RN exams clinical judgment practice questions, set 120
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 120
You notice cues, form a hypothesis, act, and evaluate — the same loop Next Generation items reward. Five of the 15 questions include the correct answer and rationale. The other ten keep answers in the study hub. Continue with the RN exams exam guide or more RN exams practice questions.
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 has a history of excessive drinking, which has led to multiple arrests for driving under the influence (DUI). The client states, \'I work hard to provide for my family. I don\'t see why I can\'t drink to relax.\' The nurse recognizes the use of which defense mechanism?
A. Projection
B. Rationalization
C. Regression
D. Sublimation
Show answer and rationale
Correct answer: B — Rationalization
The correct answer is B: Rationalization. Rationalization is a defense mechanism where individuals justify their unacceptable behaviors or feelings with logical reasons, often to avoid guilt or anxiety. In this scenario, the client is rationalizing their excessive drinking by mentioning their hard work to provide for their family. This rationalization allows the client to believe that drinking to relax is justified due to their perceived efforts in supporting their family. Projection involves attributing one's own undesirable traits or emotions to others; regression involves reverting to an earlier stage of development under stress; and sublimation is the channeling of unacceptable impulses into socially acceptable behaviors. Therefore, the most suitable defense mechanism in this case is rationalization.
Question 2
Which of the following is a function of the placenta?
A. Filter and block all substances from reaching the fetus
B. Stops estrogen production
C. Provide nutrition to the fetus
D. Provide antibiotics to the fetus
Show answer and rationale
Correct answer: C — Provide nutrition to the fetus
The correct answer is C: 'Provide nutrition to the fetus.' The placenta serves as a vital connection between the mother and the developing fetus, ensuring the transfer of essential nutrients such as oxygen, water, and nutrients from the mother's bloodstream to the fetus. It also aids in the removal of waste products and carbon dioxide from the fetal bloodstream. While the placenta does act as a barrier to some harmful substances, it does not filter and block all substances completely. Additionally, the placenta does not provide antibiotics but rather helps protect the fetus from infections by transferring maternal antibodies. Overall, the placenta's primary role is to facilitate the exchange of nutrients and waste products between the mother and the fetus, supporting the fetus's growth and development.
Question 3
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.
Show answer and rationale
Correct answer: A — Frequency and duration of pain episodes.
When assessing a client with chronic pain, understanding the frequency and duration of pain episodes is crucial as it provides insight into the nature and severity of the pain. This information helps the nurse determine the appropriate interventions and treatment options for the client. Family history of chronic pain (option B) may provide some context but focusing on the client's current experience is more immediate. The impact of pain on daily activities (option C) is important to assess but does not directly address the history of the pain. Previous pain management strategies (option D) are relevant, but understanding the current status of pain episodes takes precedence in the assessment process. Therefore, option A is the most appropriate choice for assessing the client's history of chronic pain.
Question 4
Nursing interventions that can help the patient to relax and sleep restfully include all of the following except:
A. Have the patient take a 30- to 60-minute nap in the afternoon
B. Turn on the television in the patient’s room
C. Provide quiet music and interesting reading material
D. Massage the patient’s back with long strokes
Show answer and rationale
Correct answer: A — Have the patient take a 30- to 60-minute nap in the afternoon
The correct answer is option B: 'Turn on the television in the patient's room.' While providing quiet music and interesting reading material, as mentioned in option C, can help the patient relax and sleep restfully by creating a calming environment, turning on the television can have the opposite effect. Television can be stimulating and disrupt sleep patterns due to the bright lights and engaging content. Option A suggests having the patient take a nap in the afternoon, which can actually improve restfulness and relaxation for the patient. Similarly, option D of massaging the patient's back with long strokes can promote relaxation and improve sleep quality by reducing muscle tension. Therefore, turning on the television is the exception as it may hinder rather than aid relaxation and restful sleep.
Question 5
A nurse is reviewing signs of effective breastfeeding with a client who is 5 days postpartum. Which of the following information should the nurse include in the teaching?
A. You should feel a tugging sensation when the baby is sucking.
B. You should expect your baby to have two to three wet diapers in 24 hour period
C. Your baby\'s urine should appear dark and concentrated.
D. Your breast should stay firm after the baby breastfeeds.
Show answer and rationale
Correct answer: A — You should feel a tugging sensation when the baby is sucking.
The correct answer is A: "You should feel a tugging sensation when the baby is sucking." This is an important sign of effective breastfeeding as it indicates that the baby is latched on properly and actively feeding. Feeling a tugging or pulling sensation is normal and shows that the baby is actively sucking and stimulating milk flow. This sensation is a positive sign that the baby is effectively extracting milk from the breast. Options B, C, and D are incorrect because expecting the baby to have two to three wet diapers in a 24-hour period, dark and concentrated urine, and firm breasts after breastfeeding are not indications of successful breastfeeding. It is crucial for the nurse to educate the client on these signs to ensure successful breastfeeding and the well-being of both the mother and baby.
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Question 6
.A client with bipolar disorder is in the manic phase. Which nursing intervention should the nurse implement to ensure the client\'s safety?
A. Provide a structured environment with minimal stimuli.
B. Encourage the client to participate in group activities.
C. Monitor the client closely for signs of exhaustion.
D. Encourage the client to rest and sleep as needed.
Correct answer:
The correct answer is A: 'Provide a structured environment with minimal stimuli.' During the manic phase of bipolar disorder, individuals may experience heightened energy levels, impulsivity, and decreased need for sleep. Providing a structured environment with minimal stimuli can help reduce potential triggers for increased agitation or impulsivity. This intervention aims to create a predictable and calming atmosphere to promote the client's safety and well-being. Encouraging the client to participate in group activities (option B) may exacerbate their symptoms, while monitoring for signs of exhaustion (option C) is important but not the primary intervention during the manic phase. Encouraging the client to rest and sleep as needed (option D) may be challenging due to their increased energy levels.
An 84-year-old patient is admitted to the hospital because of kidney stones. The patient is in acute pain. Which statement about administering analgesics to the elderly is accurate?
A. The patient will require careful monitoring for side effects.
B. The patient should receive a higher dose because of increased tolerance.
C. The patient should receive the same dose as a younger adult.
D. The patient will require less frequent dosing.
Correct answer:
The correct answer is A: 'The patient will require careful monitoring for side effects.' This is because elderly patients are more susceptible to the side effects of analgesics due to age-related changes in metabolism and organ function. Monitoring is crucial to prevent adverse reactions or complications. Option B is incorrect as elderly patients may require lower doses due to age-related changes in drug metabolism and increased sensitivity. Option C is incorrect as dosing for elderly patients may need adjustments based on factors like organ function and overall health. Option D is incorrect as elderly patients may require more frequent dosing due to altered drug metabolism and clearance. Therefore, careful monitoring for side effects is essential when administering analgesics to elderly patients.
.A nurse is assessing a client who has been diagnosed with major depressive disorder. The client states, \'I feel like I can\'t go on.\' Which of the following actions should the nurse take first?
A. Administer a prescribed antidepressant medication.
B. Ask the client if they have a plan to commit suicide.
C. Encourage the client to attend a support group.
D. Contact the client\'s family to provide support.
Correct answer:
The correct action for the nurse to take first when a client expresses feeling like they can't go on due to major depressive disorder is to ask the client if they have a plan to commit suicide (option B). This is a critical step in assessing the client's risk and ensuring their safety. Understanding if the client has a specific plan for suicide can help determine the level of intervention needed, such as hospitalization or increased monitoring. Administering antidepressant medication (option A) may be part of the treatment plan but is not the immediate priority in this situation. Encouraging the client to attend a support group (option C) and contacting the client's family for support (option D) are also important but assessing the client's risk of suicide takes precedence to ensure their safety.
.A nurse is evaluating a client\'s progress in psychotherapy. Which is an appropriate outcome for the client?
A. The client will identify triggers for anxiety.
B. The client will develop coping strategies.
C. The client will decrease avoidance behaviors.
D. The client will express feelings of anger.
Correct answer:
The correct answer is A because identifying triggers for anxiety is an important step in managing and overcoming anxiety in psychotherapy. By recognizing specific situations or thoughts that lead to anxiety, the client can work with the therapist to develop coping strategies and address these triggers effectively. Options B and C are also important outcomes in psychotherapy, but identifying triggers for anxiety is a more foundational goal that can help in the development of coping strategies and decreasing avoidance behaviors. Option D, expressing feelings of anger, may be a part of the therapeutic process but is not directly related to the evaluation of progress in psychotherapy. Therefore, the most appropriate outcome for the client to focus on at this stage is identifying triggers for anxiety.
The nurse is preparing a teaching plan for a client with migraine headaches who has been prescribed a beta blocker daily to help manage this disorder. Which instructions would be appropriate to relay to this client?
A. Take this drug only when you have prodromal symptoms indicating the onset of a migraine headache.
B. Assess the patient\'s level of fatigue.
C. Evaluate the complete blood count (CBC).
D. Use a pulse oximeter on the patient\'s ear lobe.
Correct answer:
Option B is the correct answer because assessing the patient's level of fatigue is relevant when taking a beta blocker for migraine headaches. Beta blockers can cause side effects such as fatigue, so monitoring fatigue levels can help in evaluating the medication's effectiveness and managing potential adverse effects. Options A, C, and D are not appropriate instructions for a client prescribed a beta blocker for migraine headaches. Option A suggests using the drug as needed, which is not how beta blockers are typically taken for migraine prevention. Option C, evaluating the complete blood count, is not directly related to beta blocker use for migraines. Option D, using a pulse oximeter on the patient's ear lobe, is not relevant to monitoring the effects of beta blockers for migraine headaches.
.A nurse is preparing a teaching plan for a client with generalized anxiety disorder. Which information should the nurse include?
A. Avoiding caffeine and other stimulants
B. Engaging in regular physical activity
C. Practicing relaxation techniques
D. Keeping a journal of anxiety triggers
Correct answer:
The correct answer is C: Practicing relaxation techniques. Generalized anxiety disorder is characterized by excessive worry and tension. Teaching the client relaxation techniques, such as deep breathing exercises or progressive muscle relaxation, can help manage anxiety levels. These techniques promote a sense of calm and can be used whenever the client feels anxious. Avoiding caffeine and stimulants (choice A) can also be helpful as they can exacerbate anxiety symptoms. Engaging in regular physical activity (choice B) is beneficial for overall mental health but may not directly address anxiety symptoms. Keeping a journal of anxiety triggers (choice D) can be a useful tool for identifying patterns, but actively practicing relaxation techniques is more directly therapeutic for managing anxiety.
A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?
A. Early decelerations
B. Accelerations
C. Late decelerations
D. Variable decelerations
Correct answer:
The correct answer is D: 'Variable decelerations.' Variable decelerations in the fetal heart rate monitor tracing can indicate issues with the umbilical cord. These decelerations are abrupt and variable in shape, depth, and duration, often resembling a 'V' or 'W' shape. They are typically caused by umbilical cord compression, which can lead to decreased oxygen supply to the fetus. It is essential for the nurse to recognize variable decelerations promptly and take appropriate interventions to relieve the cord compression, such as changing the mother's position or providing oxygen. Early decelerations (A) are a response to head compression during contractions, accelerations (B) are reassuring signs of fetal well-being, and late decelerations (C) are associated with uteroplacental insufficiency.
The nurse differentiates the humoral response from the cell-mediated response in that in the cell-mediated response:
A. the sensitized lymphocytes attack the cell for which they were sensitized.
B. cells produce new antibodies
C. the response does not occur until the white blood cell (WBC) count rises.
D. there is a systemic response of fever and malaise
Correct answer:
In the cell-mediated response, sensitized lymphocytes directly attack and destroy the specific target cells, such as infected or cancerous cells. This is a key difference from the humoral response, where antibodies produced by B cells circulate in the bloodstream to neutralize pathogens. The cell-mediated response does not require the production of new antibodies (option B) as it relies on the activity of cytotoxic T cells. Option C is incorrect because the cell-mediated response can occur independently of the total white blood cell count. Option D describes the general symptoms of an immune response, but it is not specific to the mechanism of the cell-mediated response. Therefore, option A is the correct answer as it accurately characterizes the process of the cell-mediated immune response.
A nurse is providing discharge teaching to a new parent about car seat safety. Which of the following statements by the parent indicates an understanding of the teaching?
A. I should position my baby\'s car seat at a 45-degree angle in the car.
B. I should place the car seat rear facing until my baby is 12 months old.
C. I should place the harness snugly in a slot above my baby\'s shoulders.
D. I should position the retainer clip at the top of my baby\'s abdomen.
Correct answer:
The correct answer is B. Placing the car seat rear facing until the baby is 12 months old or reaches the maximum weight or height limit recommended by the manufacturer is essential for safety. Rear-facing seats provide the best protection for infants in the event of a crash by supporting the head, neck, and spine. A 45-degree angle is generally recommended for newborns to prevent their head from falling forward and obstructing the airway. Placing the harness above the baby's shoulders ensures a secure fit and prevents slippage in the event of a crash. Positioning the retainer clip at the armpit level, rather than the top of the abdomen, helps to secure the harness properly and prevent injury. Therefore, option B is the most accurate statement indicating an understanding of car seat safety.
.A nurse is caring for a client who has been diagnosed with post-traumatic stress disorder (PTSD). The client states, \'I can\'t sleep at night because I keep having nightmares about the event.\' Which of the following actions should the nurse take first?
A. Encourage the client to talk about the event during the day.
B. Encourage the client to avoid caffeine and alcohol.
C. Administer a prescribed sedative at bedtime.
D. Schedule a follow-up appointment with the client\'s therapist.
Correct answer:
The correct answer is A: 'Encourage the client to talk about the event during the day.' This is the most appropriate initial action because it allows the client to process and express their feelings in a safe environment, which can help decrease the intensity of nightmares. Talking about the traumatic event during the day can also facilitate the processing of emotions and memories, potentially reducing the frequency of nightmares. It is important for the nurse to create a supportive and non-judgmental space for the client to share their experiences. Encouraging daytime discussion can also help the client feel more in control and may lead to improved sleep patterns over time. The other options, while important in managing PTSD symptoms, are not the first-line interventions in this scenario.
RN exams clinical judgment practice questions, set 120 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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