RN exams clinical judgment practice questions, set 103
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 103
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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
Determining nursing care priorities is a part of which of the following steps in determining and fulfilling the nursing care needs of the patient?
A. Evaluation
B. Planning
C. Implementation
D. Assessment
Show answer and rationale
Correct answer: B — Planning
Corrected Rationale: Planning in nursing involves setting priorities based on the patient's needs, resources, and desired outcomes. It includes organizing and coordinating care activities to achieve the identified goals. Therefore, determining nursing care priorities is a key aspect of the planning phase.\n
Incorrect Rationales:\n- Evaluation (Choice A) comes after implementing the care plan to assess the effectiveness of interventions and make necessary adjustments.\n- Implementation (Choice C) is the phase where the care plan is put into action, involving carrying out the nursing interventions designed during the planning phase.\n- Assessment (Choice D) is the initial step in the nursing process where data about the patient's health status is collected and analyzed to identify needs and formulate a care plan. It precedes planning and determining care priorities.
Question 2
A pregnant patient is 36 weeks gestation and reports increased vaginal discharge. What is the nurse's priority action?
A. Assess the nature of the discharge for signs of infection.
B. Instruct the patient to monitor the discharge at home.
C. Recommend the patient use panty liners to manage the discharge.
D. Provide education about normal pregnancy changes, including discharge.
Show answer and rationale
Correct answer: A — Assess the nature of the discharge for signs of infection.
The correct answer is A: Assess the nature of the discharge for signs of infection. At 36 weeks gestation, increased vaginal discharge could be a sign of infection, such as bacterial vaginosis or yeast infection, which can lead to preterm labor. The nurse's priority is to assess for infection to prevent any potential harm to the mother and baby. By assessing the nature of the discharge, the nurse can determine if further evaluation or treatment is needed.
Choice B is incorrect because instructing the patient to monitor the discharge at home does not address the potential seriousness of the situation. Choice C is incorrect as using panty liners only manages the symptom without addressing the underlying cause. Choice D is incorrect because providing education about normal pregnancy changes does not address the immediate need to rule out infection in this scenario.
Question 3
The nurse is caring for a pregnant patient who is 34 weeks gestation and is concerned about the safety of using herbal remedies. What is the nurse's most appropriate response?
A. Herbal remedies are always safe during pregnancy as long as they are natural.
B. You should avoid all herbal remedies during pregnancy without consulting your healthcare provider.
C. Herbal remedies are only unsafe during the first trimester of pregnancy.
D. Herbal remedies are safe as long as they are purchased from a reputable source.
Show answer and rationale
Correct answer: B — You should avoid all herbal remedies during pregnancy without consulting your healthcare provider.
The correct answer is B because pregnant patients should avoid all herbal remedies without consulting their healthcare provider. During pregnancy, there can be potential risks associated with herbal remedies, as their safety and efficacy are not well studied. It is crucial for healthcare providers to assess the individual patient's medical history and current health status before recommending any herbal remedies.
Choice A is incorrect because not all herbal remedies are safe during pregnancy, regardless of being natural. Choice C is incorrect because herbal remedies can pose risks throughout pregnancy, not just in the first trimester. Choice D is incorrect because the safety of herbal remedies cannot be guaranteed solely by purchasing them from a reputable source. Consulting a healthcare provider is essential to ensure the safety of both the mother and the baby.
Question 4
A highly emotional client presents at an outpatient clinic appointment wearing flamboyant attire, spiked heels, and theatrical makeup. Which personality disorder should the nurse associate with these assessment data?
A. Compulsive personality disorder
B. Schizotypal personality disorder
C. Histrionic personality disorder (HPD)
D. Manic personality disorder
Show answer and rationale
Correct answer: C — Histrionic personality disorder (HPD)
The correct answer is C: Histrionic personality disorder (HPD). This disorder is characterized by attention-seeking behavior, emotional overreaction, and dramatic appearance. In this case, the client's flamboyant attire, spiked heels, and theatrical makeup align with the attention-seeking and dramatic features of HPD.
A: Compulsive personality disorder is characterized by perfectionism and rigidity, not flamboyant or attention-seeking behavior.
B: Schizotypal personality disorder involves social isolation and eccentric behavior, not attention-seeking or dramatic appearance.
D: Manic personality disorder is a mood disorder characterized by elevated mood and increased energy, not necessarily flamboyant attire or theatrical makeup.
Therefore, the best fit for the client's presentation is Histrionic personality disorder based on the assessment data provided.
Question 5
Which of the following phrases best describes hospitals today?
A. focus on chronic illnesses
B. focus on acute care needs
C. primary care centers
D. voluntary agencies
Show answer and rationale
Correct answer: B — focus on acute care needs
The correct answer is B: focus on acute care needs. Hospitals today primarily cater to providing immediate and intensive medical care for patients with severe or urgent health issues. This is evident in their specialized departments such as emergency rooms, intensive care units, and surgical suites. Hospitals are equipped with advanced technologies and specialized medical professionals to address acute conditions promptly.
Choice A (focus on chronic illnesses) is incorrect as hospitals mainly deal with acute conditions. Choice C (primary care centers) is incorrect as primary care centers provide routine and preventive care, whereas hospitals focus on more complex and urgent medical needs. Choice D (voluntary agencies) is incorrect as hospitals are healthcare institutions that may operate as public, private, or non-profit entities, rather than voluntary agencies.
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Question 6
A nurse is teaching a client about the purpose of pursed-lip breathing. Which of the following explanations should the nurse provide?
A. To increase oxygen intake
B. To promote relaxation
C. To strengthen respiratory muscles
D. To improve carbon dioxide elimination
Correct answer:
The correct answer is D: To improve carbon dioxide elimination. Pursed-lip breathing involves exhaling through pursed lips to create back pressure, helping to keep airways open longer and improving carbon dioxide elimination. This technique reduces the work of breathing and can be beneficial for clients with chronic obstructive pulmonary disease (COPD) or other respiratory conditions.
Explanation for other choices:
A: To increase oxygen intake - Pursed-lip breathing primarily helps with exhaling, not increasing oxygen intake.
B: To promote relaxation - While pursed-lip breathing can promote relaxation by slowing down breathing and reducing anxiety, its primary purpose is related to respiratory function.
C: To strengthen respiratory muscles - Pursed-lip breathing mainly focuses on improving breathing efficiency rather than strengthening respiratory muscles.
Why is a beta-blocker prescribed to a client with a history of myocardial infarction?
A. To reduce myocardial oxygen demand.
B. To increase cardiac output.
C. To prevent arrhythmias.
D. To prevent the development of angina.
Correct answer:
The primary reason for administering a beta-blocker to a client with a history of myocardial infarction is to reduce myocardial oxygen demand. By reducing myocardial oxygen demand, beta-blockers help decrease the workload on the heart, making it easier for the heart to function effectively. This is crucial for clients with a history of myocardial infarction to prevent further damage to the heart. Choice B is incorrect because beta-blockers do not aim to increase cardiac output; instead, they help improve cardiac function by reducing workload. Choice C is incorrect because while beta-blockers can help prevent certain arrhythmias, the primary reason for their use in this case is to reduce myocardial oxygen demand. Choice D is incorrect as preventing angina is not the primary purpose of administering beta-blockers to a client with a history of myocardial infarction.
A client with chronic heart failure is receiving furosemide (Lasix). Which assessment finding requires immediate intervention?
A. Heart rate of 60 beats per minute
B. Blood pressure of 110/70 mmHg
C. Crackles in the lungs
D. Peripheral edema
Correct answer:
In a client with chronic heart failure receiving furosemide, crackles in the lungs indicate pulmonary congestion, requiring immediate intervention. This finding suggests fluid accumulation in the lungs, impairing oxygen exchange and potentially leading to respiratory distress. Monitoring and managing pulmonary congestion promptly are crucial to prevent worsening heart failure and respiratory compromise. The other options, while important to assess in a client with heart failure, do not indicate an immediate need for intervention like crackles in the lungs do. A heart rate of 60 beats per minute may be within the normal range for some individuals, a blood pressure of 110/70 mmHg is relatively stable, and peripheral edema is a common manifestation of heart failure that should be monitored but does not require immediate intervention compared to pulmonary congestion.
A patient has allergic rhinitis. In planning care for the patient, the nurse understands that if the patient does not remain compliant with the treatment regimen, the patient is at risk for developing which of the following?
A. Sinusitis
B. Lymphadenopathy
C. Anaphylaxis
D. Angioedema
Correct answer:
The correct answer is A: Sinusitis. Allergic rhinitis causes inflammation in the nasal passages, leading to congestion and blockage of the sinuses. If the patient does not comply with the treatment regimen, the inflammation can worsen, increasing the risk of developing sinusitis, which is an infection or inflammation of the sinuses. Sinusitis can result in severe pain, pressure, and potentially lead to complications.
Summary of other choices:
B: Lymphadenopathy - Enlargement of lymph nodes, not directly related to non-compliance with treatment for allergic rhinitis.
C: Anaphylaxis - Life-threatening allergic reaction, not a typical consequence of non-compliance with treatment for allergic rhinitis.
D: Angioedema - Swelling of deeper layers of skin, usually associated with allergies but not a common outcome of non-compliance with treatment for allergic rhinitis.
The nurse is careful to monitor a patient's cardiac output because this helps the nurse to determine
A. Peripheral extremity circulation.
B. Oxygenation requirements.
C. Cardiac arrhythmias.
D. Ventilation status.
Correct answer:
The correct answer is B: Oxygenation requirements. Monitoring cardiac output helps determine the amount of blood the heart is pumping, which directly affects the delivery of oxygen to tissues. This information is crucial in assessing the patient's oxygenation status and ensuring adequate oxygen supply to meet the body's needs.
A: Peripheral extremity circulation - While cardiac output can impact peripheral circulation, it is not the primary reason for monitoring cardiac output.
C: Cardiac arrhythmias - Monitoring cardiac output may indirectly help in identifying arrhythmias, but it is not the main purpose of monitoring cardiac output.
D: Ventilation status - Cardiac output and ventilation status are related but distinct parameters. Monitoring cardiac output focuses on assessing the heart's ability to pump blood, not the lungs' ability to exchange gases.
The nurse is caring for a pregnant person who is living in an underserved area of town with a history of childhood abuse, opioid use disorder, and asthma. What can the nurse do to decrease the risk of maternal mortality?
A. Connect the patient to a counselor.
B. Educate the patient on the risk factors for maternal mortality.
C. Give prn albuterol for asthma.
D. Discuss how they need to move out of the poor area of town.
Correct answer:
Correct Answer: A
Rationale:
1. Connecting the patient to a counselor addresses the underlying issues of childhood abuse and opioid use disorder, which can contribute to maternal mortality.
2. Counseling can provide support, coping strategies, and mental health assistance crucial for at-risk individuals.
3. Addressing mental health concerns can improve overall well-being and increase the likelihood of seeking appropriate prenatal care.
Summary:
B: While education on risk factors is important, it may not directly address the patient's specific mental health and trauma history.
C: Giving albuterol for asthma is essential but does not directly address the underlying factors contributing to maternal mortality.
D: Moving out of the poor area is not a feasible or realistic solution and does not address the patient's mental health and substance abuse issues.
Which of the following is responsible for causing gonorrhea?
A. Neisseria gonorrhoeae
B. Chlamydia trachomatis
C. Mycobacterium tuberculosis
D. Treponema pallidum
Correct answer:
Neisseria gonorrhoeae is the correct answer because it is the specific bacterium responsible for causing gonorrhea. It is a sexually transmitted infection that primarily affects the genital tract. Neisseria gonorrhoeae is transmitted through sexual contact and can lead to symptoms such as painful urination, discharge, and pelvic pain.
Chlamydia trachomatis (Choice B) is another sexually transmitted bacterium, but it causes chlamydia, not gonorrhea.
Mycobacterium tuberculosis (Choice C) is responsible for tuberculosis, a different infectious disease that primarily affects the lungs.
Treponema pallidum (Choice D) causes syphilis, another sexually transmitted infection that presents with distinct symptoms from gonorrhea.
Therefore, Neisseria gonorrhoeae is the correct choice for causing gonorrhea due to its specific association with this particular infection.
A 55-year-old man presents at the clinic complaining of erectile dysfunction. The patient has a history of diabetes. The physician orders tadalafil (Cialis) to be taken 1 hour before sexual intercourse. The nurse reviews the patients history prior to instructing the patient on the use of this medication. What disorder will contraindicate the use of tadalafil (Cialis)?
A. Cataracts
B. Retinopathy
C. Hypotension
D. Diabetic nephropathy
Correct answer:
The correct answer is B: Retinopathy. Tadalafil (Cialis) is contraindicated in patients with retinopathy due to the potential risk of worsening vision problems. Retinopathy is a serious eye condition commonly associated with diabetes, and using tadalafil can lead to further complications in the eyes. It is crucial for patients with retinopathy to avoid medications that can exacerbate their eye condition.
Incorrect choices:
A: Cataracts - Cataracts do not contraindicate the use of tadalafil. Tadalafil does not have a direct negative impact on cataracts.
C: Hypotension - Hypotension is not a contraindication for tadalafil use. In fact, tadalafil can cause a drop in blood pressure, so it should be used with caution in patients with hypotension.
D: Diabetic nephropathy - Diabetic nephropathy is not a direct contraindication for tadalafil use. Tadalafil is generally
What dietary advice should the nurse give to clients with HIV/AIDS?
A. Encourage the intake of fat soluble vitamins in amounts 2 to 5 times the recommended daily allowance (RDA)
B. Encourage intake of water soluble vitamins in amounts 2 to 5 times the RDA
C. Increase the intake of iron and zinc
D. Decrease the intake of trace elements and antioxidant supplements
Correct answer:
The correct answer is D: Decrease the intake of trace elements and antioxidant supplements. Clients with HIV/AIDS do not require additional trace elements and antioxidant supplements, as excessive intake can be harmful. HIV/AIDS already places stress on the immune system, so taking excessive supplements may lead to toxicity. It is important to focus on a balanced diet rich in essential nutrients rather than overloading the body with unnecessary supplements. Encouraging a healthy, balanced diet will help support overall health and immune function in clients with HIV/AIDS.
Choices A, B, and C are incorrect because encouraging excessive intake of fat-soluble vitamins, water-soluble vitamins, iron, and zinc can also lead to potential adverse effects. It is important to focus on meeting the recommended daily allowances for these nutrients rather than exceeding them.
Following insertion of a pulmonary artery catheter (PAC),a bthirbe. cpohmy/tessitc ian orders the nurse to obtain a blood sample for mixed venous oxygen saturation (SvO ). Which action by the nurse best ensures the obtained value is accurate?
A. Zero referencing the transducer at the level of the phlebostatic axis following insertion WWWWWW ..TTHHEENNUURRSSIINNGGMMAASSTTEERRYY..CCOOMM
B. Calibrating the system with a central venous blood sample and arterial blood gas value
C. Ensuring patency of the catheter using a 0.9% normal asbailrbin.ceo ms/otelsut tion pressurized at 300 mm Hg
D. Using noncompliant pressure tubing that is no longer t han 36 to 48 inches and has minimal stopcocks
Correct answer:
The correct answer is B because calibrating the system with central venous and arterial blood samples ensures accuracy of the mixed venous oxygen saturation (SvO2) measurement. This calibration allows for comparison of the values obtained from both sources to confirm the accuracy of the measurement.
Choice A is incorrect because zero referencing the transducer at the level of the phlebostatic axis does not directly address the accuracy of the SvO2 measurement.
Choice C is incorrect because ensuring patency of the catheter using normal saline pressurized at 300 mm Hg does not directly impact the accuracy of the SvO2 measurement.
Choice D is incorrect because using noncompliant pressure tubing does not ensure the accuracy of the SvO2 measurement. The length of the tubing and the presence of stopcocks are not directly related to obtaining an accurate SvO2 value.
RN exams clinical judgment practice questions, set 103 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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