NCLEX-RN clinical judgment practice questions, set 72
NCLEX-RN · clinical judgment
NCLEX-RN clinical judgment practice questionsset 72
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
When administering a-interferon and ribavirin (Rebetol) to a patient with chronic hepatitis C, the nurse should monitor for which complication?
A. Leukopenia.
B. Hypokalemia.
C. Polycythemia.
D. Hypoglycemia.
Show answer and rationale
Correct answer: B — Hypokalemia.
When administering a-interferon and ribavirin (Rebetol) for chronic hepatitis C, the nurse should monitor for hypokalemia. This combination therapy is known to cause leukopenia, not polycythemia or hypoglycemia. Hypokalemia is a common electrolyte imbalance that can occur with these medications, making it the correct answer to monitor for in this case.
Question 2
Mobility is an important human function. The hazards of immobility lead to many physical and emotional problems. Immobility can lead to detrimental cardiac, muscular, respiratory, skeletal, urinary, gastrointestinal, skin, and emotional changes. Which of the following is an example of a skeletal hazard of immobility?
A. Contractures.
B. Constipation.
C. Calcium loss.
D. Catabolism.
Show answer and rationale
Correct answer: C — Calcium loss.
All choices are hazards of immobility, but only calcium loss from the bones is a skeletal system impairment that results from immobility. Contractures are muscle shortening due to prolonged positioning, which affects the muscular system. Constipation is a gastrointestinal issue. Catabolism is a metabolic process, not specific to the skeletal system.
Question 3
Which of the following is NOT an acceptable abbreviation?
A. D/C
B. tid
C. bid
D. qid
Show answer and rationale
Correct answer: A — D/C
The correct answer is A: D/C. D/C is not an acceptable abbreviation as it can be easily confused with both 'discharge' and 'discontinue.' The abbreviations 'tid' (three times a day), 'bid' (twice a day), and 'qid' (four times a day) are commonly used in medical contexts to indicate dosing frequencies and are widely accepted in healthcare settings.
Question 4
Which of the following conditions most commonly causes acute glomerulonephritis?
A. A congenital condition leading to renal dysfunction.
B. Prior infection with group A Streptococcus within the past 10-14 days.
C. Viral infection of the glomeruli.
D. Nephrotic syndrome.
Show answer and rationale
Correct answer: B — Prior infection with group A Streptococcus within the past 10-14 days.
Acute glomerulonephritis is most commonly caused by the immune response to a prior
upper respiratory infection with group A Streptococcus. Glomerular inflammation occurs
about 10-14 days after the infection, resulting in scant, dark urine and retention of body
fluid. Periorbital edema and hypertension are common signs at diagnosis.
Question 5
Which of the following conditions most commonly causes acute glomerulonephritis?
A. A congenital condition leading to renal dysfunction.
B. Prior infection with group A Streptococcus within the past 10-14 days.
C. Viral infection of the glomeruli.
D. Nephrotic syndrome.
Show answer and rationale
Correct answer: B — Prior infection with group A Streptococcus within the past 10-14 days.
Acute glomerulonephritis is most commonly caused by the immune response to a prior
upper respiratory infection with group A Streptococcus. Glomerular inflammation occurs
about 10-14 days after the infection, resulting in scant, dark urine and retention of body
fluid. Periorbital edema and hypertension are common signs at diagnosis.
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Question 6
A man is prescribed lithium to treat bipolar disorder. The nurse is most concerned about lithium toxicity when he notices which of these assessment findings?
A. The patient states he had a manic episode a week ago
B. The patient states he has been having diarrhea every day
C. The patient presents as severely depressed
D. The patient has a rash and pruritus on his arms and legs
Correct answer:
The correct answer is when the patient states he has been having diarrhea every day. Persistent diarrhea can lead to dehydration, which can increase the risk of lithium toxicity. The other options, such as a manic episode, severe depression, or rash and pruritus, are not directly associated with an increased risk of lithium toxicity.
You are taking care of Mary Eden, an elderly and frail 91-year-old resident. She gets confused during evening hours and at times she thinks that she hears her daughter calling her from the other side of the nursing home. Which physical problem places Mary Eden at risk for falls?
A. Her confusion
B. Her daughter
C. Evening hours
D. Her frailness
Correct answer:
Mary Eden's frail and weak muscles due to her age and physical condition place her at risk for falls. While her confusion can contribute to falls, it is considered an emotional or cognitive issue rather than a physical problem. Her daughter and the evening hours are not physical problems that directly increase her risk of falling.
Using the illustrated technique, the healthcare provider is assessing for which finding in a patient with chronic obstructive pulmonary disease (COPD)?
A. Hyperresonance
B. Tripod positioning
C. Accessory muscle use
D. Reduced chest expansion
Correct answer:
The technique for palpation for chest expansion is shown in the illustrated technique. Reduced chest expansion would be noted on palpation of a patient's chest with COPD. Hyperresonance would be assessed through percussion, not palpation. Accessory muscle use and tripod positioning would be assessed by inspection, not palpation.
Which of the following interventions should be prioritized in the care of the suicidal client?
A. Remove all potentially harmful items from the client's room
B. Allow the client to express feelings of hopelessness
C. Note the client's capabilities to increase self esteem
D. Set a "no suicide"? contract with the client
Correct answer:
accessibility of the means of suicide increases the lethality. Allowing a patient to
express feelings and setting a no suicide contract are interventions for suicidal client but
blocking the means of suicide is priority. Increasing self esteem is an intervention for depressed
clients but not specifically for suicide.
Your elderly patient has a temperature of 98.5 degrees. Is there anything else that a nurse should do, in addition to documenting this temperature?
A. No, this temperature is within normal limits.
B. No, this temperature is normally hyperthermic.
C. Yes, this temperature is highly hyperthermic.
D. Yes, this temperature is highly hypothermic.
Correct answer:
No, there is nothing else that a nurse should do. A temperature of 98.5 degrees for an elderly patient falls within normal limits. Other choices are incorrect because the temperature is not hyperthermic (abnormally high) or hypothermic (abnormally low), making choices B, C, and D inaccurate responses in this scenario.
Which of the following clients is most likely ready to be dismissed from
an inpatient care setting to home?
A. A 65-year old male with urine output of 60cc in the past four hours
B. A 2-month old female with a temperature of 100.6 rectally
C. A 38-year old female who transitioned from IV TPN to full liquids six
hours ago
D. A 4-year old male with an oxygen saturation of 96% on room air
Correct answer:
Clients must meet a certain amount of set criteria before
they will be discharged from a healthcare facility. Although guidelines
may vary between locations, most healthcare facilities expect clients to have adequate oxygenation, nutrition, and elimination; and be free from fever, vomiting, and significant pain
The nurse provides discharge instructions to a patient who was hospitalized for pneumonia.
Which statement, if made by the patient, indicates a good understanding of the instructions?
A. I will call the doctor if I still feel tired after a week.
B. I will continue to do the deep breathing and coughing exercises at home.
C. I will continue to do the deep breathing and coughing exercises at home.
D. I'll cancel my chest x-ray appointment if Im feeling better in a couple weeks
Correct answer:
Patients should continue to cough and deep breathe after discharge. Fatigue is expected for
several weeks. The Pneumovax and influenza vaccines can be given at the same time in different
arms. Explain that a follow-up chest x-ray needs to be done in 6 to 8 weeks to evaluate resolution
of pneumonia.
Match the abbreviation with the correct definition:
A. bid: twice a day
B. tid: three times a day
C. ac: before meals
D. pc: after meals
Correct answer:
The abbreviation 'ac' stands for 'ante cibum,' which means 'before meals.' 'Bid' means twice a day. 'Tid' means three times a day, and 'pc' means after meals. When interpreting medical abbreviations, it is crucial to understand their precise meanings to ensure accurate communication and patient care.
A 75-year-old man with a history of hypertension was recently changed to a new antihypertensive
drug. He reports feeling dizzy at times. How would the nurse evaluate his blood pressure?
A. Blood pressure and pulse should be recorded in the supine, sitting, and standing
positions.
B. The patient should be directed to walk around the room and his blood pressure
assessed after this activity.
C. Blood pressure and pulse are assessed at the beginning and at the end of the
examination.
D. Blood pressure is taken on the right arm and then 5 minutes later on the left arm.
Correct answer:
Orthostatic vital signs should be taken when the person is hypertensive or is taking antihypertensive
medications, when the person reports fainting or syncope, or when volume depletion is suspected.
The blood pressure and pulse readings are recorded in the supine, sitting, and standing positions.
Which client is at highest risk for developing a pressure ulcer?
A. 23 year-old in traction for fractured femur
B. 72 year-old with peripheral vascular disease, who is unable to walk without assistance
C. 75 year-old with left sided paresthesia and is incontinent of urine and stool
D. 30 year-old who is comatose following a ruptured aneurysm
Correct answer:
Risk factors for pressure ulcers include: immobility, absence of
sensation, decreased LOC, poor nutrition and hydration, skin moisture, incontinence,
increased age, decreased immune response. This client has the greatest number of risk
factors.
NCLEX-RN clinical judgment practice questions, set 72 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.
