RN exams clinical judgment practice questions, set 100
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 100
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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
During outcome identification and planning, from what part of the nursing diagnoses are outcomes derived?
A. The defining characteristics
B. The related factors
C. The problem statement
D. The database
Show answer and rationale
Correct answer: C — The problem statement
During outcome identification and planning, outcomes are derived from the problem statement of the nursing diagnoses. This is because the problem statement clearly defines the patient's health issue or condition that needs to be addressed, thus guiding the development of specific, measurable, and achievable outcomes. The defining characteristics (choice A) describe the signs and symptoms of the health problem but do not directly lead to outcome identification. The related factors (choice B) represent the potential causes or contributing factors to the health problem and are not used to derive outcomes. The database (choice D) consists of the patient's health history, assessment data, and laboratory findings, which are essential for diagnosing but do not directly determine outcomes. Therefore, the correct answer is C as it directly informs the outcomes to be achieved.
Question 2
While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?
A. Consider cultural differences during this assessment.
B. Ask the patient to make eye contact to determine her affect.
C. Continue with the interview and document that the patient is depressed.
D. Notify the health care provider to recommend a psychological evaluation.
Show answer and rationale
Correct answer: A — Consider cultural differences during this assessment.
The correct answer is A: Consider cultural differences during this assessment. In many Asian cultures, avoiding direct eye contact is a sign of respect, humility, or shyness, rather than an indication of depression or dishonesty. By understanding and respecting cultural norms, the nurse can build rapport and trust with the patient. This approach promotes effective communication and a positive patient-provider relationship.
Option B is incorrect because forcing the patient to make eye contact may make her uncomfortable and hinder the therapeutic relationship. Option C is incorrect because assuming the patient is depressed based on cultural differences is inappropriate and may lead to misdiagnosis. Option D is incorrect because jumping to recommendations for a psychological evaluation without considering cultural differences first can be stigmatizing and unnecessary.
Question 3
The nurse is evaluating the effectiveness of a bronchodilator for a client with asthma. Which finding indicates improvement?
A. Decreased wheezing on auscultation.
B. Respiratory rate increased to 24 breaths per minute.
C. Heart rate increased to 110 beats per minute.
D. Mild hand tremors reported by the client.
Show answer and rationale
Correct answer: A — Decreased wheezing on auscultation.
The correct answer is A: Decreased wheezing on auscultation. Wheezing is a common symptom of asthma due to narrowed airways. Improvement in asthma would lead to decreased wheezing as the airways open up, allowing for better airflow. This indicates that the bronchodilator is effectively working to dilate the airways and improve respiratory function.
Choice B: Respiratory rate increased to 24 breaths per minute is incorrect as an increased respiratory rate could indicate respiratory distress or worsening of asthma symptoms.
Choice C: Heart rate increased to 110 beats per minute is incorrect as an increased heart rate could indicate stress or anxiety, not necessarily improvement in asthma.
Choice D: Mild hand tremors reported by the client is incorrect as hand tremors are a common side effect of bronchodilators and not a direct indicator of asthma improvement.
Question 4
When performing an otoscopic examination on a 5-year-old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber-yellow in colour and there are air bubbles behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. The preliminary analysis based on this information would be that:
A. this is most likely serous otitis media.
B. the child has acute purulent otitis media.
C. there is evidence of a resolving cholesteatoma.
D. the child is experiencing the early stages of perforation.
Show answer and rationale
Correct answer: A — this is most likely serous otitis media.
The correct answer is A: this is most likely serous otitis media. In a child with chronic ear infections, amber-yellow tympanic membrane color and air bubbles suggest fluid accumulation behind the eardrum, characteristic of serous otitis media. The occasional hearing loss and popping sound with swallowing are also common symptoms. Serous otitis media is a non-infectious condition caused by Eustachian tube dysfunction.
Choice B: Acute purulent otitis media presents with more severe symptoms like fever and severe ear pain, which are not mentioned in the case.
Choice C: Cholesteatoma is a more serious condition characterized by a cyst-like growth in the middle ear, not just fluid accumulation as seen in this case.
Choice D: Perforation typically presents with a visible hole in the eardrum and is not consistent with the findings of fluid and air bubbles in this case.
Question 5
The nurse is performing an assessment on a 21-year-old patient and notes that his nasal mucosa appears pale, grey, and swollen. What would be the most appropriate question to ask the patient?
A. "Are you aware of having any allergies?"
B. "Do you have an elevated temperature?"
C. "Have you had any symptoms of a cold?"
D. "Have you been having frequent nosebleeds?"
Show answer and rationale
Correct answer: A — "Are you aware of having any allergies?"
The correct answer is A: "Are you aware of having any allergies?" This question is appropriate because the patient's symptoms of pale, grey, and swollen nasal mucosa suggest an allergic reaction. By asking about allergies, the nurse can gather important information to determine the cause of the symptoms.
B: "Do you have an elevated temperature?" - This question is not directly related to the patient's nasal symptoms and does not address the likely allergic reaction.
C: "Have you had any symptoms of a cold?" - While cold symptoms may present similarly to allergies, the patient's specific symptoms of pale, grey, and swollen nasal mucosa are more indicative of an allergic reaction.
D: "Have you been having frequent nosebleeds?" - This question does not directly address the patient's current symptoms and is not likely related to the nasal mucosa appearance described.
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Question 6
A nurse is caring for a patient with a history of asthma. The patient is experiencing shortness of breath. What is the priority intervention?
A. Administer a bronchodilator.
B. Administer insulin therapy.
C. Administer short-acting bronchodilators.
D. Administer corticosteroids.
Correct answer:
The correct answer is A: Administer a bronchodilator. The priority intervention for a patient with asthma experiencing shortness of breath is to administer a bronchodilator to help open up the airways and improve breathing. Bronchodilators work quickly to relieve acute symptoms of asthma by relaxing the muscles around the airways. This intervention is crucial in managing an acute asthma exacerbation.
Summary:
- Option B: Administer insulin therapy is incorrect because it is not indicated for managing asthma exacerbation.
- Option C: Administer short-acting bronchodilators is partially correct but not as specific as option A, which specifies the immediate need for bronchodilator therapy.
- Option D: Administer corticosteroids is important for long-term control of asthma but not the priority intervention in an acute exacerbation where immediate relief is needed.
Which of the ff. statements does the nurse understand is true concerning air conduction of sound in the ear?
A. It is caused by the vibration of bones in the skull.
B. It is less efficient than bone conduction.
C. It is heard longer than bone conduction.
D. It is caused by transmission of heat through the air.
Correct answer:
The correct answer is B because air conduction is less efficient than bone conduction due to the sound waves traveling through the air in the ear canal, which can be hindered by factors like blockages or obstructions. This results in a weaker and less clear sound transmission compared to bone conduction, where sound waves are transmitted directly through the bones of the skull, bypassing any potential obstructions in the ear canal.
Incorrect choices:
A: This statement is incorrect as air conduction of sound in the ear is not caused by the vibration of bones in the skull.
C: This statement is incorrect as air conduction is typically heard for a shorter duration than bone conduction.
D: This statement is incorrect as air conduction of sound in the ear is not caused by the transmission of heat through the air, but rather by sound waves traveling through the ear canal.
A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?
A. Document the findings and continue to monitor the client.
B. Notify the client's provider.
C. Increase the frequency of fundal massage.
D. Encourage the client to empty her bladder.
Correct answer:
The correct answer is A: Document the findings and continue to monitor the client. This is the appropriate action because the client's fundus is midline and firm, indicating good uterine tone. Lochia rubra and small clots are expected findings in the immediate postpartum period. The nurse should document these findings for future reference and continue to monitor the client's condition.
Choice B (Notify the client's provider) is incorrect because there are no concerning signs that warrant immediate provider notification, as the fundus is firm and midline.
Choice C (Increase the frequency of fundal massage) is unnecessary since the fundus is already firm at the umbilicus, indicating good uterine tone.
Choice D (Encourage the client to empty her bladder) is not the priority in this scenario, as the client's fundal assessment and lochia observations take precedence.
A nurse has achieved certification in critical care nursing. What is the most important effect that this certification will have on the nurses practice?
A. Recognition by peers
B. Increase in salary and rank
C. More flexibility in seeking employment
D. Increased confidence in critical thinking
Correct answer:
The correct answer is D: Increased confidence in critical thinking. Achieving certification in critical care nursing validates the nurse's expertise and knowledge in this specialized area, leading to increased confidence in their ability to critically think through complex patient situations. This confidence translates into improved clinical decision-making and patient outcomes.
A: Recognition by peers - While recognition by peers is important for professional growth, the primary benefit of certification is enhancing clinical skills.
B: Increase in salary and rank - While certification may lead to salary increases in some cases, the most significant impact is on improving clinical skills.
C: More flexibility in seeking employment - While certification may enhance employability, the focus is on improving critical thinking skills rather than employment opportunities.
A 78 year old male has been working on his lawn for two days, although the temperature has been above 90 degree F. he has been on thiazide diuretics for hypertension. His lab values are K 3.7 mEq/L, Na 129 mEq/L, Ca 9 mg/dl, and Cl 95 mEq/L. What would be a priority action for this man?
A. Make sure he drinks 8 glasses of water a day.
B. Monitor for fatigue, muscle weakness, restlessness, and flushed skin
C. Look for signs of hyperchloremia
D. Observe for neurologic changes
Correct answer:
The correct answer is B: Monitor for fatigue, muscle weakness, restlessness, and flushed skin. The patient is at risk for dehydration due to the combination of high temperature, age, and thiazide diuretic use. Thiazide diuretics can lead to electrolyte imbalances, including hypokalemia, which can cause symptoms such as muscle weakness and fatigue. Monitoring for signs of dehydration and electrolyte imbalances is crucial in this scenario to prevent complications.
A: Making sure he drinks 8 glasses of water a day is not the priority as he is already at risk for dehydration and electrolyte imbalances.
C: Hyperchloremia is not a common concern in this scenario based on the given lab values.
D: Neurologic changes may occur in severe cases of electrolyte imbalances but monitoring for physical symptoms such as fatigue and muscle weakness is more relevant at this stage.
Monique is a 33-year-old administrative assistant who has had intermittent lower abdominal pain approximately one week a month for the past year. It is not related to her menses. She notes relief with defecation, and a change in form and frequency of her bowel movements with these episodes. Which of the following is most likely?
A. Colon cancer
B. Cholecystitis
C. Inflammatory bowel disease
D. Irritable bowel syndrome
Correct answer:
The correct answer is D: Irritable bowel syndrome (IBS). Monique's symptoms of lower abdominal pain relieved by defecation, change in bowel movements' form and frequency, and absence of menses-related pain align with IBS criteria. IBS is a functional gastrointestinal disorder characterized by abdominal pain and altered bowel habits. It is a diagnosis of exclusion, meaning other conditions must be ruled out.
Choice A: Colon cancer is less likely due to Monique's age, absence of alarming symptoms like weight loss or blood in stool, and the intermittent nature of her symptoms.
Choice B: Cholecystitis typically presents with right upper quadrant pain, nausea, and vomiting, which do not match Monique's symptoms.
Choice C: Inflammatory bowel disease (IBD) usually presents with persistent symptoms, blood in stool, and systemic signs, which are not seen in Monique's case.
An individual with type 2 diabetes who takes glipizide has begun a formal exercise program at a local gym. While exercising on the treadmill, the individual becomes pale, diaphoretic, shaky, and has a headache. The individual feels as though she is going to pass out. What is the individual’s priority action?
A. Drink additional water to prevent dehydration.
B. Eat something with 15 g of simple carbohydrates.
C. Go to the first-aid station to have glucose checked.
D. Take another dose of the oral agent.
Correct answer:
The correct answer is B: Eat something with 15 g of simple carbohydrates. In this scenario, the individual is exhibiting signs of hypoglycemia due to the combination of glipizide (which can lower blood sugar) and exercise. The priority action is to raise blood sugar levels quickly to prevent further complications. Consuming simple carbohydrates, like glucose tablets or juice, will rapidly increase blood sugar levels. This is crucial to prevent the individual from passing out or experiencing more serious consequences.
Choice A is incorrect because while hydration is important, it is not the immediate priority in this situation. Choice C is incorrect as going to the first-aid station may waste valuable time when immediate action is needed. Choice D is incorrect as taking another dose of the oral agent can further lower blood sugar levels and worsen the hypoglycemia.
Which of the following is an example of a Type 1 hypersensitivity reaction?
A. Anaphylaxis
B. Indigestion
C. Beta cell destruction
D. ABO transfusion reaction
Correct answer:
Anaphylaxis is a classic example of a Type 1 hypersensitivity reaction. In Type 1 hypersensitivity, allergens trigger an immediate immune response mediated by IgE antibodies, leading to the release of histamine and other mediators. This reaction can result in symptoms ranging from mild itching and hives to severe conditions like anaphylaxis, which is a life-threatening emergency. The other options, such as indigestion (choice B), beta cell destruction (choice C), and ABO transfusion reaction (choice D), are not classified as Type 1 hypersensitivity reactions. Indigestion is typically related to gastrointestinal disturbances, beta cell destruction is associated with autoimmune conditions like type 1 diabetes, and ABO transfusion reaction involves antibodies targeting incompatible blood groups, which is a different immune mechanism compared to Type 1 hypersensitivity.
The healthcare provider is preparing to give an enema to a laboring client. Which client requires the most caution when carrying out this procedure?
A. A gravida 6, para 5 who is 38 years of age and in early labor.
B. A 37-week primigravida who presents at 100% effacement, 3 cm cervical dilation, and a -1 station.
C. A gravida 2, para 1 who is at 1 cm cervical dilation and a 0 station admitted for induction of labor due to postdates.
D. A 40-week primigravida who is at 6 cm cervical dilation and the presenting part is not engaged.
Correct answer:
The client at 40 weeks of gestation with a 6 cm cervical dilation and a presenting part that is not engaged requires the most caution during an enema procedure. An unengaged presenting part increases the risk of cord prolapse, which can be a serious complication during the procedure. This situation demands careful attention to prevent potential complications and ensure the safety of the client and fetus.
Choice A is incorrect as being in early labor does not pose the same level of risk as an unengaged presenting part. Choice B describes a client at 37 weeks with signs of early labor but does not indicate the same level of risk as an unengaged presenting part. Choice C involves a client at 1 cm cervical dilation and a 0 station with no mention of an unengaged presenting part, making it a less critical situation compared to an unengaged presentation, as in Choice D.
The patient is in the critical care unit and will receive dialysis this morning. The nurse will (Select all that apply.)
A. evaluate morning laboratory results and report abnormal results.
B. administer the patient’s antihypertensive medications.
C. assess the dialysis access site and report abnormalities.
D. weigh the patient to monitor fluid status.
Correct answer:
The correct answer is A. By evaluating the morning laboratory results and reporting abnormal results, the nurse can ensure the patient's safety during dialysis by addressing any concerning findings promptly. This step is crucial in monitoring the patient's condition and adjusting the treatment plan as needed.
Incorrect choices:
B: Administering antihypertensive medications is not directly related to the patient's dialysis procedure and does not address the immediate needs of the patient in the critical care unit.
C: While assessing the dialysis access site is important, reporting abnormalities alone may not be sufficient without a comprehensive evaluation of the patient's laboratory results.
D: Weighing the patient to monitor fluid status is important in the context of dialysis, but it is not as critical as evaluating laboratory results for immediate intervention.
RN exams clinical judgment practice questions, set 100 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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