RN exams clinical judgment practice questions set 125

Correct answer:

The correct answer is A: A high-protein, high-calorie diet divided into six small meals. For a person with AIDS, this diet is beneficial to maintain muscle mass, support immune function, and provide energy. High-protein helps in tissue repair, while high-calorie intake helps combat weight loss common in AIDS. Dividing into small frequent meals aids in digestion and absorption. Choice B is incorrect because a low-fat diet may not provide enough calories for the increased energy needs of a person with AIDS. Choice C is incorrect because a high-carbohydrate, fat-restricted diet may not provide sufficient protein for muscle maintenance. Choice D is incorrect because a high-fat diet may lead to weight gain and can be harder to digest for someone with compromised immunity.

Correct answer:

The correct answer is A because a semen analysis assesses important parameters such as sperm count, morphology (shape), and motility (movement), which are crucial factors in male fertility. Sperm count indicates the quantity of sperm available for fertilization. Morphology assesses the structural integrity of sperm, while motility determines their ability to reach and fertilize an egg. These parameters directly impact fertility potential. Choice B is incorrect because a semen analysis does not specifically check for genetic conditions affecting sperm. Choice C is incorrect as hormone levels are not directly evaluated in a semen analysis. Choice D is incorrect because while infections can affect fertility, they are not the primary focus of a standard semen analysis.

Correct answer:

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.

Correct answer:

In extremely low-birth-weight (ELBW) infants, a thorough systemic physical assessment is crucial to detect subtle changes that may indicate an underlying problem. These infants are highly vulnerable and may show signs of stress through changes in feeding behavior, activity, color, oxygen saturation, or vital signs. Monitoring weight in ELBW infants primarily reflects genitourinary function rather than fluid retention. Difficulties in maternal-child attachment are important but are usually assessed during parental visits and are not the primary focus of a systemic physical assessment. Changes in the Apgar score are used immediately after birth to assess the transition to extrauterine life and are not as relevant in the following 24 hours to detect ongoing subtle issues.

Correct answer:

In this scenario, the nurse should explain the reason for using only non-narcotics. Following head trauma, non-narcotic medications such as acetaminophen are preferred to avoid masking symptoms of neurological changes, such as increased intracranial pressure, that could worsen after stronger pain medication. Administering an anti-inflammatory medication (Choice A) may not be appropriate as it may not address the severity of the headache. Consulting the healthcare provider about a stronger medication (Choice C) is important, but the immediate need is to educate the client on the rationale for using non-narcotic medications first. Administering a stronger medication as requested (Choice D) could potentially mask important symptoms and should be avoided in this situation.

Correct answer:

Choice B is the correct answer because the scenario describes a 50-year-old with early-stage chronic lymphocytic leukemia who presents with chronic fatigue. Chronic lymphocytic leukemia commonly presents with symptoms like fatigue, weight loss, and enlarged lymph nodes. The other choices are less likely as they do not match the clinical presentation described in the scenario. Choice A describes a 23-year-old with a nontender lump in the axilla, which is more suggestive of a benign condition like a lipoma. Choice C describes a 19-year-old with hemophilia who wants to learn to self-administer factor VII replacement, which is unrelated to the symptoms of chronic lymphocytic leukemia. Choice D repeats the scenario, which is not relevant in selecting the appropriate answer.

Correct answer:

The correct answer is A: Assist Ms. C with perineal care. This task can be safely delegated to an Unlicensed Assistive Personnel (UAP) as it involves basic hygiene and does not require specialized medical training. Perineal care includes cleaning the area around the stoma, which is important for maintaining skin integrity and preventing infection. UAPs can be trained to provide this type of care under the supervision of a registered nurse. Choices B, C, and D involve more specialized skills such as proper positioning of the adhesive wafer, measuring colostomy contents, and reapplying a new colostomy bag, which should be performed by a licensed healthcare professional such as a nurse. Delegating these tasks to a UAP could pose a risk to the client's health and safety.

Correct answer:

The correct answer is B: Monitoring blood glucose levels and maintaining a balanced diet. This is crucial for managing gestational diabetes, as it helps control blood sugar levels to prevent complications for both the mother and baby. Regular monitoring ensures timely adjustments to treatment. A balanced diet helps regulate blood sugar levels and provides essential nutrients for the baby's growth. Choice A is important but not as critical as monitoring blood glucose levels, as weight gain should be monitored but is not the primary focus in gestational diabetes. Choice C is not directly related to managing gestational diabetes. Choice D may be necessary in some cases, but it is not the most important aspect of care compared to monitoring blood glucose levels and diet.

Correct answer:

The correct answer is B: Administer a short-acting bronchodilator. The first step in managing an asthma exacerbation is to provide quick relief by administering a short-acting bronchodilator like albuterol. This medication helps to open up the airways rapidly, providing immediate relief of symptoms such as wheezing and shortness of breath. Administering a bronchodilator is crucial in the acute management of an asthma exacerbation as it targets bronchoconstriction. Oral steroids (choice C) are typically used for more severe exacerbations or when initial bronchodilator therapy is ineffective. Administering an inhaled beta-agonist (choice D) is a valid option, but a short-acting bronchodilator is preferred for immediate relief in the initial management of an exacerbation.

Correct answer:

The correct answer is A: Oxygen saturation of 88%. This finding requires immediate intervention because it indicates significant hypoxemia, which can be life-threatening. Hypoxemia can lead to tissue damage and organ failure if not addressed promptly. Oxygen saturation below 90% is considered critically low and requires urgent attention to prevent complications. Summary: - Choice B: Pain rated 6/10 at the site is significant but does not require immediate intervention compared to hypoxemia. - Choice C: Mild tachypnea while lying flat may indicate a potential issue, but it is not as urgent as severe hypoxemia. - Choice D: Draining 300 mL of pleural fluid is a common outcome of thoracentesis and does not warrant immediate intervention unless other symptoms are present.