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NCLEX-RN clinical judgment practice questions, set 71

NCLEX-RN · clinical judgment

NCLEX-RN clinical judgment practice questions set 71

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

The nurse should wash from the ________________________ when washing a patient's eye area.

  1. A. outer canthus to the inner canthus
  2. B. inner canthus to the outer canthus
  3. C. internal nares to the external nares
  4. D. external nares to the internal nares
Show answer and rationale

Correct answer: B — inner canthus to the outer canthus

When washing a patient's eye area, it is important to start from the inner canthus (closest to the nose) and move towards the outer canthus. This direction prevents any contaminants or debris from the outer area of the eye from moving towards the inner, more sensitive area. Choices C and D are incorrect as they pertain to the nasal passages (nares), which are not relevant when washing the eye area.

Question 2

Your patient has finished a 12-ounce can of iced tea and 8 ounces of fresh orange juice. What will you record on the Intake and Output form for this patient's intake?

  1. A. 20 cc
  2. B. 20 cm
  3. C. 600 cc
  4. D. 600 cm
Show answer and rationale

Correct answer: C — 600 cc

You will record 600 cc of fluid intake. There are 600 cc in 20 ounces (12 ounces of iced tea + 8 ounces of orange juice) of fluid intake. Choice A and B are incorrect as they do not reflect the correct conversion of fluid intake from ounces to cubic centimeters. Choice D is incorrect as it provides the measurement in cubic centimeters but does not account for the total fluid intake accurately.

Question 3

When percussing over the abdomen of an obese patient, the nurse is unable to identify any changes in sound. What would the nurse do next?

  1. A. Ask the patient to take deep breaths to relax the abdominal musculature.
  2. B. Consider this finding as normal and proceed with the abdominal assessment.
  3. C. Increase the amount of strength used when attempting to percuss over the abdomen.
  4. D. Decrease the amount of strength used when attempting to percuss over the abdomen.
Show answer and rationale

Correct answer: C — Increase the amount of strength used when attempting to percuss over the abdomen.

When percussing an obese patient's abdomen, the thickness of their body wall can affect the sound produced. A stronger percussion stroke is needed for obese or very muscular patients. The force of the blow determines the loudness of the note. Asking the patient to take deep breaths, considering the finding as normal, or decreasing the strength used are not appropriate actions in this scenario.

Question 4

A patient asks a nurse administering blood how long red blood cells live in the body. What is the correct response?

  1. A. The life span of RBC is 45 days
  2. B. The life span of RBC is 60 days
  3. C. The life span of RBC is 90 days
  4. D. The life span of RBC is 120 days
Show answer and rationale

Correct answer: D — The life span of RBC is 120 days

The correct answer is that red blood cells have a lifespan of 120 days in the body. This allows for efficient oxygen transport throughout the circulatory system. Choices A, B, and C are incorrect because the lifespan of red blood cells is actually 120 days. Understanding the lifespan of red blood cells is crucial in assessing various conditions related to blood cell production and turnover.

Question 5

While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action?

  1. A. Check vital signs
  2. B. Massage the fundus
  3. C. Offer a bedpan
  4. D. Check for perineal lacerations
Show answer and rationale

Correct answer: B — Massage the fundus

Massage the fundus. The nurse's first action should be to massage the fundus until it is firm as uterine atony is the primary cause of bleeding in the first hour after delivery. Checking vital signs, offering a bedpan, or checking for perineal lacerations are important assessments but addressing the boggy uterus and vaginal bleeding due to uterine atony takes precedence in this situation.

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Question 6

The nurse is caring for a 2-year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be alert for which of the following side effects?

  1. A. Neurotoxicity
  2. B. Hepatomegaly
  3. C. Nephrotoxicity
  4. D. Ototoxicity
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Question 7

The healthcare provider is preparing to use an otoscope for an examination. Which statement is true regarding the otoscope?

  1. A. Often used to direct light into the sinuses
  2. B. Used to examine the structures of the internal ear
  3. C. Uses a short, broad speculum to help visualize the ear
  4. D. Directs light into the ear canal and onto the tympanic membrane
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Question 8

The healthcare professional is preparing to percuss the abdomen of a patient. What characteristic of the underlying tissue does percussion assess?

  1. A. Turgor
  2. B. Texture
  3. C. Density
  4. D. Consistency
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Question 9

A 2-year-old child has been brought to the clinic for a well-child checkup. What is the best way for the nurse to begin the assessment?

  1. A. Ask the parent to place the child on the examining table.
  2. B. Have the parent remove all of the child's clothing before the examination.
  3. C. Allow the child to keep a security object such as a toy or blanket during the examination.
  4. D. Initially focus the interactions on the child, essentially ignoring the parent until the child's trust has been obtained.
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Question 10

A complication of osteoporosis is _______________?

  1. A. rheumatoid arthritis
  2. B. gouty arthritis
  3. C. dorsiflexion
  4. D. joint deformity
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Question 11

The abbreviation ac is defined as _____________.

  1. A. before the meal
  2. B. with the meal
  3. C. after the meal
  4. D. ante cibum
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Question 12

Which risk factor places patients and residents at the greatest risk for falls?

  1. A. Old age
  2. B. Middle age
  3. C. Pneumonia
  4. D. COPD
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Question 13

While caring for Mrs. Thomas, you see a notation on the nursing care plan that states 'ambulate at least 10 yards qid'. This patient will be assisted with ambulation at which of the following times?

  1. A. 10:00 AM
  2. B. 10 am and 2 pm
  3. C. 10 am and 2 pm
  4. D. 10 am, 2 pm, 6 pm, and 10 pm
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Question 14

Your patient ate an 8-ounce cup of Italian ice. How much will you record on the patient's Intake and Output form in terms of this patient's fluid intake?

  1. A. 240 cc
  2. B. 120 cc
  3. C. 8 cc
  4. D. 0 cc because Italian ice is not a fluid
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Question 15

A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information obtained by the nurse is a priority to communicate to the health care provider before the CT?

  1. A. Allergy to shellfish
  2. B. Apical pulse of 104
  3. C. Respiratory rate of 30
  4. D. Oxygen saturation of 90%
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About these NCLEX-RN clinical judgment questions

NCLEX-RN clinical judgment practice questions, set 71 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

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