RN exams clinical judgment practice questions, set 114
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 114
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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 nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin level. What action should the nurse take?
A. Use a photometer to monitor the lamp\'s energy.
B. Apply lotion to the newborn\'s skin to prevent dryness.
C. Keep the newborn\'s eyes uncovered to monitor for any changes.
D. Dress the newborn in warm clothing.
Show answer and rationale
Correct answer: A — Use a photometer to monitor the lamp\'s energy.
The correct action the nurse should take when caring for a newborn receiving phototherapy for an elevated bilirubin level is to use a photometer to monitor the lamp's energy (Option A). Phototherapy is used to break down bilirubin in the baby's blood, and it is crucial to ensure that the newborn is receiving the appropriate amount of light energy to effectively reduce bilirubin levels. Using a photometer helps the nurse accurately measure the light intensity and adjust it as needed to achieve optimal therapeutic effects. Applying lotion to the skin (Option B) is not directly related to phototherapy but can be beneficial for preventing dryness. Keeping the newborn's eyes uncovered (Option C) is important to monitor for any changes or adverse effects from the phototherapy. Dressing the newborn in warm clothing (Option D) is not recommended during phototherapy as it can interfere with the effectiveness of the treatment. Therefore, the most appropriate action for the nurse in this scenario
Question 2
A nurse is caring for a client who is at 37 weeks of gestation and is undergoing a nonstress test. The FHR is 130 without accelerations for the past 10 minutes. What should the nurse do?
A. Use vibroacoustic stimulation on the client\'s abdomen for 3 seconds.
B. Continue monitoring the FHR.
C. Notify the provider immediately.
D. Reposition the client to the left lateral position.
Show answer and rationale
Correct answer: A — Use vibroacoustic stimulation on the client\'s abdomen for 3 seconds.
In this scenario, the nonstress test is showing a fetal heart rate (FHR) of 130 without accelerations for the past 10 minutes, which could indicate a non-reactive test. Vibroacoustic stimulation can be used to elicit a response from the fetus by providing auditory and tactile stimulation. This can help determine the overall well-being of the fetus and assess its reactivity. By using vibroacoustic stimulation for 3 seconds, the nurse can attempt to provoke a response in the FHR pattern. If there are no accelerations following the stimulation, further action may be needed. Therefore, the correct course of action in this situation is to use vibroacoustic stimulation on the client's abdomen for 3 seconds (option A). Continuing to monitor the FHR (option B) without attempting to elicit a response may not provide additional information. Notifying the provider immediately (option C) may be necessary if the FHR remains non-reactive after stimulation. Repositioning the client to the left latera
Question 3
A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6cm of cervical dilation and 100% cervical effacement. The nurse obtains the client\'s blood pressure reading as 82/52mmHg. Which of the following nursing interventions should the nurse perform?
A. Prepare for a cesarean birth.
B. Assist the client to an upright position.
C. Prepare for an immediate vaginal delivery.
D. Assist the client to turn onto her side.
Show answer and rationale
Correct answer: D — Assist the client to turn onto her side.
The correct answer is D: "Assist the client to turn onto her side." The client's low blood pressure reading of 82/52mmHg indicates hypotension, which can be common during labor due to various factors including epidural anesthesia or dehydration. Turning the client onto her side can help improve blood flow and perfusion to vital organs, which may help stabilize her blood pressure. This position change can also relieve pressure on the vena cava, facilitating better circulation and potentially improving the client's blood pressure. Option A is incorrect because preparing for a cesarean birth is not indicated solely based on the blood pressure reading. Option B, assisting the client to an upright position, may worsen hypotension. Option C, preparing for an immediate vaginal delivery, is not necessary based on the information provided and would not address the client's hypotension. Therefore, the priority intervention is to assist the client to turn onto her side to address the low blood pr
Question 4
A nurse on the labor and delivery unit is assessing four clients. Which of the following clients is a candidate for an induction of labor with misoprostol?
A. A client who has active genital herpes
B. A client who has gestational diabetes mellitus
C. A client who has a previous uterine incision
D. A client who has placenta previa
Show answer and rationale
Correct answer: B — A client who has gestational diabetes mellitus
The correct answer is B: 'A client who has gestational diabetes mellitus.' Gestational diabetes mellitus is a condition that may necessitate the need for labor induction to prevent complications for both the mother and the baby. Misoprostol is a prostaglandin medication commonly used for labor induction in cases where there is a medical need to expedite the birth process. Clients with active genital herpes (option A) may not be candidates for misoprostol induction due to the risk of viral transmission. A previous uterine incision (option C) may indicate a previous cesarean section, which could impact the method of labor induction chosen. Placenta previa (option D) is a condition where the placenta partially or fully covers the cervix, and misoprostol induction may not be suitable in this case due to the risk of increased bleeding. Therefore, the client with gestational diabetes mellitus would be a candidate for induction of labor with misoprostol to ensure optimal outcomes for both the
Question 5
.A nurse is providing education to the family of a client who has been diagnosed with major depressive disorder. Which of the following instructions should the nurse include?
A. Encourage the client to avoid caffeine.
B. Encourage the client to participate in physical activity.
C. Encourage the client to express their feelings.
D. Encourage the client to avoid isolation.
Show answer and rationale
Correct answer: E
The correct answer is not provided in the options given. However, in educating the family of a client with major depressive disorder, it is essential to include instructions that promote the client's mental health and well-being. Encouraging the client to participate in physical activity is crucial as exercise has been shown to improve mood and alleviate symptoms of depression. Additionally, expressing feelings and avoiding isolation are also important aspects of managing depression. By expressing their emotions, clients can release pent-up feelings and receive support from their loved ones. Avoiding isolation can help prevent feelings of loneliness and promote social connections, which are beneficial for mental health. While avoiding caffeine may be helpful for some individuals with depression, it is not as universally applicable or impactful as the other options provided. Therefore, the most comprehensive approach to supporting a client with major depressive disorder includes encoura
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Question 6
.A nurse is providing discharge instructions to a client who has been prescribed bupropion (Wellbutrin) for the treatment of depression. Which of the following instructions should the nurse include?
A. Take the medication with a full glass of water.
B. Stop taking the medication if you feel better.
C. Avoid drinking alcohol while taking this medication.
D. Double the dose if you miss a dose.
Correct answer:
The correct answer is B: 'Stop taking the medication if you feel better.' It is important for the nurse to instruct the client to never stop taking bupropion abruptly without consulting their healthcare provider. This is because suddenly discontinuing the medication can lead to withdrawal symptoms and potentially worsen the client's condition. It is crucial for the client to follow the prescribed treatment plan and dosage as directed by their healthcare provider. Therefore, advising the client to stop taking the medication if they feel better is incorrect and potentially harmful to their health. Option A is not directly related to the medication's administration. Option C is important as bupropion can interact with alcohol and increase the risk of side effects. Option D is incorrect because doubling the dose of medication is not safe and can lead to overdose. It is essential for the client to adhere to the prescribed dosage and consult their healthcare provider for any concerns or miss
.A client with anorexia nervosa is admitted to the psychiatric unit. Which intervention should the nurse implement to address the client\'s nutritional needs?
A. Provide small, frequent meals throughout the day.
B. Monitor the client\'s weight daily.
C. Provide a liquid supplement if the client refuses solid food.
D. Offer the client a variety of food choices.
Correct answer:
The correct answer is A: "Provide small, frequent meals throughout the day." This intervention is important for clients with anorexia nervosa because it helps prevent overwhelming the client with large meals, which can be anxiety-provoking. Small, frequent meals can also help stabilize blood sugar levels and prevent excessive fullness, making it easier for the client to consume adequate nutrients. Monitoring the client's weight daily (option B) is not the most appropriate intervention as it can contribute to increased anxiety and reinforce the client's preoccupation with weight. Providing a liquid supplement if the client refuses solid food (option C) may not address the underlying psychological issues related to eating. Offering the client a variety of food choices (option D) may be overwhelming and may not support consistent nutrient intake. Overall, providing small, frequent meals is the most therapeutic approach to addressing the nutritional needs of a client with anorexia nervosa.
The nursing professional development specialist facilitates selection by using the decision-making technique of:
A. Brainstorming
B. Consensus
C. Convergent thinking
D. Groupthink
Correct answer:
The correct answer is C: "Convergent thinking." Convergent thinking is a decision-making technique that involves narrowing down options to find the best solution or choice. In the context of selecting strategies or interventions for nursing professional development, the specialist would use convergent thinking to carefully evaluate and weigh different options before making a final decision. Brainstorming (option A) is a technique for generating ideas, not for making decisions. Consensus (option B) involves reaching a general agreement among group members, which may not always lead to the best choice. Groupthink (option D) is a phenomenon where group members prioritize harmony and conformity over critical evaluation of alternatives, which can lead to poor decision-making. Therefore, in facilitating selection processes, the nursing professional development specialist would utilize convergent thinking to make well-informed decisions based on thoughtful evaluation of available options.
A nurse is creating the plan of care for a client who is at 39 weeks of gestation and in active labor. Which of the following actions should the nurse include in the plan of care?
A. Keep four side rails up while the client is in bed.
B. Check the cervix prior to analgesic administration.
C. Monitor the fetal heart rate (FHR) every hour.
D. Insert an indwelling urinary catheter.
Correct answer:
The correct answer is B: 'Check the cervix prior to analgesic administration.' During active labor at 39 weeks of gestation, regular cervical checks are essential to monitor the progress of labor and ensure appropriate timing for analgesic administration. It is crucial to assess the cervix for dilation and effacement to determine the stage of labor and make informed decisions about pain management. Monitoring the fetal heart rate (FHR) every hour (option C) is important but not directly related to analgesic administration. Keeping four side rails up while the client is in bed (option A) is a safety measure to prevent falls but is not specifically related to labor management. Inserting an indwelling urinary catheter (option D) is usually avoided during labor unless medically necessary to reduce the risk of infection. Therefore, the most pertinent action in this scenario is to check the cervix before administering analgesia to optimize pain relief and labor progression.
A nurse is assessing a client with chronic pain. What should the nurse ask about the client\'s history?
A. Frequency and duration of pain episodes.
B. Family history of chronic pain.
C. Impact of pain on daily activities.
D. Previous pain management strategies.
Correct answer:
The correct answer is A: 'Frequency and duration of pain episodes.' When assessing a client with chronic pain, it is essential to understand the frequency and duration of pain episodes to gauge the severity and pattern of the pain. This information helps in determining the appropriate treatment plan and monitoring the effectiveness of interventions. Family history of chronic pain (option B) may provide some insight into potential genetic factors but is not as crucial for immediate assessment. While understanding the impact of pain on daily activities (option C) is important, it is more related to the current state of the client rather than historical information. Previous pain management strategies (option D) are relevant but do not provide as much insight into the current status of the client's pain as knowing the frequency and duration of pain episodes. Therefore, option A is the most pertinent question to ask when assessing a client with chronic pain.
A staff nurse who is promoted to assistant nurse manager may feel uncomfortable initially when supervising her former peers. She can best decrease this discomfort by:
A. Writing down all assignments
B. Making changes after evaluating the situation and having discussions with the staff
C. Telling the staff nurses that she is making changes to benefit their performance
D. Evaluating the clinical performance of each staff nurse in a private conference
Correct answer:
Option B is the best choice because it demonstrates effective leadership skills by involving the staff in the decision-making process. By evaluating the situation and having discussions with the staff before implementing changes, the assistant nurse manager can gain valuable input and buy-in from her team. This approach fosters collaboration, open communication, and mutual respect, which can help alleviate the discomfort of supervising former peers. Writing down all assignments (Option A) may be helpful for organization but does not address the underlying issue of discomfort. Telling staff nurses about changes (Option C) without involving them in the process may lead to resistance. Evaluating clinical performance in private conferences (Option D) can create tension and undermine team dynamics. Therefore, option B is the most effective way for the assistant nurse manager to decrease her discomfort and establish positive relationships with her team.
A nurse is caring for a client at 37 weeks and is undergoing a nonstress test. The FHR is 130 without accelerations for the past 10 min. What should the nurse do?
A. Use vibroacoustic stimulation on the client\'s abdomen for 3 seconds
B. Continue monitoring the FHR.
C. Notify the provider immediately.
D. Reposition the client to the left lateral position.
Correct answer:
In this scenario, the nonstress test is indicating a lack of fetal heart rate accelerations, which can be concerning as it may signify fetal hypoxia. Vibroacoustic stimulation is a method used to stimulate the fetus and provoke accelerations in the heart rate. By using vibroacoustic stimulation for a short duration, the nurse can attempt to elicit the desired response in the fetal heart rate. Continuing to monitor the FHR without any intervention may not address the current lack of accelerations. Notifying the provider immediately may be necessary in some cases, but attempting vibroacoustic stimulation first is the appropriate initial action. Repositioning the client to the left lateral position is a general measure that can help optimize fetal oxygenation but may not directly address the lack of accelerations. Therefore, the best course of action in this situation is to utilize vibroacoustic stimulation on the client's abdomen for 3 seconds.
.A nurse is providing discharge instructions to a client who has been prescribed escitalopram (Lexapro) for the treatment of depression. Which of the following instructions should the nurse include?
A. Take the medication at bedtime to avoid daytime drowsiness.
B. Avoid drinking alcohol while taking this medication.
C. Take the medication with food to avoid stomach upset.
D. Stop taking the medication if you feel better.
Correct answer:
The correct answer is B: 'Avoid drinking alcohol while taking this medication.' It is important for patients taking escitalopram to avoid alcohol as it can increase the risk of side effects such as drowsiness, dizziness, and impaired judgment. Alcohol can also worsen symptoms of depression and interfere with the effectiveness of the medication. Instructing the patient to avoid alcohol while on escitalopram is crucial for their safety and treatment outcomes. Taking the medication at bedtime (option A) may not be necessary for everyone and can be individualized based on the patient's response to the medication. While taking the medication with food (option C) can help reduce stomach upset, it is not as critical as avoiding alcohol. Option D is incorrect because abruptly stopping the medication can lead to withdrawal symptoms and a relapse of depression. Therefore, option B is the most important instruction to include in the discharge education.
A nurse is caring for a client who is in the transition phase of labor and reports a pain level of 7 on a scale of 0 to 10. Which of the following actions should the nurse take?
A. Instruct the client to use effleurage
B. Apply counter pressure to the client sacral.
C. Assist the client with patterned-paced breathing.
D. Teach the client the technique of biofeedback.
Correct answer:
The correct answer is B: "Apply counter pressure to the client's sacral." During the transition phase of labor, which is the most intense phase, the client experiences increased pain and pressure. Applying counter pressure to the sacral area can help relieve some of this pain and discomfort by providing support and reducing the intensity of contractions. Effleurage (choice A) involves light stroking movements and is more commonly used during the early stages of labor. Patterned-paced breathing (choice C) is a technique to help manage pain and stay focused during labor but may not be sufficient for a pain level of 7. Biofeedback (choice D) is a technique that helps individuals gain control over certain body functions, but it is not typically used for pain management during labor. Therefore, applying counter pressure to the sacral area is the most appropriate action to help alleviate the client's pain during the transition phase of labor.
A nurse is preparing to administer a medication from an ampule. Which of the following is an appropriate action for the nurse to make?
A. Inject air into the ampule prior to drawing the medication into a syringe.
B. Add 0.5 mL of diluent to the medication.
C. Cleanse the tip of the ampule with an alcohol swab after opening.
D. Use a filter needle to aspirate the medication.
Correct answer:
Using a filter needle to aspirate the medication from an ampule is the correct action to prevent glass particles or any potential contaminants from being drawn into the syringe. Filter needles have a membrane that filters out debris, ensuring the medication remains sterile and safe for administration. Injecting air into an ampule prior to drawing the medication (option A) is unnecessary and can increase the risk of contamination. Adding diluent to the medication (option B) is not appropriate for medication from an ampule, as ampules typically contain a single-dose of sterile medication. Cleaning the tip of the ampule with an alcohol swab after opening (option C) is important for preventing contamination but is not directly related to the process of aspirating the medication. Therefore, using a filter needle (option D) is the most appropriate and safe action for the nurse to take when preparing to administer medication from an ampule.
RN exams clinical judgment practice questions, set 114 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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