RN exams clinical judgment practice questions, set 110
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 110
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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, age 34, has been physically abused by her husband five times during the past 2 years. During her last discussion with the nurse, the client stated, 'I probably should not keep going back to my husband, since he continues to abuse me.' The nurse is aware that the final decision to leave a batterer:
A. Often occurs after the victim suffers a serious injury
B. Is usually a gradual process that occurs over time
C. Is more likely if the client has approval from the church
D. Is made with the batterer's permission
Show answer and rationale
Correct answer: B — Is usually a gradual process that occurs over time
The correct answer is B: Is usually a gradual process that occurs over time.
Rationale:
1. Leaving an abusive partner is a complex and difficult decision that often requires careful planning and support.
2. Victims may face various barriers such as financial dependence, emotional attachment, and fear of further violence.
3. It is rare for victims to abruptly leave without considering their safety and well-being.
4. The statement 'I probably should not keep going back' indicates a gradual realization and contemplation of leaving.
Summary:
A: The decision to leave is not solely based on serious injury; victims may leave before any significant harm occurs.
C: Approval from the church may influence the victim's decision but is not a determining factor.
D: Leaving an abusive partner should not require the batterer's permission; it is a personal choice made by the victim.
Question 2
A multiparous patient reports severe uterine cramps the first day after a vaginal delivery. The nurse is aware the patient is breastfeeding and associates the patient's pain primarily with which occurrence?
A. An increase in oxytocin release related to the newborn suckling
B. The presence of intense afterbirth pains related to multiparity
C. An expected response to the daily administration of oxytocin
D. The efforts of the uterus to return to a prepregnancy condition
Show answer and rationale
Correct answer: A — An increase in oxytocin release related to the newborn suckling
The correct answer is A: An increase in oxytocin release related to the newborn suckling. After delivery, breastfeeding stimulates the release of oxytocin, causing uterine contractions. This helps the uterus to contract, reduce bleeding, and return to its normal size. This process can result in uterine cramps, especially in multiparous women.
B: The presence of intense afterbirth pains related to multiparity - Afterbirth pains are common in multiparous women, but they are different from uterine cramps due to breastfeeding.
C: An expected response to the daily administration of oxytocin - The patient is breastfeeding, not receiving daily oxytocin administration.
D: The efforts of the uterus to return to a prepregnancy condition - While this is true, the primary reason for the uterine cramps in this scenario is the increased oxytocin release from breastfeeding.
Question 3
A postpartum patient calls the clinic 4 days after the birth of her newborn because she is extremely tired and her vaginal bleeding is heavier. Which does the nurse anticipate when advising her to come in to the office right now?
A. A hematocrit will be drawn, and the licensed provider will check for retained placental fragments.
B. Her stress level and sleep deprivation will be evaluated, and a prescription for sleeping medication will be given.
C. The perineum will be evaluated for lacerations that were missed.
D. Reassure the client that this is all normal and provide a prescription for slow-release iron tablets.
Show answer and rationale
Correct answer: A — A hematocrit will be drawn, and the licensed provider will check for retained placental fragments.
The correct answer is A. The nurse anticipates that a hematocrit will be drawn and the provider will check for retained placental fragments because heavy vaginal bleeding and extreme fatigue could indicate postpartum hemorrhage due to retained placental tissue. This is a serious complication that requires immediate medical attention to prevent further complications such as infection or hemorrhagic shock.
Choice B is incorrect because prescribing sleeping medication does not address the underlying cause of the symptoms. Choice C is incorrect because lacerations would typically have been evaluated and repaired during delivery, and would not likely be missed. Choice D is incorrect because reassuring the client without further evaluation could lead to potential serious consequences if the underlying issue of retained placental fragments is not addressed promptly.
Question 4
When a patient with anorexia nervosa is admitted for treatment, the milieu should provide: (Select all that apply.)
A. Flexible mealtimes.
B. Unscheduled weight checks.
C. Adherence to a selected menu.
D. None of the above.
Show answer and rationale
Correct answer: A — Flexible mealtimes.
The correct answer is A: Flexible mealtimes. In the treatment of anorexia nervosa, providing flexible mealtimes allows patients to regain a sense of control over their eating habits, which is crucial in their recovery process. This approach helps to reduce anxiety around food and promotes a healthier relationship with eating.
Choice B: Unscheduled weight checks can be triggering and anxiety-provoking for patients with anorexia nervosa, as weight monitoring can be a significant source of distress for them.
Choice C: Adherence to a selected menu may reinforce rigid eating patterns and control issues related to food, which can be counterproductive in the treatment of anorexia nervosa.
Choice D: None of the above is incorrect because providing flexible mealtimes is essential in creating a supportive and therapeutic environment for patients with anorexia nervosa.
Question 5
A patient who has chest pain is admitted to the emergency department (ED), and all of the following are ordered. Which one should the nurse arrange to be completed first?
A. Chest x-ray
B. Troponin level
C. Electrocardiogram (ECG)
D. . Insertion of a peripheral IV
Show answer and rationale
Correct answer: C — Electrocardiogram (ECG)
The correct answer is C: Electrocardiogram (ECG). This should be arranged first because it provides immediate information on the patient's cardiac status, helping to determine if the chest pain is due to a heart-related issue like a myocardial infarction. A quick ECG can identify any acute changes in the heart's electrical activity. This is crucial for prompt intervention and treatment.
Summary of other choices:
A: Chest x-ray - While important for assessing lung and chest abnormalities, it does not provide immediate information on the patient's cardiac status.
B: Troponin level - Useful for detecting myocardial damage, but results may take time to be available. Not as immediate as an ECG.
D: Insertion of a peripheral IV - Important for administering medications and fluids, but not a priority over assessing the cardiac status in a patient with chest pain.
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Question 6
A 40-year-old G2, P1 woman is admitted to the labor and delivery unit with contractions 6 minutes apart. She is 36 weeks pregnant, has a history of placenta previa, and is currently experiencing moderate vaginal bleeding. What should the nurse be prepared to do?
A. Perform a vaginal examination to determine cervical dilation
B. Assist the health care provider to perform artificial rupture of the membranes
C. Initiate external fetal monitoring
D. Encourage patient to ambulate to intensify labor
Correct answer:
The correct answer is C: Initiate external fetal monitoring. In this scenario, the patient is at 36 weeks of gestation with a history of placenta previa and moderate vaginal bleeding, indicating a high-risk situation. External fetal monitoring allows for continuous assessment of the fetal heart rate and uterine contractions, which is crucial for identifying signs of fetal distress or complications related to placenta previa. This monitoring can help guide timely interventions and decision-making to ensure the safety of the mother and baby. Performing a vaginal examination (A) may increase the risk of bleeding in cases of placenta previa. Artificial rupture of membranes (B) can also lead to increased bleeding and should be avoided in this situation. Encouraging ambulation (D) is not recommended due to the risk of exacerbating bleeding and potential complications.
An expectant patient in her third trimester reports that she developed a strong tie to her baby from the beginning and now is really in tune to her baby's temperament. The nurse interprets this as the development of which maternal task of pregnancy?
A. Learning to give of herself
B. Developing attachment with the baby
C. Securing acceptance of the baby by others
D. Seeking safe passage for herself and her baby
Correct answer:
The correct answer is B: Developing attachment with the baby. In the scenario described, the expectant patient's strong tie and attunement to the baby's temperament indicate the development of an emotional bond or attachment with the baby. This is an essential maternal task during pregnancy as it promotes maternal-infant bonding and prepares the mother for the caregiving role postpartum.
A: Learning to give of herself - While important in motherhood, this choice doesn't specifically address the emotional bond being described in the scenario.
C: Securing acceptance of the baby by others - This choice focuses on external factors rather than the maternal relationship with the baby.
D: Seeking safe passage for herself and her baby - This choice pertains more to physical safety and well-being rather than the emotional connection between the mother and the baby.
Which intervention is an essential part of nursing care for a laboring patient?
A. Helping the woman manage the pain
B. Eliminating the pain associated with labor
C. Feeling comfortable with the predictable nature of intrapartal care
D. Sharing personal experiences regarding labor and birth to decrease her anxiety
Correct answer:
The correct answer is A because helping the woman manage the pain is essential in nursing care for a laboring patient to ensure her comfort and well-being during labor. This intervention includes providing pain relief measures, such as positioning, massage, breathing techniques, and administering pain medication if needed. The focus is on supporting the woman's coping mechanisms and enhancing her overall birthing experience.
Choice B is incorrect because eliminating pain completely is not always possible or recommended in labor, as some pain is a natural part of the process. Choice C is incorrect as comfort with the predictable nature of care is not as crucial as providing active pain management. Choice D is incorrect because sharing personal experiences may not be relevant or helpful to the laboring patient and may not address her specific needs during labor.
The nurse is researching for evidence-based practice related to a mother's response during the postpartum period. Based on research by Rubin and Mercer, which finding will the nurse be able to easily implement to change the culture of the unit?
A. Satisfaction questionnaires
B. Alterations in terminology
C. Decrease nurse/patient ratios
D. Soliciting paternal expectations
Correct answer:
The correct answer is B: Alterations in terminology. Rubin and Mercer's research focuses on the importance of language and terminology used during the postpartum period. By implementing changes in the unit's terminology to be more supportive and empowering for mothers, the nurse can positively impact the culture of the unit. This can help create a more nurturing and understanding environment for new mothers.
Incorrect choices:
A: Satisfaction questionnaires are not directly related to changing the culture of the unit based on Rubin and Mercer's research.
C: Decreasing nurse/patient ratios may improve patient care but is not specifically mentioned in the research as a way to change the unit's culture.
D: Soliciting paternal expectations is not the focus of Rubin and Mercer's research, which is centered on the mother's response during the postpartum period.
A nurse checks with assistive personnel on the unit throughout the shift to determine if they are completing tasks. The nurse is demonstrating which of the following rights of delegation?
A. Right circumstances
B. Right communication
C. Right person
D. Right supervision
Correct answer:
The correct answer is D: Right supervision. The nurse checking in with assistive personnel to ensure tasks are completed is an example of proper supervision, which is one of the rights of delegation. Supervision involves overseeing and guiding the work of others to ensure tasks are being carried out correctly and safely. This helps maintain accountability and quality of care.
Summary of other choices:
A: Right circumstances - This refers to ensuring the task is appropriate for delegation based on factors such as patient condition and complexity.
B: Right communication - This involves clear and effective communication of tasks, responsibilities, and expectations between the nurse and assistive personnel.
C: Right person - This focuses on selecting the most qualified and competent individual to perform the delegated task based on their skill level and training.
When assessing the health status of super-centenarians in a long-term care facility, which statement is most accurate regarding their general capabilities?
A. A significant number of super-centenarians are dependent on full-time nursing care for daily activities.
B. Many super-centenarians exhibit a high level of functional independence despite their advanced age.
C. The majority of super-centenarians are unable to engage in social activities due to health limitations.
D. Most super-centenarians experience severe cognitive decline that affects their daily living.
Correct answer:
The correct answer is B because super-centenarians, who are individuals aged 110 years or older, often exhibit a high level of functional independence despite their advanced age. This is supported by research showing that many super-centenarians maintain physical and cognitive abilities that allow them to perform daily activities without significant assistance. This statement aligns with the concept of successful aging, where individuals maintain autonomy and independence in later years.
Option A is incorrect because a significant number of super-centenarians are not dependent on full-time nursing care for daily activities. Option C is incorrect as many super-centenarians can still engage in social activities despite health limitations. Option D is incorrect as most super-centenarians do not experience severe cognitive decline that affects their daily living.
A female client is admitted to the emergency department with complaints of chest pain shortness of breath. The nurse's assessment reveals jugular vein distention. The nurse knows that when a client has jugular vein distension, it's typically due to:
A. A neck tumor
B. An electrolyte imbalance
C. Dehydration
D. Fluid overload
Correct answer:
Jugular vein distention (JVD)visible neck vein bulgingindicates elevated central venous pressure, typically from fluid overload (Choice D). This occurs when excess volume (e.g., heart failure, IV overload) backs up into the venous system, distending the jugular veins. Chest pain and shortness of breath align with this, suggesting cardiac strain (e.g., right heart failure). A neck tumor (Choice A) might compress veins, but JVD requires systemic pressure, not local obstruction, and lacks respiratory symptoms. Electrolyte imbalance (Choice B) affects cellular function, not directly venous pressure. Dehydration (Choice C) collapses veins, opposite to JVD. For example, in congestive heart failure, fluid retention raises venous return, causing JVD, detectable at 45° elevation. Fluid overload's pathophysiology fits the presentation, making Choice D the correct cause.
What are the two main outcomes of clonal selection?
A. T cell activation and cytokine suppression
B. Differentiation into effector and memory cells
C. Pathogen destruction and tissue repair
D. Phagocytosis and complement activation
Correct answer:
The correct answer is B: Differentiation into effector and memory cells. During clonal selection, activated lymphocytes undergo differentiation into effector cells that combat the current infection and memory cells that provide long-lasting immunity. Effector cells directly eliminate pathogens, while memory cells remember the specific pathogen for future encounters. Choices A, C, and D are incorrect as they do not accurately represent the main outcomes of clonal selection. T cell activation and cytokine suppression (A) are processes involved in immune response regulation rather than the direct outcomes of clonal selection. Pathogen destruction and tissue repair (C) are broader immune responses that occur after clonal selection. Phagocytosis and complement activation (D) involve innate immune responses, not the adaptive immune responses seen in clonal selection.
A client's angiogram demonstrates the final stage of atherosclerosis. The nurse concludes that this client's pathophysiology includes which of the following elements?
A. The presence of atheromas.
B. Fatty deposits in the intima
C. Lipoprotein accumulation in the intima
D. Inflammation of the arterial wall
Correct answer:
The correct answer is A: The presence of atheromas. Atheromas are plaques that form in the arterial wall due to the accumulation of cholesterol and other substances. In the final stage of atherosclerosis, these atheromas can lead to complete blockages or rupture, causing serious health issues.
Choice B (Fatty deposits in the intima) is incorrect because while fatty deposits are a part of atherosclerosis, the final stage involves the formation of atheromas, not just fatty deposits.
Choice C (Lipoprotein accumulation in the intima) is incorrect because lipoprotein accumulation is an early stage of atherosclerosis, not the final stage involving atheromas.
Choice D (Inflammation of the arterial wall) is incorrect because although inflammation plays a role in atherosclerosis, the final stage is characterized by the presence of atheromas, not just inflammation.
A client diagnosed with schizophrenia, who has been taking antipsychotic medication for the last 5 months, presents in an emergency department (ED) with uncontrollable tongue movements, stiff neck, and difficulty swallowing. The nurse would expect the physician to recognize which condition and implement which treatment?
A. Neuroleptic malignant syndrome, treated by discontinuing antipsychotic medications
B. Agranulocytosis, treated by administration of clozapine (Clozaril)
C. Extrapyramidal symptoms, treated by administration of benztropine (Cogentin)
D. Tardive dyskinesia, treated by discontinuing antipsychotic medications
Correct answer:
The correct answer is D: Tardive dyskinesia, treated by discontinuing antipsychotic medications. Tardive dyskinesia is characterized by uncontrollable tongue movements, stiff neck, and difficulty swallowing, which are common side effects of long-term antipsychotic use. The treatment involves discontinuing the antipsychotic medication to prevent further worsening of symptoms. Neuroleptic malignant syndrome (choice A) presents with fever, muscle rigidity, altered mental status, and autonomic dysfunction, requiring immediate discontinuation of antipsychotic medication. Agranulocytosis (choice B) is a rare but serious side effect of clozapine, not associated with the symptoms described. Extrapyramidal symptoms (choice C) are movement disorders that can occur with antipsychotic use, but benztropine is typically used to treat parkinsonism, not the symptoms described.
RN exams clinical judgment practice questions, set 110 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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