RN exams clinical judgment practice questions, set 102
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 102
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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
A client is using a metered-dose inhaler (MDI) for the first time. What is the correct sequence for its use?
A. Shake the inhaler, exhale fully, press the inhaler while inhaling deeply, hold breath for 10 seconds.
B. Press the inhaler, inhale quickly, exhale fully, shake the inhaler.
C. Shake the inhaler, inhale quickly, press the inhaler, exhale slowly.
D. Exhale fully, press the inhaler, shake the inhaler, inhale deeply.
Show answer and rationale
Correct answer: A — Shake the inhaler, exhale fully, press the inhaler while inhaling deeply, hold breath for 10 seconds.
The correct sequence for using a metered-dose inhaler (MDI) for the first time is A: Shake the inhaler, exhale fully, press the inhaler while inhaling deeply, hold breath for 10 seconds.
Rationale:
1. Shake the inhaler: This helps to mix the medication properly.
2. Exhale fully: Emptying the lungs before inhaling ensures better medication delivery.
3. Press the inhaler while inhaling deeply: This allows the medication to reach deep into the lungs.
4. Hold breath for 10 seconds: Holding the breath allows the medication to be absorbed effectively.
Summary of other choices:
B: Incorrect because inhaling quickly may lead to improper medication delivery.
C: Incorrect because pressing the inhaler before inhaling may result in less effective medication delivery.
D: Incorrect because shaking the inhaler after pressing it may disrupt the medication dispersion.
Question 2
The nurse is reviewing a patient’s database for significant changes and discovers that the patient has not voided in over 8 hours. The patient’s kidney function lab results are abnormal, and the patient’s oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review?
A. Diagnosis
B. Planning NursingStoreRN
C. Implementation
D. Evaluation
Show answer and rationale
Correct answer: A — Diagnosis
The correct answer is A: Diagnosis. After reviewing the patient's database and identifying concerning findings such as abnormal kidney function, lack of voiding, and decreased oral intake, the nurse needs to move to the diagnosis step of the nursing process. This involves analyzing the data collected to identify the patient's health problems and risks. In this case, the nurse needs to determine potential underlying issues related to the kidney function abnormalities and lack of voiding, and formulate a nursing diagnosis based on the findings.
Summary of other choices:
B: Planning comes after diagnosis and involves setting goals and creating a plan of care.
C: Implementation follows planning and involves carrying out the plan of care.
D: Evaluation is the final step of the nursing process where the nurse assesses the effectiveness of the interventions implemented.
Question 3
The nurse sees that Mr. B (bladder cancer) has received docusate for the past 2 days. Which question is the nurse most likely to ask to evaluate the effectiveness of the docusate?
A. "Are you experiencing any burning with urination?"
B. "Did you have a bowel movement today or yesterday?"
C. "Has the medication helped to relieve the nausea?"
D. "Were you able to sleep soundly the last couple of nights?"
Show answer and rationale
Correct answer: B — "Did you have a bowel movement today or yesterday?"
The correct answer is B. Docusate is a stool softener commonly used to prevent constipation, which is a common side effect of opioid pain medications. By asking if the patient had a bowel movement today or yesterday, the nurse can evaluate the effectiveness of docusate in facilitating bowel movements. This question directly assesses the expected outcome of the medication.
A: "Are you experiencing any burning with urination?" - This question is more relevant to urinary tract infections, not related to docusate use for constipation.
C: "Has the medication helped to relieve the nausea?" - Docusate is not typically used to relieve nausea, so this question is not relevant to evaluating its effectiveness.
D: "Were you able to sleep soundly the last couple of nights?" - This question is not directly related to the expected outcome of docusate in treating constipation.
Question 4
Which intervention is appropriate to assist the patient to co pe with admission to the critical care unit?
A. Allowing unrestricted visiting by several family members at one time
B. Explaining all procedures in easy-to-understand terms
C. Providing back massage and mouth care
D. Turning down the alarm volume on the cardiac monito r
Show answer and rationale
Correct answer: B — Explaining all procedures in easy-to-understand terms
The correct answer is B: Explaining all procedures in easy-to-understand terms. This intervention is appropriate as it helps reduce the patient's anxiety by providing clear information about what to expect during their stay in the critical care unit. This promotes a sense of control and understanding, which can positively impact the patient's coping mechanisms.
A: Allowing unrestricted visiting by several family members at one time may overwhelm the patient and interfere with their rest and recovery.
C: Providing back massage and mouth care may be beneficial but may not directly address the patient's need for information and understanding.
D: Turning down the alarm volume on the cardiac monitor may provide a more comfortable environment but does not address the patient's emotional and psychological needs related to coping with admission to the critical care unit.
Question 5
During the first few years after menopause, follicle-stimulating hormone (FSH) levels are normally extremely high. A 56-year-old woman completed menopause 3 years ago. However, she is found to have low levels of FSH in her blood. Which of the following is the best explanation for this finding?
A. She has been receiving hormone replacement therapy with estrogen and progesterone since she completed menopause
B. Her adrenal glands continue to produce estrogen
C. Her ovaries continue to secrete estrogen
D. She took birth control pills for 20 years before menopause
Show answer and rationale
Correct answer: A — She has been receiving hormone replacement therapy with estrogen and progesterone since she completed menopause
The correct answer is A: She has been receiving hormone replacement therapy with estrogen and progesterone since she completed menopause. Hormone replacement therapy suppresses the release of FSH by providing exogenous hormones, thereby reducing the body's need to produce FSH. This explains the low levels of FSH in her blood despite being postmenopausal.
Explanation for why the other choices are incorrect:
B: Her adrenal glands continue to produce estrogen - Adrenal glands do produce small amounts of estrogen, but not in sufficient quantities to significantly impact FSH levels.
C: Her ovaries continue to secrete estrogen - Ovaries cease estrogen production after menopause, so this would not explain the low FSH levels.
D: She took birth control pills for 20 years before menopause - Birth control pills do not directly impact FSH levels in postmenopausal women.
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Question 6
The nurse is receiving shift report on her mother-baby couplet assignment. Which infant should the nurse evaluate first?
A. 38-weeks' gestation female newborn with a blood sugar level of 60 mg/dL
B. Term male newborn with a noted axillary temperature of 37.2°C (99°F)
C. 40-weeks' gestation female newborn with reported poor feed at last attempt
D. 39-weeks' gestation male newborn who has been crying prior to initial bath
Correct answer:
The correct answer is C, to evaluate the 40-weeks' gestation female newborn with reported poor feed at the last attempt first. This choice should be prioritized as poor feeding in a newborn can be a sign of potential serious issues such as inadequate nutrition, dehydration, or underlying medical conditions. Addressing this concern promptly is crucial for the infant's well-being.
Option A can be considered as the blood sugar level of 60 mg/dL in the 38-weeks' gestation female newborn is slightly low, but it is not an immediate priority compared to poor feeding. Option B's axillary temperature of 37.2°C is within the normal range for a newborn, so it can be assessed after addressing the concern of poor feeding. Option D, a 39-weeks' gestation male newborn crying prior to the initial bath, can also be evaluated after addressing the more urgent issue of poor feed.
A journalist's body temperature has sharply increased in the morning three weeks after his mission in India, it was accompanied with shivering and bad headache. A few hours later the temperature decreased. The attacks began to repeat in a day. He was diagnosed with tropical malaria. What stage of development of Plasmodium is infective for anopheles-female?
A. Gametocytes
B. B.Shizontes
C. C.Merozoites
D. E.Sporozoites
Correct answer:
The correct answer is D: Sporozoites. Sporozoites are the infective stage of Plasmodium for the female Anopheles mosquito. Here's the rationale: After being transmitted to a human host through a mosquito bite, the sporozoites travel to the liver where they mature and reproduce asexually as merozoites (not the infective stage for mosquitoes). The merozoites then infect red blood cells, leading to symptoms like fever, headache, and shivering. During the blood stage, some merozoites develop into male and female gametocytes, which are not infective to mosquitoes. When a mosquito bites an infected person, it ingests gametocytes, which then develop into male and female gametes and fuse to form ookinetes. Ookinetes develop into oocysts in the mosquito's gut, releasing sporozoites that migrate to the salivary glands, ready to infect a new human host when the mosquito bites
What describes the expanded role of a nurse after specialized training and credentialing?
A. Primary care nurse.
B. Private duty nurse.
C. Clinical nurse specialist.
D. Visiting nurse.
Correct answer:
The correct answer is C, Clinical Nurse Specialist (CNS). A CNS has specialized training and credentialing, allowing them to provide expert clinical care, education, research, and leadership in a specific area of nursing practice. They have advanced knowledge and skills to improve patient outcomes and influence healthcare delivery.
A: A Primary Care Nurse typically provides general healthcare services to a variety of patients.
B: Private Duty Nurse provides one-on-one care to individual patients in their homes.
D: A Visiting Nurse provides care to patients in their homes, but without the specialized training and credentialing of a CNS.
In summary, the expanded role of a nurse with specialized training and credentialing is best represented by a Clinical Nurse Specialist due to their advanced clinical expertise and ability to impact healthcare on a broader scale.
A 6-month-old infant involved in a vehicle crash with respiratory distress and unsuccessful intubation. The most appropriate procedure is:
A. "Perform needle cricothyroidotomy with jet insufflation"
B. Administer heliox and racemic epinephrine
C. Perform nasotracheal intubation
D. Perform surgical cricothyroidotomy
Correct answer:
The correct answer is A: "Perform needle cricothyroidotomy with jet insufflation." In this scenario, the infant is in respiratory distress and intubation has been unsuccessful. Needle cricothyroidotomy is the most appropriate procedure as it is a rapid and effective method to secure an airway in emergency situations. It involves creating a temporary airway using a needle inserted into the cricothyroid membrane. Jet insufflation can then provide oxygen to the patient.
Choice B is incorrect as administering heliox and racemic epinephrine does not address the immediate need to secure the airway. Choice C, performing nasotracheal intubation, may not be feasible in this emergency situation. Choice D, performing surgical cricothyroidotomy, is a more invasive procedure compared to needle cricothyroidotomy and may not be as quickly performed in this critical situation.
Why is respiration rate usually counted directly after taking the pulse rate, while the fingers are still on the wrist?
A. It is less work for the nursing assistant to count respirations right after taking the pulse.
B. People may breathe more quickly if they know they are being observed.
C. The chest will not rise and fall if the rate is not counted immediately.
D. The respiration rate will be different if the nursing assistant waits to take it.
Correct answer:
Correct Answer: A
Rationale: Counting respiration rate directly after pulse helps ensure accuracy as the person's breathing pattern may change quickly. It is convenient to count both while fingers are already placed on the wrist, reducing the need to find the pulse again. This method saves time and effort for the nursing assistant, streamlining the process of vital signs assessment efficiently.
Summary of Other Choices:
B: This choice assumes that people may consciously alter their breathing rate when observed, which may not necessarily be true in a clinical setting.
C: The chest may rise and fall even if the rate is not counted immediately; delaying the count would not affect the chest movements.
D: While breathing rates can vary, waiting to take the rate does not guarantee a different result. It is more about ensuring accuracy and efficiency in measurement.
A 37-year-old male client was admitted to the coronary care unit (CCU) 2 days ago with an acute myocardial infarction. Which of the following actions would breach the client confidentiality?
A. The CCU nurse gives a verbal report to the nurse on the telemetry unit before transferring the client to that unit
B. The CCU nurse notifies the on-call physician about a change in the client's condition
C. The emergency department nurse calls up the latest electrocardiogram results to check the client's progress.
D. At the client's request, the CCU nurse updates the client's wife on his condition
Correct answer:
The correct answer is C because calling up the latest electrocardiogram results to check the client's progress breaches the client's confidentiality since this action involves disclosing the client's medical information to someone unauthorized to receive it. This violates the client's right to privacy and confidentiality.
A, B, and D are incorrect:
A: Giving a verbal report to the nurse on the telemetry unit is appropriate as it facilitates continuity of care and is within the scope of healthcare providers involved in the client's treatment.
B: Notifying the on-call physician about a change in the client's condition is also essential for timely medical intervention and does not breach confidentiality.
D: Updating the client's wife on his condition at his request is permissible as long as the client consents to sharing his medical information with his spouse.
When performing an admission assessment of a client diagnosed with a brain tumor, which question is most important for the nurse to ask the client?
A. When did your symptoms first begin?
B. Can you describe the pain and how it feels?
C. Do you have any changes in vision?
D. Have you experienced any seizures?
Correct answer:
The correct answer is D: Have you experienced any seizures? This question is crucial because seizures can be a common symptom of a brain tumor. By asking about seizures, the nurse can gather important information about the client's condition and potential complications. Seizures can also indicate the location and size of the tumor.
A: When did your symptoms first begin? This question is important, but seizures are more specific to brain tumor assessment.
B: Can you describe the pain and how it feels? Pain can vary and may not always be present with a brain tumor.
C: Do you have any changes in vision? Vision changes can occur but may not be as indicative of a brain tumor as seizures.
In summary, asking about seizures is crucial for immediate assessment and management of a client with a brain tumor, as it can provide valuable insight into the client's condition.
The nurse is caring for a postpartum client who is exhibiting symptoms of a spinal headache 24 hours following the delivery of a normal newborn. Prior to the anesthesiologist's arrival on the unit, which action should the nurse perform?
A. Apply an abdominal binder.
B. Cleanse the spinal injection site.
C. Insert an indwelling Foley catheter.
D. Place procedure equipment at the bedside.
Correct answer:
In a postpartum client exhibiting symptoms of a spinal headache, applying an abdominal binder is a priority action. The abdominal binder can help reduce the severity of a spinal headache by increasing intra-abdominal pressure, which may relieve pressure on the dural sac and alleviate symptoms. This intervention can be performed promptly by the nurse to provide immediate relief while waiting for further evaluation and management by the anesthesiologist. Cleansing the spinal injection site (Choice B) is not the priority in this situation as the headache is likely due to a dural puncture during epidural anesthesia rather than infection. Inserting an indwelling Foley catheter (Choice C) and placing procedure equipment at the bedside (Choice D) are not the appropriate actions to address a spinal headache and should not take precedence over applying an abdominal binder.
A 29-year-old married computer programmer comes to your clinic, complaining of "something strange" going on in his scrotum. Last month while he was doing his testicular self- examination he felt a lump in his left testis. He waited a month and felt the area again, but the lump was still there. He has had some aching in his left testis but denies any pain with urination or sexual intercourse. He denies any fever, malaise, or night sweats. His past medical history consists of groin surgery when he was a baby and a tonsillectomy as a teenager. He eats a healthy diet and works out at the gym five times a week. He denies any tobacco or illegal drugs and drinks alcohol occasionally. His parents are both healthy. On examination you see a muscular, healthy, young-appearing man with unremarkable vital signs. On visualization the penis is circumcised with no lesions; there is a scar in his right inguinal region. There is no lymphadenopathy. Palpation of his scrotum is unremarkable on the right but indicates a large mass on the left. Placing a finger through the inguinal ring on the right, you have the patient bear down. Nothing is felt. You attempt to place your finger through the left inguinal ring but cannot get above the mass. On rectal examination his prostate is unremarkable. What disorder of the testes is most likely the diagnosis?
A. Hydrocele
B. Scrotal hernia
C. Scrotal edema
D. Varicocele
Correct answer:
The most likely diagnosis in this case is a scrotal hernia. The patient's history of a previous groin surgery as a baby is a key clue, as it increases the risk for developing a hernia. The lump in the left testis with aching, along with the inability to palpate above the mass through the left inguinal ring, suggests that the lump may be a hernia protruding through the inguinal canal into the scrotum. The presence of a scar in the right inguinal region also supports the likelihood of a hernia. The normal prostate on rectal examination rules out any involvement of the prostate in the presentation. Scrotal hernias may present as painless masses in the scrotum, often increasing in size with activities that increase intra-abdominal pressure, such as straining or coughing. Surgical repair is often necessary to prevent complications such as incarceration or strangulation
The client tells the nurse, 'I thought my psychiatrist was the best doctor in the world. I thought he understood me completely. Now, I hate him! He doesn't understand me at all. He's just dumping me to go on a 2-week vacation.' The nurse assesses the client's description of feelings about the physician as evidence of the use of:
A. Splitting
B. Projective identification
C. Isolation of affect
D. Dissociation
Correct answer:
The correct answer is A: Splitting. Splitting is a defense mechanism where a person sees things as all good or all bad, leading to extreme shifts in perception. In this case, the client initially viewed the psychiatrist as the best doctor but now hates him completely due to feeling abandoned. This sudden shift from idealization to devaluation is characteristic of splitting.
Choice B: Projective identification involves attributing one's own unacceptable feelings or traits onto another. This is not evident in the client's description.
Choice C: Isolation of affect refers to separating emotions from their source. The client is expressing strong emotions towards the psychiatrist, not isolating them.
Choice D: Dissociation involves a disruption in consciousness, memory, identity, or perception. The client is not displaying symptoms of dissociation in this scenario.
RN exams clinical judgment practice questions, set 102 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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