RN exams clinical judgment practice questions, set 104
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 104
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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 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
Show answer and rationale
Correct answer: A — "Perform needle cricothyroidotomy with jet insufflation"
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.
Question 2
When the nurse makes the statement, "We can come back to that later—right now I need to know about when your symptoms started," the nurse is:
A. letting the patient know that topic of conversation was inappropriate.
B. setting limits on the expression of feelings.
C. refocusing the patient to the issue at hand when the conversation has wandered.
D. closing off the conversation by quickly getting to the point of the interview.
Show answer and rationale
Correct answer: C — refocusing the patient to the issue at hand when the conversation has wandered.
The correct answer is C. By saying, "We can come back to that later—right now I need to know about when your symptoms started," the nurse is refocusing the patient to the issue at hand when the conversation has wandered. This response helps maintain the focus of the conversation on gathering important information about the patient's symptoms, which is crucial for providing appropriate care. It acknowledges the patient's concerns while redirecting the conversation back to the main topic.
Choices A, B, and D are incorrect because they do not accurately reflect the nurse's intention in the given statement. Choice A implies judgment on the patient's conversation topic, choice B suggests limiting the patient's emotional expression, and choice D implies a rushed or dismissive attitude towards the conversation, none of which are demonstrated by the nurse's response.
Question 3
What is the priority nursing intervention for a patient with bulimia nervosa who is engaging in purging behaviors?
A. Monitor electrolyte levels and cardiac function.
B. Encourage self-monitoring of food intake.
C. Provide emotional support and promote body image acceptance.
D. Focus on encouraging weight loss through diet control.
Show answer and rationale
Correct answer: A — Monitor electrolyte levels and cardiac function.
The correct answer is A. The priority nursing intervention for a patient with bulimia nervosa engaging in purging behaviors is to monitor electrolyte levels and cardiac function. This is crucial due to the potential electrolyte imbalances and cardiac complications resulting from purging behaviors. Monitoring these parameters helps prevent life-threatening conditions such as hypokalemia and arrhythmias.
Option B is incorrect as self-monitoring of food intake may not address the immediate health risks associated with purging behaviors. Option C is also incorrect as emotional support and body image acceptance are important but not the immediate priority in this case. Option D is incorrect as focusing on weight loss through diet control can exacerbate the patient's eating disorder behaviors and does not address the urgent medical concerns associated with purging.
Question 4
A patient has been living with seasonal allergies for many years, but does not take antihistamines, stating, When I was young I used to take antihistamines, but they always put me to sleep. How should the nurse best respond?
A. Newer antihistamines are combined with a stimulant that offsets drowsiness.
B. Most people find that they develop a tolerance to sedation after a few months.
C. The newer antihistamines are different than in years past, and cause less sedation.
D. Have you considered taking them at bedtime instead of in the morning?
Show answer and rationale
Correct answer: C — The newer antihistamines are different than in years past, and cause less sedation.
Rationale for Correct Answer (C):
1. The newer antihistamines, such as second-generation antihistamines like loratadine or cetirizine, are designed to cause less sedation compared to older antihistamines like diphenhydramine.
2. These newer antihistamines have a lower affinity for crossing the blood-brain barrier, reducing the sedative effects.
3. Therefore, suggesting that the newer antihistamines are different and cause less sedation is the best response to address the patient's concerns.
Summary of Incorrect Choices:
A. While some newer antihistamines may be combined with decongestants to offset drowsiness, this is not a consistent feature of all newer antihistamines.
B. Developing tolerance to sedation after a few months is not a common or reliable response to antihistamines.
D. Taking antihistamines at bedtime may help with sedation, but it does not address
Question 5
While taking a health history on a 20-year-old female patient, the nurse ascertains that this patient is taking miconazole (Monistat). The nurse is justified in presuming that this patient has what medical condition?
A. Bacterial vaginosis
B. Human papillomavirus (HPV)
C. Candidiasis
D. Toxic shock syndrome (TSS)
Show answer and rationale
Correct answer: C — Candidiasis
Rationale for Correct Answer (C): The nurse can presume the patient has candidiasis since miconazole is commonly used to treat fungal infections like vaginal yeast infections caused by Candida. This medication works by stopping the growth of the fungus. Therefore, the patient's use of miconazole indicates a probable diagnosis of candidiasis.
Summary of Incorrect Choices:
A (Bacterial vaginosis): Miconazole is not used to treat bacterial infections like bacterial vaginosis, which is caused by an imbalance of bacteria in the vagina.
B (HPV): Miconazole is not used to treat viral infections like HPV, which is a sexually transmitted infection caused by certain types of human papillomavirus.
D (TSS): Miconazole is not used to treat toxic shock syndrome, which is a severe complication of certain bacterial infections and is not typically associated with miconazole use.
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Question 6
How long should clamping of the cord be delayed in an uncomplicated delivery to increase the newborn's hemoglobin levels and improve circulation?
A. 30–60 seconds
B. 15–30 seconds
C. 30 seconds
D. Delayed cord clamping is not recommended.
Correct answer:
The correct answer is A (30-60 seconds) for delayed cord clamping in an uncomplicated delivery. Delaying cord clamping for 30-60 seconds allows more blood to flow from the placenta to the baby, increasing the baby's hemoglobin levels and improving circulation. This extra blood transfer can provide the baby with essential nutrients and oxygen, reducing the risk of anemia and improving overall health outcomes.
Choice B (15-30 seconds) may not provide enough time for sufficient blood transfer compared to the optimal window of 30-60 seconds.
Choice C (30 seconds) is within the recommended range, but 30-60 seconds is considered more beneficial for maximizing blood flow to the newborn.
Choice D (Delayed cord clamping is not recommended) is incorrect as delayed cord clamping has been shown to have various benefits for newborns when done in uncomplicated deliveries.
A visitor from Poland who does not speak English appears somewhat apprehensive while the nurse is examining his neck. He would probably be most comfortable if the nurse were examining his thyroid:
A. from behind, with the nurse's hands placed firmly around his neck.
B. from the side, with the nurse's eyes averted toward the ceiling and the thumbs on his neck.
C. from the front, with the nurse's thumbs placed on either side of his trachea and his head tilted forward.
D. from the front, with the nurse's thumbs placed on either side of his trachea and his head tilted backward.
Correct answer:
The correct answer is C because it demonstrates cultural sensitivity and respect for the patient's comfort. Placing the nurse's thumbs on either side of the trachea and tilting the patient's head forward is a non-threatening and non-invasive approach to examining the thyroid. This position allows the nurse to assess the thyroid gland without causing discomfort or intimidation to the patient.
Choice A is incorrect because having the nurse's hands placed firmly around the neck from behind may be perceived as invasive and threatening to the patient. Choice B is incorrect because having the nurse's thumbs on the patient's neck with eyes averted toward the ceiling may come across as awkward and unprofessional. Choice D is incorrect because tilting the patient's head backward can cause discomfort and may not be culturally sensitive as it can be perceived as invasive.
Which educational intervention by the nurse would be most effective in promoting self-care for a childbearing client in their second trimester who is diagnosed with gestational diabetes?
A. Providing a list of local support groups for pregnant clients with gestational diabetes
B. Teaching the client how to monitor blood glucose levels at home
C. Giving the client a strict diet plan to follow that limits sugars
D. Scheduling weekly checkups to closely monitor their condition
Correct answer:
The correct answer is B because teaching the client how to monitor blood glucose levels at home empowers them to actively manage their condition. This intervention promotes self-care by enabling the client to track their glucose levels regularly and make informed decisions about their diet and lifestyle. Monitoring blood glucose levels is crucial in managing gestational diabetes effectively.
A: Providing a list of local support groups may be beneficial for emotional support but does not directly address self-care through blood glucose monitoring.
C: Giving a strict diet plan is important, but it is not as effective as teaching the client to monitor their own blood glucose levels.
D: Scheduling weekly checkups is helpful for monitoring progress, but it does not promote the same level of self-care as teaching the client to monitor their own blood glucose levels.
What is the pathophysiologic process responsible for the decreased glomerular filtration rate in a patient with acute glomerulonephritis?
A. Decreased renal-induced constriction of the renal arteries
B. Immune complex deposition, increased capillary permeability, and cellular proliferation
C. Necrosis of 70% or more of the nephrons secondary to increased kidney interstitial hydrostatic pressure
D. Scar tissue formation throughout the proximal convoluted tubule secondary to toxin-induced collagen synthesis
Correct answer:
The correct answer is B: Immune complex deposition, increased capillary permeability, and cellular proliferation. Acute glomerulonephritis is characterized by inflammation of the glomeruli in the kidneys. This inflammation leads to the deposition of immune complexes, increased capillary permeability, and cellular proliferation, which collectively contribute to a decreased glomerular filtration rate. Choice A is incorrect as decreased renal-induced constriction of the renal arteries would not directly result in decreased glomerular filtration rate. Choice C is incorrect as necrosis of nephrons due to increased kidney interstitial hydrostatic pressure would affect kidney function differently. Choice D is incorrect as scar tissue formation in the proximal convoluted tubule due to toxin-induced collagen synthesis is not a typical feature of acute glomerulonephritis.
A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
A. Provide a stimulating environment
B. Monitor blood glucose level every hr.
C. Initiate seizure precautions.
D. Place the infants on his back with legs extended.
Correct answer:
Neonatal abstinence syndrome (NAS) occurs in infants who are exposed to addictive substances in utero, typically opioids. The signs of NAS can include irritability, tremors, feeding difficulties, and seizures. Therefore, it is essential for the nurse to initiate seizure precautions when caring for an infant with signs of NAS. This includes ensuring a safe environment, padding the crib, monitoring closely for seizure activity, and having emergency medications readily available if needed. Providing a stimulative environment (Option A) would be inappropriate as it can exacerbate symptoms of NAS. While monitoring blood glucose (Option B) is important in some situations, such as for infants of diabetic mothers, it is not the priority in NAS. Placing the infant on their back with legs extended (Option D) does not directly address the immediate concerns related to NAS.
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 patient asks when she should make an appointment for her first Pap (Papanicolaou) test to screen for cervical cancer. What is the nurse’s most appropriate response?
A. There is no need for Pap tests until after you have become pregnant.
B. All women should have the first Pap test after reaching menarche.
C. All women should have the first Pap test after they are 19 years of age.
D. All women should have the first Pap test when they become sexually active or at age 21.
Correct answer:
The correct answer is D. The first Pap test should be done when a woman becomes sexually active or at age 21, whichever comes first. This is because cervical cancer is associated with the human papillomavirus (HPV), which is a sexually transmitted infection. Screening at this stage helps detect any abnormalities early on, increasing the chances of successful treatment.
A: Incorrect. Waiting until after pregnancy is not recommended as early detection is crucial in preventing cervical cancer.
B: Incorrect. The age of menarche is not a reliable indicator for when to start screening for cervical cancer.
C: Incorrect. Waiting until 19 may miss early signs of cervical abnormalities that could lead to cancer.
In summary, choice D is the most appropriate response as it aligns with current screening guidelines and focuses on early detection for optimal outcomes.
The nurse is teaching parents of a newborn about feeding their infant. Which instruction should the nurse include?
A. Use the defrost setting on microwave ovens to warm bottles.
B. When refrigerating formula, don't feed the baby partially used bottles after 24 hours.
C. When using formula concentrate, mix two parts water and one part concentrate.
D. Add new formula to partially used bottles to fill them.
Correct answer:
Rationale for Correct Answer A:
1. Using the defrost setting on microwave ovens to warm bottles is safe because it ensures even heating without creating hot spots that could burn the baby's mouth.
2. This method helps to preserve the nutrients in the breast milk or formula.
3. It is important to warm the bottle to body temperature to mimic the natural feel of breast milk for the baby's comfort.
Summary of Incorrect Choices:
B: Feeding the baby partially used bottles after 24 hours can increase the risk of bacterial contamination and foodborne illness.
C: Mixing two parts water and one part concentrate for formula concentrate is incorrect as it may dilute the formula, leading to inadequate nutrition for the baby.
D: Adding new formula to partially used bottles can alter the balance of nutrients and increase the risk of contamination, affecting the baby's health.
A 15 year old male presents following a motorcycle crash. Initial examination reveals normal vital signs. There is a large bruise over his epigastrium that extends to the left flank. He has no other apparent injuries. A CT-scan of the abdomen demonstrates a ruptured spleen surrounded by a large hematoma and fluid in the pelvis. The next step in the patient's management is:
A. "Splenic artery embolization"
B. "Pneumococcal vaccine"
C. "Urgent laparotomy"
D. "Surgical consult"
Correct answer:
The correct answer is D: "Surgical consult." In this scenario, the patient has a ruptured spleen with associated hematoma and fluid in the pelvis, indicating active bleeding. A surgical consult is necessary to evaluate the need for surgical intervention such as splenectomy or splenic artery embolization. A surgical approach is crucial to control bleeding and manage potential complications. Choice A, splenic artery embolization, may be a treatment option, but a surgical consult is needed first to assess the patient's overall condition and suitability for this procedure. Choice B, pneumococcal vaccine, is important for patients with splenectomy but is not the immediate priority in this acute setting. Choice C, urgent laparotomy, is too specific without knowing the patient's stability and overall condition, making a surgical consult a more appropriate initial step.
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.
RN exams clinical judgment practice questions, set 104 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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