse is assigned to care for a child who is scheduled for an appendectomy. Select the prescriptions that the nurse anticipates will be prescribed. Select one that doesn't apply.
A. Initiate an IV line.
B. Maintain an NPO status.
C. Administer a Fleet enema.
D. Administer intravenous antibiotics.
Correct answer:
For a child scheduled for an appendectomy, the administration of a Fleet enema is not typically required. An IV line is often initiated for fluid and medication administration, maintaining NPO status is necessary to prevent aspiration during surgery, and administering intravenous antibiotics may be part of the preoperative regimen. Therefore, the correct choice that does not apply in this case is administering a Fleet enema.
A healthcare professional is preparing to administer an enteral feeding through a gastrostomy tube. Before administering the feeding, the healthcare professional aspirates some stomach contents and checks the pH. The result is 3.9. What is the next action of the healthcare professional?
A. Administer the feeding as ordered
B. Pull the feeding tube out approximately 3 cm
C. Flush the feeding tube with 60 cc of water
D. Contact the physician
Correct answer:
When the pH of the aspirated stomach contents is 4 or less, it indicates that the gastrostomy tube is in the stomach, confirming correct placement. A pH of 3.9 falls within this range, so the healthcare professional can proceed with administering the enteral feeding. There is no need to adjust the tube placement, flush with water, or contact the physician in this situation as the tube is appropriately positioned for feeding.
Which of the following is one of the three smallest bones in the body?
A. Vomer
B. Distal phalanx of the small toe
C. Stapes
D. Coccyx
Correct answer:
The stapes, along with the malleus and incus, are the three smallest bones in the human body. These bones are located in the inner ear and play a crucial role in hearing. The vomer is a bone in the nasal cavity and is not one of the smallest bones. The distal phalanx of the small toe is relatively larger and not among the smallest bones. The coccyx, also known as the tailbone, is not one of the smallest bones in the body.
While caring for Mr. Charles Y., you see a notation on the nursing care plan that states, 'remind the patient to use the incentive spirometer tid.' This patient will be reminded at which of the following times?
A. 10:00 AM
B. 10 am and 2 pm
C. 10 am, 2 pm, and 6 pm
D. 10 am, 2 pm, 6 pm, and 10 pm
Correct answer:
The abbreviation 'tid' stands for 'ter in die,' which means three times a day. In this case, the patient should be reminded to use the incentive spirometer at 10 am, 2 pm, and 6 pm. Option A, '10 am,' is too infrequent for tid dosing. Option B, '10 am and 2 pm,' is missing the third reminder at 6 pm. Option D, '10 am, 2 pm, 6 pm, and 10 pm,' includes an additional time that is not part of the standard tid dosing schedule.
When taking Mr. D's blood pressure, the first sound you hear is at 162, and the second sound you hear is at 86. You should document and report that the blood pressure is _____________.
A. 86/162
B. irregular and high
C. 162/86
D. normal for people of all ages
Correct answer:
You should document and report that the blood pressure measurement for Mr. D is 162/86. The first sound heard corresponds to the systolic reading (top number), and the second sound corresponds to the diastolic reading (bottom number). Blood pressure readings are not irregular; irregularities are typically associated with pulses. The blood pressure recorded is not normal for individuals of all ages; it is considered high.
When admitting a 64-year-old patient with acute pancreatitis, the healthcare provider should specifically inquire about a history of
A. diabetes mellitus.
B. high-protein diet.
C. cigarette smoking.
D. alcohol consumption.
Correct answer:
In patients with acute pancreatitis, alcohol consumption is a significant risk factor and one of the most common causes in the United States. It is crucial to assess alcohol intake as it plays a key role in the development of pancreatitis. While cigarette smoking, diabetes mellitus, and high-protein diets can contribute to various health issues, they are not directly associated with the development of acute pancreatitis.
Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient with acute pancreatitis?
A. Nausea and vomiting
B. Hypotonic bowel sounds
C. Abdominal tenderness and guarding
D. Muscle twitching and finger numbness
Correct answer:
The correct answer is muscle twitching and finger numbness. These symptoms indicate hypocalcemia, which can lead to tetany if not promptly addressed with calcium gluconate administration. Nausea and vomiting, hypotonic bowel sounds, and abdominal tenderness and guarding are important findings in acute pancreatitis but do not require the same urgent intervention as hypocalcemia to prevent potential severe complications.
The client is being prepared for insertion of a pulmonary artery catheter (Swan-Ganz catheter). What information does the client need to know about the purpose of this catheter insertion?
A. Stroke volume
B. Cardiac output
C. Venous pressure
D. Left ventricular functioning
Correct answer:
The correct answer is D: Left ventricular functioning. The purpose of inserting a pulmonary artery catheter is to obtain information about left ventricular functioning when the catheter balloon is inflated. Choices A, B, and C are incorrect because while a pulmonary artery catheter can provide information on stroke volume, cardiac output, and venous pressure, its primary purpose is to assess left ventricular function.
A client with an enlarged prostate is having trouble starting his flow of urine when using the bathroom. Another name for this condition is:
A. Hesitancy
B. Oliguria
C. Retention
D. Urgency
Correct answer:
Urinary hesitancy occurs when a client has difficulty starting a flow of urine while using the bathroom. Hesitancy may be due to physiological factors, such as obstruction from an enlarged prostate, or due to psychological factors, such as anxiety or embarrassment. Oliguria refers to decreased urine output, retention is the inability to empty the bladder fully, and urgency is the sudden and strong need to urinate.
NCLEX-RN clinical judgment practice questions, set 69 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.
