RN exams clinical judgment practice questions, set 119
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 119
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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 with bipolar disorder is experiencing a depressive episode. Which intervention should the nurse implement to support the client\'s recovery?
A. Encourage the client to engage in physical activity.
B. Encourage the client to maintain a regular sleep schedule.
C. Encourage the client to set realistic goals for daily activities.
D. Encourage the client to express feelings of sadness.
Show answer and rationale
Correct answer: C — Encourage the client to set realistic goals for daily activities.
The correct answer is C: 'Encourage the client to set realistic goals for daily activities.' During a depressive episode in bipolar disorder, individuals may struggle with feelings of worthlessness and low energy, making it challenging to engage in tasks. By assisting the client in setting achievable goals, the nurse can provide structure and a sense of accomplishment, which can help improve mood and motivation. Encouraging physical activity (option A) can be beneficial but may be difficult for a client experiencing depressive symptoms. Maintaining a regular sleep schedule (option B) is important, but setting goals can address the broader range of symptoms associated with depression. Expressing feelings of sadness (option D) is important, but it is not a proactive intervention to support recovery from a depressive episode.
Question 2
A nurse is preparing a client for a colonoscopy. What instructions should the nurse give?
A. Eat a light breakfast the day of the procedure.
B. Drink clear liquids 24 hours before the procedure.
C. Take a laxative the night before the procedure.
D. Refrain from all food and drink 12 hours before the procedure.
Show answer and rationale
Correct answer: B — Drink clear liquids 24 hours before the procedure.
The correct answer is B: "Drink clear liquids 24 hours before the procedure." This instruction is important before a colonoscopy to ensure the colon is adequately cleaned out for accurate examination. Drinking clear liquids helps clear the colon of any remaining stool, making it easier for the healthcare provider to visualize the colon during the procedure. Eating a light breakfast (option A) the day of the procedure may introduce solid food particles into the colon, hindering the examination process. Taking a laxative the night before (option C) helps with bowel cleansing, but clear liquid intake is also necessary. Refraining from all food and drink 12 hours before the procedure (option D) is not typically required for a colonoscopy. Therefore, the best instruction is to drink clear liquids 24 hours before the procedure.
Question 3
A nurse is planning care for a client who is receiving oxytocin by continuous IV infusion for labor induction. Which of the following interventions should the nurse include in the plan?
A. Increase the infusion rate every 30 to 60 min.
B. Maintain the client in a supine position.
C. Titrate the infusion rate by 4 milliunits/min.
D. Limit IV intake to 4 L per 24 hr.
Show answer and rationale
Correct answer: A — Increase the infusion rate every 30 to 60 min.
The correct answer is A: 'Increase the infusion rate every 30 to 60 min.' Oxytocin is a medication commonly used for labor induction. The nurse must monitor the client's response to oxytocin closely and adjust the infusion rate as needed to achieve optimal uterine contractions. Increasing the infusion rate at regular intervals allows for a gradual titration of the medication to achieve the desired effect while minimizing the risk of adverse effects. Options B and D are incorrect because maintaining the client in a supine position and limiting IV intake to 4 L per 24 hr are not specific interventions related to oxytocin infusion for labor induction. Option C is incorrect because titrating the infusion rate by 4 milliunits/min is not a general recommendation and does not account for individual client responses or needs.
Question 4
Which of the following is the primary purpose of the use of standard precautions?
A. To protect patients from hospital-acquired infections
B. To protect patients from themselves
C. To protect healthcare workers and patients from infection
D. To protect healthcare workers from injury
Show answer and rationale
Correct answer: C — To protect healthcare workers and patients from infection
The correct answer is C. The primary purpose of the use of standard precautions is to protect both healthcare workers and patients from infections. Standard precautions are a set of infection control practices to prevent the transmission of infectious diseases in healthcare settings. These precautions include practices such as hand hygiene, the use of personal protective equipment, safe injection practices, and proper handling of potentially infectious materials. By following standard precautions, healthcare workers can reduce the risk of spreading infections to patients and can also protect themselves from acquiring infections from patients. Therefore, the main goal of standard precautions is to ensure the safety and well-being of both healthcare workers and patients by minimizing the risk of infection transmission.
Question 5
A nurse is caring for a client who is in labor and requests nonpharmacological pain management. Which of the following nursing actions promotes client comfort?
A. Assisting the client into squatting position
B. Having the client lie in a supine position
C. Applying fundal pressure during contractions
D. Encouraging the client to void every 6 hr.
Show answer and rationale
Correct answer: A — Assisting the client into squatting position
The correct answer is A: Assisting the client into a squatting position. During labor, squatting can help relieve pressure on the pelvis and may open the pelvic outlet, aiding in the descent of the baby. This position can also help widen the pelvic diameter, potentially reducing the intensity of contractions. Additionally, squatting can facilitate the rotation of the baby's head, which may help progress labor. Lying in a supine position (option B) can compress blood vessels, reducing blood flow to the uterus and potentially increasing discomfort. Applying fundal pressure during contractions (option C) is not recommended as it can increase the risk of uterine rupture. Encouraging the client to void every 6 hours (option D) is important for bladder emptying but is not directly related to promoting comfort during labor.
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Question 6
A nurse is caring for a child who has a history of seizures. Which of the following precautions should the nurse implement?
A. Place the child in a room near the nurses\' station.
B. Ensure the child has a private room.
C. Allow the child to roam freely.
D. Pad the side rails of the bed.
Correct answer:
The correct answer is D. Padding the side rails of the bed is important for a child with a history of seizures to prevent injury during a seizure episode. This precaution helps ensure the child's safety by minimizing the risk of hitting or injuring themselves on the hard rails. Placing the child in a room near the nurses' station (option A) may facilitate quick response in case of an emergency but does not directly address the safety of the child during a seizure. Providing a private room (option B) may offer comfort and privacy but is not a necessary precaution for seizure management. Allowing the child to roam freely (option C) without supervision increases the risk of injury if a seizure occurs. Therefore, padding the side rails of the bed is the most appropriate precaution to protect the child during a seizure.
.A nurse is providing education to the family of a client who has been diagnosed with dissociative identity disorder. Which of the following instructions should the nurse include?
A. Encourage the client to avoid stressful situations.
B. Encourage the client to participate in daily activities.
C. Encourage the client to express their feelings.
D. Encourage the client to develop a daily routine.
Correct answer:
The correct answer is not listed among the options provided. Dissociative identity disorder (DID) is a complex mental health condition where a person experiences two or more distinct identities or personality states. The nurse should educate the family to create a safe and supportive environment for the client. Encouraging the client to attend therapy sessions regularly, follow a structured routine, communicate openly with healthcare providers, and engage in activities that promote self-care and stress management are crucial. Therefore, the family should be instructed to support the client in maintaining a consistent daily routine, attending therapy sessions, and fostering open communication with healthcare providers. These strategies can help the client manage their symptoms and improve their overall well-being.
Which behavior is most likely to encourage open communication?
A. Speaking with minimal eye contact
B. Directing the patient in healthcare decisions
C. Listening and reflecting patient feelings
D. Giving advice and telling the patient what to do
Correct answer:
The behavior that is most likely to encourage open communication is listening and reflecting patient feelings (option C). By actively listening to the patient and reflecting their emotions, healthcare providers demonstrate empathy and understanding, which can help build trust and rapport. This approach creates a safe space for patients to express themselves openly and honestly, leading to more effective communication and better patient outcomes. Speaking with minimal eye contact (option A) may convey disinterest or lack of attention. Directing the patient in healthcare decisions (option B) can be perceived as controlling and may inhibit open dialogue. Giving advice and telling the patient what to do (option D) can hinder the patient's autonomy and may discourage them from sharing their true thoughts and feelings.
A nurse is caring for a client in active labor and has meconium-stained fluid. The nurse notes a reassuring FHR tracing from the external fetal monitor. What should the nurse do?
A. Prepare equipment needed for newborn resuscitation.
B. Administer an amnioinfusion.
C. Continue with routine monitoring.
D. Notify the healthcare provider immediately.
Correct answer:
The correct answer is A: 'Prepare equipment needed for newborn resuscitation.' Meconium-stained amniotic fluid can indicate fetal distress as it may lead to meconium aspiration syndrome in the newborn. Even though the FHR tracing is reassuring currently, being prepared for any potential complications is crucial. Meconium aspiration can result in respiratory distress in the newborn, so having resuscitation equipment ready is essential for prompt intervention if needed. Administering an amnioinfusion (choice B) may be indicated in cases of oligohydramnios but is not the priority in this situation. Continuing with routine monitoring (choice C) may delay necessary interventions. Notifying the healthcare provider immediately (choice D) is important but should be done after preparing for potential resuscitation needs.
A nurse is assisting in the transfer of a client who has left-side weakness from a bed to chair. Which of the following actions should the nurse take?
A. Flex hips and knees when assisting the client to a standing position
B. Pivot on the foot farthest from the bed when assisting the client into the chair
C. Raise the bed to waist level before moving the client
D. Stand on the client’s stronger side when moving the client into the chair
Correct answer:
The correct action for the nurse to take when assisting a client with left-side weakness from a bed to a chair is to flex the client's hips and knees when helping them to a standing position. This technique helps to provide additional support and stability to the client during the transfer. By flexing the hips and knees, the nurse can assist the client in maintaining their balance and prevent falls. Option B, pivoting on the foot farthest from the bed, may not provide adequate support for the client with left-side weakness. Option C, raising the bed to waist level, is not directly related to the transfer process. Option D, standing on the client's stronger side, may not provide optimal support for the client's weaker side. Therefore, option A is the most appropriate action for the nurse to take in this scenario.
A nurse is caring for a client who is taking acetazolamide for chronic open-angle glaucoma. For which of the following adverse effects should the nurse instruct the client to monitor and report?
A. Monitor for decreased appetite.
B. Watch for signs of hypokalemia.
C. Look for any visual disturbances.
D. Assess for tinnitus.
Correct answer:
The correct answer is A: "Monitor for decreased appetite." Acetazolamide is a diuretic medication commonly used to treat glaucoma by reducing intraocular pressure. One of the common side effects of acetazolamide is loss of appetite or decreased appetite. This adverse effect may lead to weight loss and nutritional deficiencies if not addressed. Monitoring for changes in appetite is crucial to ensure the client's overall well-being. While hypokalemia (B) and visual disturbances (C) can be potential side effects of acetazolamide, decreased appetite is a more common and specific adverse effect associated with this medication. Tinnitus (D) is not a typical adverse effect of acetazolamide. Therefore, the nurse should instruct the client to monitor and report any changes in appetite to address this common side effect.
Which best describes the purpose of therapeutic communication?
A. To encourage the patient to express feelings
B. To teach the patient about illness
C. To increase the patient\'s knowledge base
D. To develop a positive nurse-patient relationship
Correct answer:
The purpose of therapeutic communication is to encourage the patient to express their feelings, thoughts, and concerns openly. This type of communication helps build trust, fosters a supportive environment, and allows the healthcare provider to better understand the patient's needs. By actively listening and providing empathy, the nurse can create a safe space for the patient to share their emotions and experiences, leading to improved outcomes and a stronger nurse-patient relationship. Teaching about illness (option B) and increasing knowledge base (option C) are important aspects of patient education but not the primary purpose of therapeutic communication. Developing a positive nurse-patient relationship (option D) is a potential outcome of effective therapeutic communication, but it is not the sole purpose.
.A psychiatric nurse observes that a client diagnosed with schizophrenia is pacing up and down the corridor. The client is muttering to himself, and his hands are trembling. Which of the following actions should the nurse take first?
A. Ask the client if he is hearing voices.
B. Offer the client a PRN medication for anxiety.
C. Encourage the client to participate in a relaxation exercise.
D. Remove the client to a quieter environment.
Correct answer:
The correct answer is D: 'Remove the client to a quieter environment.' In this situation, the client's behavior indicates distress and potential exacerbation of symptoms. Pacing, muttering, and trembling hands suggest the client may be experiencing increased anxiety or agitation. Moving the client to a quieter environment can help reduce stimuli that may be triggering or aggravating the symptoms of schizophrenia. This action prioritizes the client's immediate needs for a more calming and less overwhelming space, promoting their well-being and potentially preventing escalation of symptoms. It is important to address the environmental factors first before exploring further interventions such as medication or relaxation exercises, as these may not be as effective if the client is in a distressing environment.
A nurse is caring for a client who is in labor and has an epidural anesthesia block. The client\'s blood pressure is 80/40 mmHg, and the fetal heart rate is 140/min. Which of the following is the priority nursing action?
A. Elevate the client\'s legs.
B. Monitor vital signs every 5 min.
C. Notify the provider.
D. Place the client in a lateral position.
Correct answer:
The correct answer is D: 'Place the client in a lateral position.' When a client with epidural anesthesia block experiences hypotension (blood pressure 80/40 mmHg), it is essential to prioritize improving blood flow to the placenta by positioning the client in a lateral position to enhance venous return to the heart and increase blood pressure. This position helps prevent supine hypotensive syndrome and improves fetal perfusion. Elevating the client's legs may not be effective in this situation and could potentially worsen the hypotension. While monitoring vital signs is important, immediate action to address the hypotension is crucial. Notifying the provider can be done after stabilizing the client's condition. Thus, placing the client in a lateral position is the priority nursing action in this scenario.
A nurse is caring for four clients. For which of the following clients should the nurse auscultate the fetal heart rate during the prenatal visit?
A. A client who has an ultrasound that confirms a molar pregnancy
B. A client who has a crown-rump length of 7 weeks gestation
C. A client who has a positive urine pregnancy test 1 week after missed menses
D. A client who has felt quickening for the first time
Correct answer:
The correct answer is D because feeling quickening, or the baby's first movements, is a subjective sign of fetal well-being. It indicates fetal viability and activity, making it appropriate for the nurse to auscultate the fetal heart rate during the prenatal visit for this client. Options A, B, and C do not necessarily indicate current fetal well-being or the need for immediate fetal heart rate assessment. A molar pregnancy (A) is not a viable pregnancy, crown-rump length (B) is a measurement used in early pregnancy but does not indicate immediate need for fetal heart rate auscultation, and a positive urine pregnancy test (C) alone does not provide real-time information on fetal well-being. Therefore, option D is the most appropriate choice for auscultating the fetal heart rate during the prenatal visit.
RN exams clinical judgment practice questions, set 119 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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