RN exams clinical judgment practice questions, set 134
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 134
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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
An infant is born with a gastroschisis. Care preoperatively should include which priority intervention?
A. Prone position
B. Sterile water feedings
C. Monitoring serum laboratory electrolytes
D. Covering the defect with a sterile bowel bag
Show answer and rationale
Correct answer: D — Covering the defect with a sterile bowel bag
The correct priority intervention for an infant with gastroschisis is to cover the exposed abdominal contents with a sterile bowel bag. This action helps protect the intestines from injury, contamination, and dehydration before surgical repair. Choice A, placing the infant in the prone position, is not appropriate as it does not address the immediate need to protect the exposed intestines. Choice B, sterile water feedings, and Choice C, monitoring serum laboratory electrolytes, are not the priority interventions for this condition. Sterile water feedings may not provide the necessary protection for the exposed intestines, and monitoring electrolytes, while important, is secondary to the immediate need for protection and hydration of the exposed abdominal contents.
Question 2
Which of the following decreases the resistance in the arteries leading to the sinuses of the penis?
A. Stimulation of the sympathetic nerves innervating the arteries
B. Nitric oxide
C. Inhibition of activity of the parasympathetic nerves leading to the arteries
D. All of the above
Show answer and rationale
Correct answer: B — Nitric oxide
The correct answer is B: Nitric oxide. Nitric oxide is a potent vasodilator that relaxes smooth muscle in the arterial walls, leading to decreased resistance in the arteries. This results in increased blood flow to the sinuses of the penis, contributing to erectile function.
A: Stimulation of the sympathetic nerves innervating the arteries would actually increase resistance by causing vasoconstriction.
C: Inhibition of activity of the parasympathetic nerves leading to the arteries would also increase resistance as parasympathetic stimulation typically leads to vasodilation.
Therefore, the correct answer is B as it directly causes vasodilation and decreases resistance in the arteries leading to the sinuses of the penis, which is essential for erectile function.
Question 3
A nurse is planning care for a client with thrombocytopenia. Which action should be included?
A. Encourage the client to floss daily.
B. Remove fresh flowers from the client's room.
C. Provide the client with a stool softener.
D. Avoid serving the client raw vegetables.
Show answer and rationale
Correct answer: C — Provide the client with a stool softener.
The correct action to include in the care plan for a client with thrombocytopenia is to provide a stool softener. Thrombocytopenia is a condition characterized by low platelet count, which can lead to an increased risk of bleeding. Providing a stool softener helps prevent straining during bowel movements, reducing the risk of bleeding episodes. Encouraging the client to floss daily (choice A) is important for oral hygiene but is not directly related to thrombocytopenia. Removing fresh flowers from the client's room (choice B) is more relevant for clients with neutropenia to reduce the risk of infection. Avoiding serving the client raw vegetables (choice D) is important for clients with compromised immune systems but is not specifically related to thrombocytopenia.
Question 4
What is one way a nursing assistant can help a family respond to the death of a loved one?
A. Influencing the family with the NA's religion
B. Promptly reporting a request for a clergy visit
C. Isolating the family and friends
D. Judging past behavior to make the family feel better
Show answer and rationale
Correct answer: B — Promptly reporting a request for a clergy visit
The correct answer is B because promptly reporting a request for a clergy visit can provide spiritual support and guidance to the family during a difficult time. This option respects the family's beliefs and preferences, offering them a source of comfort and solace. By involving a clergy member, the family can receive emotional support and guidance in coping with the loss.
Choices A, C, and D are incorrect:
A: Influencing the family with the NA's religion is inappropriate as it may not align with the family's beliefs, potentially causing discomfort.
C: Isolating the family and friends is detrimental as social support is crucial in the grieving process.
D: Judging past behavior to make the family feel better is judgmental and may lead to added emotional distress.
Question 5
A patient with a history of hypertension is giving birth. During delivery, the staff was not able to stabilize the patient's blood pressure. As a result, the patient died shortly after delivery. This is an example of what type of death?
A. Early maternal death
B. Late maternal death
C. Direct obstetric death
D. Indirect obstetric death
Show answer and rationale
Correct answer: D — Indirect obstetric death
The correct answer is D: Indirect obstetric death. In this scenario, the patient's death was not directly caused by the obstetric event of giving birth, but rather by a pre-existing condition (hypertension) that was exacerbated during delivery. Indirect obstetric deaths are those caused by pre-existing conditions or external factors that are aggravated by the physiological effects of pregnancy. In contrast, early maternal death (choice A) occurs within 42 days of termination of pregnancy but is directly related to the pregnancy process. Late maternal death (choice B) occurs between 43 days and 1 year after termination of pregnancy. Direct obstetric deaths (choice C) are deaths resulting from obstetric complications during pregnancy, delivery, or postpartum period.
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Question 6
The patient has been in bed for several days and needs to be ambulated. What action should the nurse take first?
A. Dangle the patient at the bedside.
B. Encourage isometric exercises.
C. Suggest a high-calcium diet.
D. Maintain a narrow base of support.
Correct answer:
The correct answer is A: 'Dangle the patient at the bedside.' When a patient has been in bed for an extended period and needs to be ambulated, it is essential to dangle the patient at the bedside first. Dangling involves helping the patient sit on the edge of the bed with their legs over the side before standing up. This action helps prevent orthostatic hypotension, a sudden drop in blood pressure when moving from lying down to standing up, which can lead to dizziness or fainting. Encouraging isometric exercises (choice B) or suggesting a high-calcium diet (choice C) are not the first actions to take before ambulating a patient. Maintaining a narrow base of support (choice D) is related to assisting with ambulation but is not the initial step that should be taken.
A nurse is preparing to administer dopamine hydrochloride at 4 mcg/kg/min for a client weighing 80 kg. How many mL/hr should the nurse set the IV infusion to deliver?
A. 6 mL/hr
B. 8 mL/hr
C. 12 mL/hr
D. 16 mL/hr
Correct answer:
To calculate the correct rate, you first need to convert the weight to micrograms: 4 mcg/kg/min * 80 kg = 320 mcg/min. Then, convert micrograms to milligrams: 320 mcg/min / 1000 = 0.32 mg/min. Next, calculate how many milligrams per hour: 0.32 mg/min * 60 min/hr = 19.2 mg/hr. Finally, determine the mL/hr rate by using the concentration provided: 19.2 mg/hr / 800 mg in 250 mL = 6 mL/hr. Therefore, the correct answer is 6 mL/hr. Choice B, 8 mL/hr, is incorrect as it does not reflect the accurate calculation based on the weight and drug concentration. Choices C and D, 12 mL/hr and 16 mL/hr, are also incorrect as they do not align with the correct calculation of the infusion rate for dopamine hydrochloride based on the client's weight and the medication concentration.
The correct answer is B: Setting a bedtime routine. This is because establishing a consistent bedtime routine can help regulate the individual's sleep-wake cycle and reduce the symptoms of sundowning. By creating a calming environment and promoting relaxation before bedtime, the nursing assistant can help the individual transition to sleep more smoothly.
Other choices are incorrect because:
A: Adding more caffeine to the diet can exacerbate symptoms of sundowning by disrupting sleep patterns and increasing agitation.
C: Restricting exercise during the day can lead to restlessness and pent-up energy, potentially worsening sundowning symptoms.
D: Scheduling activities during this time may be overwhelming for the individual and can increase confusion and agitation.
One of the complications of prolonged bed rest is decubitus ulcer. Which of the following can best prevent its occurrence?
A. Massage reddened areas with lotion or oils
B. Use special water mattress
C. Turn frequently every 2 hours
D. Keep skin clean and dry
Correct answer:
The correct answer is C: Turn frequently every 2 hours. This is because changing positions regularly helps to relieve pressure on specific areas, reducing the risk of developing decubitus ulcers. Turning every 2 hours helps to maintain blood flow and prevent tissue damage.
A: Massaging reddened areas with lotion or oils can actually cause further damage by increasing friction and pressure on the skin.
B: While using a special water mattress can help distribute pressure more evenly, it is not as effective as regular turning to prevent decubitus ulcers.
D: Keeping the skin clean and dry is important for overall skin health but alone is not sufficient to prevent decubitus ulcers. Regular repositioning is crucial in reducing pressure and avoiding tissue breakdown.
A new patient in an alcoholism rehabilitation program says, 'I’m just a social drinker. I usually have a drink or two at brunch, a few cocktails in the afternoon, wine at dinner, and a few drinks in the evening.' Which response by the nurse will help the patient view the drinking more honestly?
A. I see,' and use interested silence.
B. I think you may be drinking more than you report.'
C. Being a social drinker involves having a drink or two once or twice a week.'
D. You describe drinking steadily throughout the day and evening. Am I correct?'
Correct answer:
Step 1: The nurse needs to provide a reflection that highlights the patient's patterns of drinking.
Step 2: Option D reflects the patient's drinking pattern accurately and objectively.
Step 3: By repeating the patient's own words back to them, the nurse helps the patient see the extent of their drinking.
Step 4: This response encourages the patient to reflect on their alcohol consumption more honestly.
Step 5: Option D is correct as it addresses the patient's behavior directly and prompts self-reflection.
Summary:
- Option A is passive and does not challenge the patient's perception.
- Option B is confrontational and may lead to defensiveness.
- Option C provides a generalized definition of social drinking, not addressing the patient's specific behavior.
Mucous membrane partially or completely covering the vaginal orifice is called as:
A. Clitoris
B. Labia
C. Hymen
D. Vulva
Correct answer:
The correct answer is C: Hymen. The hymen is a mucous membrane that partially or completely covers the vaginal orifice. It is a thin tissue located at the opening of the vagina. The hymen can vary in appearance and may partially cover the vaginal opening, making it an essential anatomical structure to consider. The other choices are incorrect because:
A: Clitoris - The clitoris is a highly sensitive sexual organ located above the vaginal opening, not covering it.
B: Labia - The labia are the folds of skin surrounding the vaginal opening, not covering it entirely.
D: Vulva - The vulva refers to the external female genitalia, including the labia, clitoris, and vaginal opening, but it does not specifically refer to the mucous membrane covering the vaginal orifice.
What is the best way to monitor for infection in a patient with a central line?
A. Check the central line site daily
B. Monitor the patient's vital signs
C. Check the central line dressing every other day
D. Check for signs of sepsis
Correct answer:
The correct answer is A: Check the central line site daily. Monitoring the central line site daily is crucial in detecting early signs of infection, such as redness, swelling, tenderness, or drainage. By checking the site regularly, healthcare providers can take prompt action to prevent complications. Choice B, monitoring the patient's vital signs, while important in assessing overall health, may not specifically indicate an infection related to the central line. Choice C, checking the central line dressing every other day, may not be frequent enough to catch early signs of infection. Choice D, checking for signs of sepsis, is important but represents a more severe stage of infection and may occur after local signs at the central line site have already manifested.
A man was admitted to the hospital on the 5th day of disease that manifested itself by jaundice, muscle aching, chill, nose bleedings. In course of laboratory diagnostics a bacteriologist performed darkfield microscopy of the patient's blood drop. Name a causative agent of this disease:
A. Leptospira interrogans
B. Borrelia dutlonii
C. Calymmatobacterium granulomatis
D. Bartonella bacilloformis
Correct answer:
The correct answer is A: Leptospira interrogans. Darkfield microscopy is used to visualize spirochetes, which are spiral-shaped bacteria. Leptospira is a spirochete bacterium that causes leptospirosis, which presents with jaundice, muscle aching, chill, and nosebleeds. Leptospira is commonly transmitted through contact with contaminated water or soil.
B: Borrelia dutlonii causes Lyme disease, which is transmitted by ticks and does not typically present with jaundice or nosebleeds.
C: Calymmatobacterium granulomatis causes granuloma inguinale, a sexually transmitted infection that does not present with the symptoms described.
D: Bartonella bacilloformis causes Carrion's disease, which presents with fever, anemia, and skin lesions but not jaundice or nosebleeds.
The nurse is assigned to a client with acquired immunodeficiency syndrome (AIDS). When handling the client’s blood and body fluids, the nurse uses standard precautions, which include:
A. Wearing gloves to empty a bedpan
B. Wearing gown, gloves, and protective eyewear when obtaining a urine specimen via catheterization
C. Disposing of needles uncapped
D. Wearing gloves when applying eyedrops
Correct answer:
The correct answer is A. Standard precautions include wearing gloves when there is a potential for contact with blood or body fluids. Emptying a bedpan involves contact with bodily fluids, thus gloves are necessary to prevent exposure to pathogens.
Choice B is incorrect because wearing a gown and protective eyewear is not necessary for obtaining a urine specimen via catheterization unless there is a risk of splashing or spraying of fluids.
Choice C is incorrect as needles should always be disposed of in a proper sharps container with the cap secured to prevent accidental needlestick injuries.
Choice D is incorrect because applying eyedrops does not involve contact with blood or body fluids, so wearing gloves is not necessary according to standard precautions.
A pregnant patient has lactose intolerance. Which recommendation will the nurse provide to best help the patient meet dietary needs for calcium?
A. Add foods such as nuts, dried fruit, and broccoli to the diet.
B. Consume dairy products but take an over-the-counter anti-gas product.
C. Increase the intake of dark leafy vegetables, such as spinach and chard.
D. Use powdered milk instead of liquid forms of milk.
Correct answer:
The correct answer is A: Add foods such as nuts, dried fruit, and broccoli to the diet. This recommendation is best because these foods are good sources of calcium and are also lactose-free, which is important for a pregnant patient with lactose intolerance. Nuts and dried fruits are rich in calcium, while broccoli is a good vegetable source of calcium.
Choice B is incorrect because consuming dairy products can exacerbate symptoms of lactose intolerance, even with an anti-gas product. Choice C is incorrect because while dark leafy vegetables are good sources of calcium, they may not provide enough for a pregnant patient's needs. Choice D is incorrect because powdered milk still contains lactose and may not be well-tolerated by someone with lactose intolerance.
RN exams clinical judgment practice questions, set 134 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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