RN exams clinical judgment practice questions, set 122
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 122
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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
Screening at 24 weeks gestation reveals that a pregnant woman has gestational diabetes mellitus (GDM). In planning the woman9s care. The nurse and the woman mutually agree that an expected outcome is to prevent injury to the fetus due to the GDM. The nurse identifies that the fetus is at risk for which of the following?
A. Congenital anomalies of the central nervous system
B. Macrosomia
C. Preterm birth
D. Low birth weight
Show answer and rationale
Correct answer: B — Macrosomia
The correct answer is B: Macrosomia. Gestational diabetes mellitus (GDM) can lead to excessive fetal growth, known as macrosomia, due to the mother's elevated blood glucose levels passing to the fetus. This condition increases the risk of birth complications, such as shoulder dystocia and the need for a cesarean delivery. While congenital anomalies of the central nervous system (Option A) can occur in pregnancies affected by uncontrolled diabetes, the primary risk associated with GDM is fetal overgrowth rather than congenital malformations. Preterm birth (Option C) and low birth weight (Option D) are generally not primary risks associated with GDM. Therefore, the priority for preventing injury to the fetus in a woman with GDM is monitoring and managing the risk of macrosomia.
Question 2
A nurse is caring for a client who is 12 hr postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?
A. Orthostatic hypotension
B. Fundus palpable at the umbilicus
C. Urine output of 3,000 mL in 12 hr
D. Heart rate 110/min.
Show answer and rationale
Correct answer: D — Heart rate 110/min.
The correct answer is D. A heart rate of 110/min in a postpartum client 12 hours after delivery is concerning as it is higher than normal. Tachycardia can be a sign of postpartum complications such as hemorrhage or infection. The nurse should further assess the client's condition and notify the healthcare provider if necessary. Orthostatic hypotension (choice A) can be a common finding after delivery due to changes in blood volume and is not necessarily indicative of a complication. A fundus palpable at the umbilicus (choice B) is expected at 12 hours postpartum as it gradually descends. A urine output of 3,000 mL in 12 hours (choice C) is a high but not alarming amount, as increased urinary output is common after delivery to eliminate excess fluid retained during pregnancy.
Question 3
A graduate nurse is performing a discharge teaching for a client newly diagnosed with migraine headaches. Which statement made by the graduate nurse indicates a correct understanding of the disorder?
A. Auras are not a symptom present with migraines
B. Beta blockers are contraindicated in clients with migraines
C. Increasing stimulating activities during an episode will help resolve the migraines
D. Verapamil is not an abortive migraine medication but used to manage and prevent migraines.
Show answer and rationale
Correct answer: D — Verapamil is not an abortive migraine medication but used to manage and prevent migraines.
The correct answer is D. Verapamil is a calcium channel blocker commonly used to manage and prevent migraines by reducing the frequency and severity of episodes. It is not typically used as an abortive medication to treat acute migraine attacks. This statement shows a correct understanding of the medication's role in migraine management. Option A is incorrect because auras, which are sensory disturbances, can occur before or during a migraine. Option B is also incorrect as beta blockers are often used to prevent migraines. Option C is incorrect as increasing stimulating activities during a migraine can exacerbate symptoms. Therefore, the graduate nurse demonstrating an understanding of verapamil's role in migraine treatment indicates a correct understanding of the disorder.
Question 4
A nurse is caring for a client who is in the second stage of labor. Which of the following manifestations should the nurse expect?
A. The client expels the placenta
B. The client experiences gradual dilation of the cervix
C. The client begins have regular contractions.
D. The client delivers the newborn
Show answer and rationale
Correct answer: D — The client delivers the newborn
In the second stage of labor, the client will deliver the newborn. This stage begins with full dilation of the cervix and ends with the baby's birth. During this stage, the mother may experience intense contractions pushing the baby down the birth canal. The nurse should be prepared to assist the mother during delivery, including coaching her through pushing efforts and monitoring both the mother and baby for any signs of distress. Expulsion of the placenta occurs during the third stage of labor, not the second stage. Gradual dilation of the cervix is characteristic of the first stage of labor, particularly during the active phase. Regular contractions are a common sign of progress in labor, but specifically, in the second stage, the focus is on the delivery of the newborn.
Question 5
A nurse is instructing a client on the application of nitroglycerin transdermal patches. Which of the following statements by the client indicates an understanding of the teaching?
A. Apply once daily in the morning.
B. Remove the patch before showering.
C. Rotate application sites to prevent skin irritation.
D. Place the patch on the same spot each day.
Show answer and rationale
Correct answer: C — Rotate application sites to prevent skin irritation.
The correct answer is C: 'Rotate application sites to prevent skin irritation.' This statement shows an understanding of the importance of alternating the location of the nitroglycerin patch to prevent skin irritation or potential reactions. Applying the patch to the same spot each day can lead to skin irritation or even a decrease in effectiveness. It is crucial to rotate application sites to allow the skin to recover and reduce the risk of irritation. The other options are incorrect: A is not recommended as nitroglycerin patches are usually applied every 12-14 hours, B is incorrect as the patch should not be removed before showering unless specifically instructed by the healthcare provider, and D is incorrect as it goes against the principle of rotating application sites.
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Question 6
.A client with borderline personality disorder is admitted to the psychiatric unit. Which intervention should the nurse implement to promote the client\'s safety?
A. Implement a no-harm contract with the client.
B. Monitor the client closely for signs of self-harm.
C. Encourage the client to participate in recreational activities.
D. Encourage the client to maintain a structured daily routine.
Correct answer:
Implementing a no-harm contract with a client who has borderline personality disorder is a crucial intervention to promote their safety. This contract involves the client agreeing not to harm themselves and to seek help if they feel the urge to self-harm. By establishing this contract, the client is actively involved in their safety plan and has a clear agreement to prevent self-harm behaviors. Monitoring for signs of self-harm, as in option B, is important but not as proactive as having a concrete plan in place like a no-harm contract. Options C and D, encouraging recreational activities and maintaining a structured routine, are beneficial for overall mental health but may not directly address the immediate safety concerns of a client with borderline personality disorder.
The nurse is addressing condom use in the context of a health promotion workshop. When discussing the correct use of condoms, what should the nurse tell the attendees?
A. Attach the condom prior to erection.
B. A condom may be reused with the same partner if ejaculation has not occurred.
C. Use skin lotion as a lubricant if alternatives are unavailable.
D. Hold the condom by the cuff upon withdrawal.
Correct answer:
The correct answer is D: Hold the condom by the cuff upon withdrawal. This is important because holding the condom by the cuff helps prevent any potential spillage of bodily fluids. During withdrawal, holding the condom by the base prevents it from slipping off and minimizes the risk of exposure to sexually transmitted infections.
Explanation of why other choices are incorrect:
A: Attaching the condom prior to erection is incorrect as it may lead to breakage or slipping off during intercourse.
B: Reusing a condom with the same partner is highly discouraged due to the risk of breakage, reduced effectiveness, and potential exposure to infections.
C: Using skin lotion as a lubricant is not recommended as it can degrade the condom material, increasing the risk of breakage.
Nurse Mandy is preparing a client for magnetic resonance imaging (MRI) to confirm or rule out a spinal cord lesion. During the MRI scan, which of the following would pose a threat to the client?
A. The client lies still.
B. The client asks questions.
C. The client hears thumping sounds.
D. The client wears a watch and wedding band.
Correct answer:
Correct Answer: D (The client wears a watch and wedding band)
Rationale:
1. MRI machines use strong magnetic fields, which can interact with metal objects like a watch and wedding band, causing them to move or heat up.
2. Movement of metal objects can lead to injury to the client or interfere with the imaging process.
3. It is essential for the client to remove all metal objects before entering the MRI room to ensure safety and accurate imaging.
Summary:
A: The client lying still is important for a successful MRI scan and does not pose a threat.
B: Client asking questions does not pose a threat, as communication is normal during the procedure.
C: Hearing thumping sounds is a common experience during an MRI scan and does not pose a direct threat to the client.
A nurse works with a patient diagnosed with posttraumatic stress disorder (PTSD) who has frequent flashbacks as well as persistent symptoms of arousal. Which intervention should be included in the plan of care?
A. Trigger flashbacks intentionally in order to help the patient learn to cope with them.
B. Explain that the physical symptoms are related to the psychological state.
C. Encourage repression of memories associated with the traumatic event.
D. Support "numbing" as a temporary way to manage intolerable feelings.
Correct answer:
The correct answer is B, "Explain that the physical symptoms are related to the psychological state." This intervention helps the patient understand the connection between their physical symptoms and their psychological state, promoting self-awareness and insight. By recognizing this link, the patient can begin to identify triggers and develop coping strategies.
Choice A is incorrect because intentionally triggering flashbacks can be harmful and retraumatizing for the patient. Choice C is incorrect as encouraging repression of memories can worsen symptoms and hinder the healing process. Choice D is incorrect because supporting "numbing" as a coping mechanism may prevent the patient from processing and addressing underlying issues, leading to long-term negative effects.
Which of the following is an example of a correct way to write a blood pressure reading?
A. 0/70
B. 0+70
C. 0-70
D. 0*70
Correct answer:
The correct way to write a blood pressure reading is in the format of systolic pressure over diastolic pressure, with a slash (/) separating the two numbers. In this case, the correct answer is A: 0/70. The systolic pressure (top number) is always written first, followed by the diastolic pressure (bottom number). This format helps healthcare professionals quickly and accurately interpret the blood pressure reading.
Explanation of why the other choices are incorrect:
B: 0+70 - The plus sign is not the appropriate symbol to separate systolic and diastolic pressure.
C: 0-70 - The minus sign is not the correct symbol for indicating blood pressure readings.
D: 0*70 - The asterisk symbol is not used in blood pressure readings to separate systolic and diastolic pressure.
A patient tells the nurse, 'I can't go to any unit meetings because when I get in that room, everyone can hear my thoughts.' The nurse can correctly assess this symptom as:
A. concrete thinking.
B. loose associations.
C. thought broadcasting.
D. auditory hallucinations.
Correct answer:
The correct answer is C: thought broadcasting. This is when a person believes that others can hear their thoughts. In this scenario, the patient's belief that everyone in the unit meetings can hear their thoughts aligns with the symptom of thought broadcasting. It is a common manifestation of certain psychiatric disorders like schizophrenia.
Choice A, concrete thinking, refers to literal thinking without abstract reasoning and is not applicable in this context. Choice B, loose associations, involves disorganized and illogical thought patterns, which are not evident in the patient's statement. Choice D, auditory hallucinations, refers to hearing voices when no external stimulus is present, which is different from the patient's belief that others can hear their thoughts.
A nurse is assessing a client following an amniocentesis. Which of the following findings should the nurse recognize as complications? (Select all that apply.)
A. Amnionitis
B. Urinary tract infection
C. Polyhydramnios
D. Leakage of amniotic fluid
Correct answer:
The correct answer is A: "Amnionitis." Following an amniocentesis, the nurse should be aware of the potential complication of amnionitis, which is an infection of the amniotic fluid. This can lead to fever, uterine tenderness, maternal or fetal tachycardia, and foul-smelling or cloudy amniotic fluid. Urinary tract infection (option B) is not a direct complication of amniocentesis. Polyhydramnios (option C) refers to an excess of amniotic fluid and is not typically associated with amniocentesis. Leakage of amniotic fluid (option D) can occur as a result of amniocentesis, but it is not classified as a complication in this context. Therefore, the nurse should recognize amnionitis as a potential complication and monitor the client closely for signs and symptoms of infection.
.A nurse is caring for a client who has been diagnosed with major depressive disorder. Which is an appropriate short-term goal for the client?
A. The client will report a decrease in depressive symptoms.
B. The client will establish a sleep routine.
C. The client will improve social interactions.
D. The client will set realistic goals for the future.
Correct answer:
The correct answer is A because the primary focus in the short-term treatment of major depressive disorder is to alleviate the symptoms of depression. By setting a goal for the client to report a decrease in depressive symptoms, the nurse can monitor the effectiveness of the interventions and treatment plan. It is crucial to address the core symptoms of depression before focusing on other aspects like sleep routine, social interactions, or future goals. Once the depressive symptoms improve, the client may find it easier to engage in activities such as establishing a sleep routine, improving social interactions, or setting realistic goals for the future. Therefore, the immediate goal should be to reduce the client's depressive symptoms to enhance their overall well-being.
What is the primary concern when caring for a patient with bulimia nervosa who has been purging regularly?
A. Managing the patient's weight gain.
B. Assessing for complications related to electrolyte imbalances.
C. Encouraging exercise to offset caloric intake.
D. Promoting food restriction to control binge eating.
Correct answer:
The correct answer is B: Assessing for complications related to electrolyte imbalances. This is the primary concern when caring for a patient with bulimia nervosa who has been purging regularly because purging behaviors, such as self-induced vomiting or laxative abuse, can lead to severe electrolyte imbalances which can be life-threatening. Electrolyte imbalances can result in cardiac arrhythmias, muscle weakness, and other serious complications. Managing weight gain (A), encouraging exercise (C), and promoting food restriction (D) are not appropriate approaches as they can exacerbate the patient's unhealthy behaviors and may worsen their condition. It is crucial to prioritize assessing and addressing electrolyte imbalances to ensure the patient's safety and well-being.
During the examination of a patient in her third trimester of pregnancy, the nurse notices that the patient's thyroid gland is slightly enlarged. No enlargement had been noted previously. The nurse suspects that:
A. she has an iodine deficiency.
B. she is exhibiting early signs of goitre.
C. this is a normal finding during pregnancy.
D. further tests are needed for possible thyroid cancer.
Correct answer:
Step-by-step rationale for why choice C is correct:
1. Enlargement of the thyroid gland during pregnancy is a normal finding due to hormonal changes.
2. The thyroid gland enlarges to meet the increased demands of thyroid hormone production.
3. This condition is known as gestational thyrotoxicosis and is usually benign.
4. No further testing is needed for thyroid cancer unless other concerning symptoms are present.
Summary:
A: Not relevant as iodine deficiency is not typically associated with thyroid enlargement in pregnancy.
B: Incorrect as early signs of goitre would involve more pronounced symptoms than just slight enlargement.
D: Unnecessary as thyroid cancer is not a common concern in this scenario of a slightly enlarged thyroid in the third trimester of pregnancy.
RN exams clinical judgment practice questions, set 122 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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