RN exams clinical judgment practice questions, set 139
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 139
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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 assessing a pregnant patient who is 30 weeks gestation and reports severe lower back pain. What is the most appropriate intervention for the nurse to recommend?
A. Instruct the patient to lie flat on her back to relieve pain.
B. Encourage the patient to perform gentle stretching exercises and maintain good posture.
C. Encourage the patient to rest in bed and avoid any physical activity.
D. Recommend taking over-the-counter pain medication to alleviate discomfort.
Show answer and rationale
Correct answer: B — Encourage the patient to perform gentle stretching exercises and maintain good posture.
The correct answer is B: Encourage the patient to perform gentle stretching exercises and maintain good posture. This option promotes active management of lower back pain in pregnancy by improving muscle strength and flexibility, reducing strain on the back. Stretching exercises can help alleviate discomfort and improve posture, which are important for managing back pain during pregnancy. Option A is incorrect as lying flat on the back is contraindicated in pregnancy due to the risk of supine hypotensive syndrome. Option C is incorrect as complete bed rest is not recommended for back pain management. Option D is incorrect as over-the-counter pain medication should be used judiciously during pregnancy and is not the first-line intervention for managing back pain.
Question 2
A client received butorphanol 2 mg intravenously 10 minutes before delivery. Which nursing action is appropriate?
A. Administer butorphanol subcutaneously
B. Have naloxone available
C. Administer intravenous fluid bolus
D. Place oxygen 10 L by nasal cannula
Show answer and rationale
Correct answer: B — Have naloxone available
The correct answer is B: Have naloxone available. Butorphanol is an opioid agonist-antagonist that can cause respiratory depression in the mother and baby. Naloxone is an opioid antagonist used to reverse opioid effects, such as respiratory depression. Having naloxone available is crucial in case the client experiences respiratory depression post-delivery due to the butorphanol administration. Administering butorphanol subcutaneously (A) is not recommended as the client has already received it intravenously. Administering intravenous fluid bolus (C) may not directly address the potential respiratory depression caused by butorphanol. Placing oxygen 10 L by nasal cannula (D) may help with oxygenation but does not directly address the opioid effects of butorphanol.
Question 3
A 24-year-old secretary comes to your clinic, complaining of difficulty sleeping, severe nightmares, and irritability. She states it all began 6 months ago when she went to a fast food restaurant at midnight. While she was waiting in her car a man entered through the passenger door and put a gun to her head. He had her drive to a remote area, where he took her money and threatened to kill her. When the gun jammed he panicked and ran off. Ever since this occurred the patient has been having these symptoms. She states she jumps at every noise and refuses to drive at night. She states her anxiety has had such a marked influence on her job performance she is afraid she will be fired. She denies any recent illnesses or injuries. Her past medical history is unremarkable. On examination you find a nervous woman appearing her stated age. Her physical examination is unremarkable. You recommend medication and counseling. What anxiety disorder to you think this young woman has?
A. Specific phobia
B. Acute stress disorder
C. Post-traumatic stress disorder
D. Generalized anxiety disorder
Show answer and rationale
Correct answer: C — Post-traumatic stress disorder
The young woman in this scenario is experiencing symptoms consistent with post-traumatic stress disorder (PTSD). PTSD is an anxiety disorder that can develop after a person is exposed to a traumatic event, such as a life-threatening situation like a robbery with a gun involved. The symptoms she is experiencing, including difficulty sleeping, severe nightmares, irritability, hypervigilance, and avoidance of triggers such as driving at night, are all classic features of PTSD. These symptoms have persisted for at least 6 months since the traumatic event occurred, which is a key criterion for making a diagnosis of PTSD. Treatment for PTSD typically involves a combination of medication and therapy to help the individual process and cope with the traumatic experience.
Question 4
The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase?
A. Completes a comprehensive database
B. Identifies pertinent nursing diagnoses
C. Intervenes based on priorities of patient care
D. Determines whether outcomes have been achieved
Show answer and rationale
Correct answer: A — Completes a comprehensive database
The correct answer is A: Completes a comprehensive database. In the first phase of the nursing process (assessment), the nurse collects data to form a comprehensive database about the patient's health status. This step is crucial as it provides the foundation for identifying nursing diagnoses, planning interventions, and evaluating outcomes. Identifying nursing diagnoses (B) occurs in the second phase (diagnosis), intervening based on priorities of patient care (C) is part of the third phase (planning), and determining whether outcomes have been achieved (D) is in the fourth phase (evaluation). Completing a comprehensive database in the first phase ensures a thorough understanding of the patient's needs before proceeding to the next steps in the nursing process.
Question 5
The nurse is assessing a pregnant patient who is 30 weeks gestation and reports severe lower back pain. What is the most appropriate intervention for the nurse to recommend?
A. Instruct the patient to lie flat on her back to relieve pain.
B. Encourage the patient to perform gentle stretching exercises and maintain good posture.
C. Encourage the patient to rest in bed and avoid any physical activity.
D. Recommend taking over-the-counter pain medication to alleviate discomfort.
Show answer and rationale
Correct answer: B — Encourage the patient to perform gentle stretching exercises and maintain good posture.
The correct answer is B: Encourage the patient to perform gentle stretching exercises and maintain good posture. This option promotes active management of lower back pain in pregnancy by improving muscle strength and flexibility, reducing strain on the back. Stretching exercises can help alleviate discomfort and improve posture, which are important for managing back pain during pregnancy. Option A is incorrect as lying flat on the back is contraindicated in pregnancy due to the risk of supine hypotensive syndrome. Option C is incorrect as complete bed rest is not recommended for back pain management. Option D is incorrect as over-the-counter pain medication should be used judiciously during pregnancy and is not the first-line intervention for managing back pain.
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Question 6
The nurse plans a teaching session with a client but postpones the planned session based on which nursing problem?
A. Knowledge deficit regarding impending surgery.
B. Ineffective management of treatment regimen.
C. Activity intolerance related to postoperative pain.
D. Noncompliance with prescribed exercise plan.
Correct answer:
Step-by-step rationale for choice C:
1. Activity intolerance is a priority nursing problem postoperatively due to pain.
2. Postoperative pain can limit the client's ability to perform activities.
3. Addressing activity intolerance is crucial for promoting recovery and preventing complications.
4. Delaying the teaching session helps the nurse focus on managing pain first.
Summary of why other choices are incorrect:
- Choice A: Knowledge deficit can be addressed after managing immediate postoperative issues.
- Choice B: Treatment regimen management is important but may not be as urgent as addressing activity intolerance related to pain.
- Choice D: Noncompliance with exercise plan can be addressed once the client's pain and activity intolerance are under control.
What is a potential sign of intrauterine fetal demise?
A. increased fetal heart rate
B. vaginal bleeding
C. decreased or absent fetal movement
D. macrosomia
Correct answer:
The correct answer is C: decreased or absent fetal movement. This is a potential sign of intrauterine fetal demise because it indicates a lack of fetal activity, which could suggest fetal distress or death. Reduced or absent fetal movement may be an early warning sign that the fetus is not receiving enough oxygen or nutrients. It is important to monitor fetal movement regularly to ensure the well-being of the fetus.
Other choices are incorrect because:
A: increased fetal heart rate is more commonly associated with fetal distress, not demise.
B: vaginal bleeding can be a sign of various conditions such as placental abruption or placenta previa, but it is not specific to fetal demise.
D: macrosomia refers to a large baby, which is not indicative of fetal demise.
On visual confrontation testing, a stroke patient is unable to see your fingers on his entire right side with either eye covered. Which of the following terms would describe this finding?
A. Bitemporal hemianopsia
B. Right temporal hemianopsia
C. Right homonymous hemianopsia
D. Binasal hemianopsia
Correct answer:
A right homonymous hemianopsia refers to a visual field defect in which the patient is unable to see objects in the right half of the visual field in both eyes. In the case described, the stroke patient is unable to see your fingers on his entire right side with either eye covered, which is consistent with a right homonymous hemianopsia. This type of visual field defect typically occurs as a result of damage to the optic tract or optic radiation on one side of the brain, which affects the processing of visual information from the opposite visual field. It is important to note that bitemporal hemianopsia, right temporal hemianopsia, and binasal hemianopsia involve different patterns of visual field loss and are not fitting descriptions for the presented scenario.
A patient with a brain tumor is admitted to the medical unit to begin radiation treatments. Which nursing action should take priority?
A. Pad the patient’s side rails
B. Teach the patient what to expect during
C. Assess the patient’s pain level radiation treatments
D. Place the patient in isolation
Correct answer:
The correct answer is C because assessing the patient's pain level is the priority when caring for a patient with a brain tumor about to begin radiation treatments. Pain management is crucial in providing comfort and ensuring the patient's well-being during treatment. Teaching the patient about what to expect and addressing any pain promptly are essential steps in delivering effective care.
Padding the side rails (choice A) is important for patient safety, but it is not the priority in this situation. Isolating the patient (choice D) is unnecessary unless there is a specific medical indication. Teaching the patient what to expect (choice B) is important but assessing and managing pain take precedence to ensure the patient's comfort and safety during treatment.
A nurse wishes to practice using the Synergy Model developed by the American Association of Critical-Care Nurses (AACN). What nursing behavior best supports use of this model?
A. Attending mandatory hospital-wide in-service programs
B. Self-directed study of best practice for the patients she cares for
C. Gathering demographic data on the patients admitted to the unit
D. Participating in a research study as a data collector
Correct answer:
The correct answer is B: Self-directed study of best practice for the patients she cares for. This choice aligns with the Synergy Model by promoting individualized patient care based on best practices. Self-directed study allows the nurse to enhance their knowledge and skills to provide optimal care tailored to each patient's unique needs. Attending mandatory in-service programs (A) may not directly support the individualized care approach. Gathering demographic data (C) is important but not specific to the Synergy Model's focus on patient acuity and nurse competencies. Participating in a research study (D) may contribute to evidence-based practice, but it does not directly relate to the Synergy Model's emphasis on aligning nurse competencies with patient needs.
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.
A. Apply internal pressure to the abdomen by means of an inflated balloon to prevent bleeding.
B. Prevent abdominal distention.
C. Instill feedings into the stomach for the post-op patient.
D. Help in the elimination of urine.
Correct answer:
The correct answer is B: Prevent abdominal distention. A Salem Sump tube is a type of nasogastric tube used for decompression and drainage of the stomach. It helps prevent abdominal distention by removing air and fluids from the stomach. This is important in preventing complications such as vomiting, aspiration, and bowel obstructions.
Choice A is incorrect because the purpose of a Salem Sump tube is not to apply internal pressure to the abdomen to prevent bleeding.
Choice C is incorrect because a Salem Sump tube is not used to instill feedings into the stomach but rather to remove contents from the stomach.
Choice D is incorrect because a Salem Sump tube is not used to help in the elimination of urine; it is specifically designed for gastric decompression.
A 30-year-old patient has come to the clinic for her yearly examination. The patient asks the nurse about ovarian cancer. What should the nurse state when describing risk factors for ovarian cancer?
A. Use of oral contraceptives increases the risk of ovarian cancer.
B. Most cases of ovarian cancer are attributed to tobacco use.
C. Most cases of ovarian cancer are considered to be random, with no obvious causation.
D. The majority of women who get ovarian cancer have a family history of the disease.
Correct answer:
Step 1: The nurse should inform the patient that most cases of ovarian cancer are considered to be random, with no obvious causation. This is the correct answer because the exact cause of ovarian cancer is not well understood, and the majority of cases are not linked to specific risk factors.
Step 2: Choice A is incorrect because the use of oral contraceptives actually decreases the risk of ovarian cancer.
Step 3: Choice B is incorrect because tobacco use is not a major risk factor for ovarian cancer. It is primarily associated with lung and other types of cancer.
Step 4: Choice D is incorrect because while a family history of ovarian cancer can increase the risk, the majority of women diagnosed with ovarian cancer do not have a family history of the disease.
A patient reports a severe throbbing headache in the frontotemporal area of his head that he experienced while studying for an examination, He says that the headache was somewhat relieved when he lay down. He tells the nurse that his mother also used to get these headaches. The nurse suspects that he may be suffering from:
A. hypertension.
B. cluster headaches.
C. tension headaches.
D. migraine headaches.
Correct answer:
The correct answer is D: migraine headaches. The patient's symptoms of severe throbbing headache in the frontotemporal area, triggered by stress (studying for an exam), partially relieved by lying down, and family history of similar headaches are indicative of migraines. Migraines commonly present with these characteristics, often exacerbated by stress and have a genetic component.
A: Hypertension does not typically present with throbbing headaches in a specific area or relief with lying down.
B: Cluster headaches are characterized by severe, unilateral headaches around the eye area, not frontotemporal.
C: Tension headaches usually present as dull, constant pressure-type headaches, not throbbing, and do not have the familial pattern described by the patient.
A school nurse wants to decrease the incidence of obesity in elementary school children. Which of the following describes a secondary prevention intervention that the nurse could implement?
A. Giving a presentation on the importance of exercise and physical fitness
B. Designing a game in which students select healthy food choices
C. Weighing students to identify those who are overweight
D. Putting students on a diet if they weigh greater than 20% of their ideal weight
Correct answer:
The correct answer is C because weighing students to identify those who are overweight is a secondary prevention intervention. This intervention aims to identify and intervene with individuals who already have risk factors for obesity. By identifying overweight students, the nurse can provide targeted interventions and support to prevent further progression to obesity.
Choice A is incorrect as it focuses on primary prevention by promoting healthy behaviors to prevent obesity in the first place. Choice B is also incorrect as it involves health promotion rather than targeting those already at risk. Choice D is incorrect as putting students on a diet without proper assessment and monitoring can be harmful and does not focus on prevention or early intervention.
RN exams clinical judgment practice questions, set 139 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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