RN exams clinical judgment practice questions, set 123
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 123
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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
The nurse is caring for a patient whose ventilator settings i nclude 15 cm H O of positive end-expiratory pressure (PEEP). The nurse understands that although beneficial, PEEP may result in what possible problem?
A. Fluid overload secondary to decreased venous return.
B. High cardiac index secondary to more efficient ventric ular function.
C. Hypoxemia secondary to prolonged positive pressure a t expiration.
D. Low cardiac output secondary to increased intrathoracic pressure
Show answer and rationale
Correct answer: D — Low cardiac output secondary to increased intrathoracic pressure
Rationale for Correct Answer (D - Low cardiac output secondary to increased intrathoracic pressure):
1. PEEP increases intrathoracic pressure, which can impede venous return to the heart.
2. Impaired venous return reduces preload, leading to decreased cardiac output.
3. Decreased cardiac output can result in inadequate tissue perfusion and oxygenation.
4. Therefore, PEEP may cause low cardiac output due to increased intrathoracic pressure.
Summary of Incorrect Choices:
A. Fluid overload is not directly related to PEEP but more to fluid administration or kidney function.
B. High cardiac index is unlikely as PEEP can decrease cardiac output.
C. Hypoxemia is not a direct result of PEEP but may occur due to other factors like inadequate ventilation or oxygenation settings.
Question 2
A 34 year old male patient consulted a doctor about face carbuncle. Objectively: a loose, painless edema of hypodermic tissue; black crust in the center of carbuncle, vesicular rash around it. Microbiological examination revealed static streptobacilli capable of capsule building. What microorganisms are the causative agents of this disease?
A. Bacillus antracis
B. Staptylococcus aureus
C. Bacillus subtilis
D. Bacillus anthracoides
Show answer and rationale
Correct answer: B — Staptylococcus aureus
The correct answer is B: Staphylococcus aureus. This bacterium is a common causative agent of skin infections like carbuncles. Staphylococcus aureus is known for its ability to produce pus-filled abscesses, which aligns with the symptoms described in the question. The presence of a vesicular rash around the carbuncle further supports this diagnosis, as Staphylococcus aureus can cause skin lesions. The other choices are not correct because:
A: Bacillus anthracis causes anthrax, which presents with different symptoms such as fever, malaise, and respiratory symptoms.
C: Bacillus subtilis is a harmless soil bacterium commonly used in research and not known to cause skin infections.
D: Bacillus anthracoides is not a known pathogen and is not associated with human infections.
Question 3
Parents have requested that their child be brought up to date on appropriate immunizations. After reviewing the child’s medical history, the nurse prepares to give the two immunizations. What additional action should be taken by the nurse before administration of the immunization?
A. Ask if there is any chance the girl child could be pregnant
B. Ask the child if she consents to the immunizations
C. Assess whether the child has a fever or other illness that would require the immunization be postponed
D. Explain the pros and cons of obtaining immunizations to the parents
Show answer and rationale
Correct answer: E
The Centers for Disease Control and Prevention produces VISs that explain the benefits and risks of vaccine to vaccine recipients, their parents, or their legal representatives. Federal law requires that VISs be handed out whenever (before each dose) certain vaccinations are given. Because the parents have previously had the child receive immunizations, they clearly have chosen to continue with immunizations so they do not need to hear the pros and cons of children being immunized. Children cannot give consent, only assent, to procedures. Because the child is a minor, the child’s parents make the decisions. [Note: The document lists E as the answer, implying an unlisted option: 'Give the parents the Vaccine Information Statement (VIS)', which aligns with the rationale.]
Question 4
Primary level of prevention is exemplified by:
A. Helping the client resume self-care.
B. Ensuring the safety of a suicidal client in the institution.
C. Teaching the client stress management techniques
D. Case finding and surveillance in the community
Show answer and rationale
Correct answer: C — Teaching the client stress management techniques
Primary prevention aims to prevent the occurrence of a health issue before it happens. Teaching stress management techniques (Choice C) falls under this category by addressing stress before it leads to health problems. This approach targets the root cause and promotes overall well-being.
Choice A (Helping the client resume self-care) focuses on rehabilitation and is considered secondary prevention. Choice B (Ensuring the safety of a suicidal client) relates to crisis intervention, which is tertiary prevention. Choice D (Case finding and surveillance) is more aligned with early detection and is also secondary prevention. In summary, teaching stress management techniques is the best example of primary prevention as it addresses the issue proactively before it escalates.
Question 5
What assessment is most important for the nurse to perform for a client with dehydration receiving IV fluids?
A. Monitor the client's electrolyte levels.
B. Check the client's urine output hourly.
C. Assess the client's skin turgor regularly.
D. Monitor the client's blood pressure every 15 minutes.
Show answer and rationale
Correct answer: A — Monitor the client's electrolyte levels.
The correct answer is to monitor the client's electrolyte levels. When a client is receiving IV fluids for dehydration, it is crucial to assess their electrolyte levels regularly. Dehydration can lead to imbalances in electrolytes, especially sodium and potassium, which are essential for maintaining fluid balance and proper organ function. Checking urine output (Choice B) is important but not as critical as monitoring electrolyte levels. Assessing skin turgor (Choice C) is an indirect method of assessing dehydration but does not provide specific information about electrolyte imbalances. Monitoring blood pressure (Choice D) is important but not the most critical assessment in this scenario as electrolyte imbalances can have a more direct impact on the client's condition.
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Question 6
A 38-week pregnant patient in active labor is experiencing frequent and painful contractions. What is the most appropriate action for the nurse?
A. Administer narcotic analgesics for pain relief
B. Provide emotional support and reassurance
C. Assess the fetal heart rate and contraction patterns
D. Prepare for delivery
Correct answer:
The correct answer is D: Prepare for delivery. At 38 weeks of gestation and in active labor, the most appropriate action is to prepare for delivery as the patient is likely to be close to giving birth. This involves ensuring that all necessary equipment and supplies are ready, notifying the healthcare team, and positioning the patient for delivery. Administering narcotic analgesics (choice A) may not be ideal at this stage as the priority is the imminent delivery. While emotional support and reassurance (choice B) are important, they should be provided alongside preparing for delivery. Assessing the fetal heart rate and contraction patterns (choice C) is crucial but should be done concurrently with preparing for delivery to ensure the safety of both the mother and baby.
Which description of disease activity in a single area corresponds to endemic levels of disease?
A. There are usually 20–30 cases each week, and this past week there were 29 cases.
B. There are usually fewer than 20 cases per year, and this past week there were 2 cases.
C. There are usually up to 10 cases per week, and this past week there were 40 cases.
D. There are usually 100,000 cases worldwide each month, and this past month there were 10 million
Correct answer:
Rationale for Correct Answer A:
- Endemic levels refer to consistent, expected rates of disease in a specific area.
- Choice A states there are usually 20-30 cases each week, consistent with endemic levels.
- The fact that there were 29 cases this past week aligns with the usual range, indicating endemicity.
- This means the disease is consistently present in that area without significant spikes or drops.
Summary of Incorrect Choices:
- Choice B: The usual rate in this choice is much lower than endemic levels, making it unlikely to be endemic.
- Choice C: The usual rate is exceeded significantly in the past week, indicating an outbreak rather than endemicity.
- Choice D: The global scale mentioned is not relevant to determining endemic levels in a single area.
Which nursing activity demonstrates the role of a professional psychiatric nurse as identified by Hildegard Peplau?
A. Managing the milieu
B. Caring for the client's physiological needs
C. Providing counseling
D. Documenting client behaviors
Correct answer:
The correct answer is C: Providing counseling. Peplau, a renowned nursing theorist, emphasized the importance of the nurse-client relationship and therapeutic communication in psychiatric nursing. Counseling is a fundamental aspect of the nurse's role in helping clients explore thoughts, emotions, and behaviors to promote healing and growth. It allows for a deeper understanding of the client's needs and facilitates positive change. Managing the milieu (A) focuses on the physical environment, not the therapeutic relationship. Caring for physiological needs (B) is important but does not capture the essence of Peplau's theory. Documenting client behaviors (D) is crucial for monitoring progress but does not directly align with Peplau's emphasis on therapeutic communication.
Nurse Raymond is handling a group of student nurses and he is teaching them about fluids and electrolytes. He is correct when he says that a substance moves from an area of higher concentration, this is:
A. osmosis
B. filtration
C. diffusion
D. active transport
Correct answer:
Correct Answer: C - Diffusion
Rationale: Diffusion is the movement of a substance from an area of higher concentration to an area of lower concentration. This process occurs naturally to achieve equilibrium. In the context of fluids and electrolytes, this movement helps maintain balance within the body. Unlike osmosis, which involves the movement of water molecules across a semi-permeable membrane, diffusion applies to the movement of all types of substances. Filtration involves the movement of substances through a barrier under pressure, and active transport requires energy to move substances against a concentration gradient. Therefore, the correct answer is diffusion as it aligns with the principle of movement from high to low concentration for achieving equilibrium.
A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 ml/hr. What intervention should the nurse anticipate?
A. Clamp the catheter.
B. Administer a fluid bolus.
C. Obtain a urine specimen for culture and sensitivity.
D. Initiate continuous bladder irrigation.
Correct answer:
In this scenario, the nurse should anticipate initiating continuous bladder irrigation. Dark yellow urine output at a rate of 25 ml/hr following abdominal surgery may indicate urinary stasis or obstruction, which could lead to complications like urinary retention. Continuous bladder irrigation helps prevent catheter obstruction and manage urinary retention by ensuring patency and promoting urine flow. Clamping the catheter (Choice A) could lead to urinary stasis and should be avoided. Administering a fluid bolus (Choice B) is not indicated solely based on the urine color and output described. Obtaining a urine specimen for culture and sensitivity (Choice C) may be necessary for assessing infection but does not directly address the issue of urinary stasis or obstruction.
A widow, aged 72 years, lives alone and is visited weekly by her son. She takes digoxin, hydrochlorothiazide, and an antihypertensive drug. She also has a prescription for diazepam (Valium) as needed for moderate to severe anxiety. When the son visited today, he found his mother confused and disoriented, with an unsteady gait. The nurse assessed the patient as having several cognitive problems, including memory and attention deficits and fluctuating levels of orientation. The nurse confirms that the patient's symptoms developed:
A. Over the past few days.
B. Over the past few weeks.
C. Over the past few months.
D. None of the above.
Correct answer:
The correct answer is A: Over the past few days. The sudden onset of confusion, disorientation, and cognitive deficits in the elderly patient suggests an acute change in her condition. This acute change is more indicative of a recent event or medication-related issue rather than a gradual decline over weeks or months. The sudden onset could be due to factors such as medication interactions, overdose, or underlying medical conditions. It is crucial to investigate recent changes in medications, lab results, or any other potential triggers that might have led to this acute cognitive decline. Choices B, C, and D are incorrect because they imply a gradual decline over weeks, months, or no specific timeframe, which does not align with the sudden onset observed in the patient.
Helena is a post-surgical patient with a hemoglobin level of 7.6 g/dL and hematocrit of 25%. Today, she was prescribed with pRBC transfusion. You took the client’s temperature and it was at 38.2 C orally. Which of the following is the correct intervention?
A. Proceed with the transfusion. This is normal post-surgery.
B. Administer anti-histamine first.
C. Administer Acetaminophen 2 tablets and proceed with transfusion.
D. Notify physician. Delay transfusion.
Correct answer:
The correct answer is D: Notify physician. Delay transfusion.
Rationale:
1. Fever (temperature of 38.2 C) indicates possible infection or reaction to transfusion.
2. In a post-surgical patient, fever could be a sign of sepsis or transfusion reaction.
3. Delaying transfusion allows for further assessment and investigation by the physician.
4. Proceeding with transfusion without addressing the fever could worsen the patient's condition.
Summary:
- Choice A is incorrect because fever post-surgery is not normal and requires further evaluation.
- Choice B is incorrect as administering anti-histamine does not address the underlying issue of fever.
- Choice C is incorrect as giving Acetaminophen without further evaluation of the cause of fever is not appropriate.
Which nursing activity demonstrates the role of a professional psychiatric nurse as identified by Hildegard Peplau?
A. Managing the milieu
B. Caring for the client's physiological needs
C. Providing counseling
D. Documenting client behaviors
Correct answer:
The correct answer is C: Providing counseling. Peplau, a renowned nursing theorist, emphasized the importance of the nurse-client relationship and therapeutic communication in psychiatric nursing. Counseling is a fundamental aspect of the nurse's role in helping clients explore thoughts, emotions, and behaviors to promote healing and growth. It allows for a deeper understanding of the client's needs and facilitates positive change. Managing the milieu (A) focuses on the physical environment, not the therapeutic relationship. Caring for physiological needs (B) is important but does not capture the essence of Peplau's theory. Documenting client behaviors (D) is crucial for monitoring progress but does not directly align with Peplau's emphasis on therapeutic communication.
A nurse is assessing a client with diabetes who reports frequent episodes of hypoglycemia. What should the nurse recommend to prevent these episodes?
A. Increase protein intake
B. Monitor blood glucose levels frequently
C. Increase the dose of insulin
D. Reduce carbohydrate intake
Correct answer:
The correct recommendation to prevent hypoglycemic episodes in a client with diabetes who reports frequent episodes is to monitor blood glucose levels frequently. By monitoring blood glucose levels, the nurse can make necessary adjustments to insulin dosage and diet to maintain blood sugar levels within the target range. Increasing protein intake (Choice A) is not directly related to preventing hypoglycemia; it is more important to focus on balancing carbohydrates and insulin. Increasing the dose of insulin (Choice C) without proper monitoring can lead to further hypoglycemic episodes. Similarly, reducing carbohydrate intake (Choice D) should be done cautiously as carbohydrates are a main source of energy and sudden reduction can cause hypoglycemia in diabetic patients.
A patient had been provisionally diagnosed with syphilis. A laboratory assistant took the blood serum for an immunologic test based on the detection of antibodies preventing the movement of treponemas and causing their death. What reaction was used for the diagnosis?
A. Immobilization
B. Complement binding
C. Agglutination
D. Precipitation
Correct answer:
The correct answer is A: Immobilization. This technique is called the Treponema pallidum immobilization (TPI) test, used to diagnose syphilis. The rationale is as follows:
1. TPI test detects antibodies that prevent the movement of treponemas, causing their death.
2. By immobilizing the treponemas, it indicates the presence of specific antibodies against syphilis.
3. This test is highly specific for syphilis diagnosis as it directly targets the causative agent.
Other choices are incorrect:
B: Complement binding - Not specific to syphilis, more commonly used for other diseases.
C: Agglutination - Detects clumping of particles, not specific to treponemas or syphilis.
D: Precipitation - Involves the formation of a solid, not directly related to treponema movement or death.
RN exams clinical judgment practice questions, set 123 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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