RN exams clinical judgment practice questions, set 144
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 144
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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
A nurse in a burn unit observes that a patient is tensed up and frowning but silent. The nurse asks the patient, Can you tell me what you are thinking now? The patient responds, I cant take this pain any more! I feel like Im about to die. What would be the best response for the nurse to give to the patient, considering that the patient is already receiving the maximum amount pain medication that is safe?
A. Try to get rid of those negative thoughtsthey only make it worse.
B. Try thinking instead, This pain will go away; I can overcome it.
C. Your pain medication is already at the highest possible dose.
D. Would you like me to raise the head of your bed?
Show answer and rationale
Correct answer: C — Your pain medication is already at the highest possible dose.
The correct response is C: Your pain medication is already at the highest possible dose. This response acknowledges the patient's pain and reassures them that they are already receiving the maximum safe amount of pain medication. By stating this, the nurse is validating the patient's experience and showing empathy. It is important for the nurse to communicate clearly about the medication to manage the patient's expectations.
Choice A is incorrect as it dismisses the patient's pain and can come across as insensitive. Choice B may be well-intentioned but does not address the immediate concern of the patient's pain. Choice D is irrelevant to the patient's statement about pain and does not offer any immediate support or reassurance regarding the pain management.
Question 2
The nurse is interviewing a Native American client. It is most important for the nurse to take which action?
A. Maintain eye contact to show respect and interest.
B. Assess whether the client is comfortable with eye contact.
C. Avoid prolonged eye contact with this client.
D. Sit next to the patient to avoid any eye contact.
Show answer and rationale
Correct answer: B — Assess whether the client is comfortable with eye contact.
The correct answer is B: Assess whether the client is comfortable with eye contact. In Native American culture, eye contact norms can vary, with some individuals finding direct eye contact disrespectful. By assessing the client's comfort with eye contact, the nurse can demonstrate cultural sensitivity and respect the client's preferences. This ensures effective communication and builds trust.
Incorrect choices:
A: Maintaining eye contact may be perceived as disrespectful by some Native American clients.
C: Avoiding prolonged eye contact assumes all Native American clients prefer limited eye contact, which is a generalization.
D: Sitting next to the patient to avoid eye contact may not address the client's preferences and could be seen as avoidance behavior.
Question 3
A mother brings her newborn in for an assessment and asks,"Is there something wrong with my baby? His head seems so big." Which of the following does the nurse know about the relative proportions of the head and trunk in the newborn?
A. At birth, the head is one fifth the total length.
B. Head circumference should be greater than chest circumference at birth.
C. The head size reaches 90% of its final size when the child is 3 years old.
D. When the anterior fontanelle closes at 2 months, the head will appear proportionate to the body.
Show answer and rationale
Correct answer: A — At birth, the head is one fifth the total length.
The correct answer is A: At birth, the head is one fifth the total length. This is because newborns have relatively larger heads compared to their body size. This is known as cephalocaudal growth, where development starts from the head and progresses down the body. The head being one-fifth of the total length is a normal proportion in newborns.
Choice B is incorrect because at birth, the chest circumference is usually greater than the head circumference. Choice C is incorrect as the head size reaches about 80% of its final size by age 2, not 3 years old. Choice D is incorrect because the closure of the anterior fontanelle at 2 months does not necessarily mean the head will appear proportionate to the body; it continues to grow in proportion to the body size.
Question 4
A nurse is caring for a client who is taking acetazolamide for chronic open-angle glaucoma. For which of the following adverse effects should the nurse instruct the client to monitor and report?
A. Monitor for decreased appetite.
B. Watch for signs of hypokalemia.
C. Look for any visual disturbances.
D. Assess for tinnitus.
Show answer and rationale
Correct answer: A — Monitor for decreased appetite.
The correct answer is A: 'Monitor for decreased appetite.' Acetazolamide is a diuretic medication commonly used to treat glaucoma by reducing intraocular pressure. One of the common side effects of acetazolamide is loss of appetite. By instructing the client to monitor for decreased appetite and report it to the nurse, potential adverse effects of the medication can be caught early and managed appropriately. While hypokalemia (B) and visual disturbances (C) can be side effects of acetazolamide, decreased appetite is more commonly associated with this medication. Tinnitus (D) is not a typical adverse effect of acetazolamide. Therefore, the priority for the nurse is to educate the client to monitor and report any changes in appetite while taking this medication.
Question 5
A nurse is caring for a laboring person who is experiencing fetal tachycardia. What is the most appropriate intervention?
A. administer oxygen
B. administer IV fluids
C. monitor maternal vital signs
D. monitor fetal heart rate continuously
Show answer and rationale
Correct answer: A — administer oxygen
Correct Answer: A: Administer oxygen
Rationale: Fetal tachycardia indicates the fetus is not getting enough oxygen. Administering oxygen to the laboring person will help increase oxygen levels in their blood, leading to better oxygen supply to the fetus and potentially improving the fetal heart rate.
Summary of Other Choices:
B: Administering IV fluids may be helpful in some cases, but it is not the priority when dealing with fetal tachycardia.
C: While monitoring maternal vital signs is important, addressing the fetal tachycardia and oxygen supply to the fetus takes precedence.
D: Continuous monitoring of fetal heart rate is essential, but administering oxygen should be the immediate intervention to address the underlying issue of oxygen deficiency.
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Question 6
The nurse is caring for a patient with newly diagnosed pulmonary embolism (PE). What is the priority nursing intervention?
A. Administer prescribed anticoagulants.
B. Position the patient supine and apply oxygen.
C. Prepare for chest x-ray and CT scan.
D. Start IV fluids to stabilize blood pressure.
Correct answer:
The priority nursing intervention for a patient with newly diagnosed pulmonary embolism (PE) is to administer prescribed anticoagulants (Choice A). This is because anticoagulants help to prevent further clot formation and reduce the risk of complications such as worsening of the PE or development of additional blood clots.
Administering anticoagulants promptly is crucial in managing PE and improving outcomes for the patient.
Positioning the patient supine and applying oxygen (Choice B) may be important, but it is not the priority over administering anticoagulants.
Preparing for chest x-ray and CT scan (Choice C) and starting IV fluids (Choice D) are important assessments and interventions but are not the priority in the immediate management of PE.
A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action should the nurse plan to promote airway clearance?
A. Restrict oral fluids during the day.
B. Encourage pursed-lip breathing technique.
C. Help the patient to splint the chest when coughing.
D. Encourage the patient to wear the nasal O2 cannula.
Correct answer:
The correct answer is C: Help the patient to splint the chest when coughing. This action supports the patient in effectively clearing thick sputum by providing external support to the chest wall during the coughing effort. Splinting the chest can help increase the force of the cough and improve the effectiveness of clearing secretions.
A: Restricting oral fluids during the day is incorrect as hydration is important in thinning sputum and promoting airway clearance.
B: Encouraging pursed-lip breathing technique is helpful for some respiratory conditions, but it may not be as effective in promoting airway clearance in this case.
D: Encouraging the patient to wear the nasal O2 cannula is important for oxygenation but does not directly address airway clearance.
A woman is considering breast reduction mammoplasty. When weighing the potential risks and benefits of this surgical procedure, the nurse should confirm that the patient is aware of what potential consequence?
A. Chronic breast pain
B. Unclear mammography results
C. Increased risk of breast cancer
D. Decreased nipple sensation
Correct answer:
The correct answer is D: Decreased nipple sensation. During breast reduction mammoplasty, nerves responsible for nipple sensation may be disrupted, leading to decreased sensation in the nipple area. This is an important consequence to consider as it can impact the patient's satisfaction and quality of life post-surgery.
Other choices are incorrect because:
A: Chronic breast pain is a potential risk of surgery but not a consequence directly related to nipple sensation.
B: Unclear mammography results may occur due to breast tissue changes from surgery, but it is not a direct consequence of decreased nipple sensation.
C: Increased risk of breast cancer is not a common consequence of breast reduction mammoplasty and is not directly related to nipple sensation.
Which of the following statements is true about the medical management of diabetic ketoacidosis?
A. Serum lactate levels are used to guide insulin administration.
B. Sodium bicarbonate is a first-line medication for treatment.
C. The degree of acidosis is assessed through continuous pulse oximetry.
D. Volume replacement and insulin infusion often correct the acidosis.
Correct answer:
The correct answer is D. Volume replacement and insulin infusion often correct the acidosis in diabetic ketoacidosis (DKA) because volume depletion and insulin deficiency are key factors in its pathophysiology. Volume replacement helps correct dehydration and improve tissue perfusion, while insulin infusion helps lower blood glucose levels and inhibit ketone production, ultimately correcting the acidosis.
A is incorrect because serum lactate levels are not typically used to guide insulin administration in DKA. B is incorrect as sodium bicarbonate is not a first-line medication for DKA treatment as it can worsen metabolic acidosis. C is incorrect as the degree of acidosis in DKA is typically assessed through blood gas analysis, not continuous pulse oximetry.
On the 8th day since the patient was inoculated with antitetanic serum because of dirty wound of his foot he has developed rising temperature up to 380% , pains in the joints, rash and itch. The blood tests revealed leukopenia and thrombocytopenia. Allergic reaction of what type has developed in this case?
A. Anaphylactic
B. Cytotoxic
C. Delayed type of hypersensitivity
D. Immunocomplex
Correct answer:
The correct answer is D: Immunocomplex. In this case, the patient's symptoms of fever, joint pains, rash, and itch along with leukopenia and thrombocytopenia indicate a serum sickness reaction. This is a type III hypersensitivity reaction where antigen-antibody complexes deposit in tissues, leading to inflammation and tissue damage. The symptoms typically occur 1-2 weeks after exposure to the antigen. Anaphylactic reaction (choice A) is immediate and involves IgE antibodies. Cytotoxic reaction (choice B) involves destruction of cells by antibodies. Delayed hypersensitivity (choice C) usually takes 48-72 hours to develop and involves T-cells. Therefore, the correct answer is D as it aligns with the symptoms and timeline of a type III hypersensitivity reaction.
A nurse is interviewing a 75-year-old patient. Why might the interview take longer with this patient?
A. An older adult has a longer story to tell.
B. An older adult is usually lonely and likes to have someone to talk to.
C. Older adults lose much of their mental abilities and require more time to complete an interview.
D. As a person ages, he or she is unable to hear well, so interviewers usually need to frequently repeat what they say.
Correct answer:
The correct answer is A. Older adults may have a longer story to tell due to their wealth of life experiences. This can include medical history, family background, and personal stories that may impact their health. It is important for the nurse to gather all relevant information to provide appropriate care.
Choice B is incorrect because not all older adults are lonely, and the reason for a longer interview is not solely based on the need for social interaction.
Choice C is incorrect because while some older adults may experience cognitive decline, it is not a blanket statement that all older adults lose mental abilities.
Choice D is incorrect because hearing loss is not a universal issue among older adults, and assuming so can lead to ageist stereotypes.
A nurse is caring for a laboring person who is in the first stage of labor. What is the most important intervention to support the person during this stage?
A. provide non-pharmacological pain relief
B. administer pain relief
C. administer analgesics
D. administer IV fluids
Correct answer:
The correct answer is A: provide non-pharmacological pain relief. During the first stage of labor, it is crucial to prioritize non-pharmacological pain relief techniques such as breathing exercises, massage, and positioning to help manage the discomfort and promote comfort. This approach aligns with the goal of supporting the person's natural labor process and minimizing interventions that could potentially affect the progress of labor. Administering pain relief (B) or analgesics (C) may not be necessary or advisable at this stage unless specifically requested by the laboring person or deemed appropriate by the healthcare provider. Administering IV fluids (D) is important for hydration but is not the most critical intervention during the first stage of labor.
A nurse is preparing to administer an IM injection to a client. Which of the following actions should the nurse take?
A. Massage the injection site after administering the medication.
B. Insert the needle at a 45° angle.
C. Use a Z-track technique to administer the injection.
D. Aspirate for blood before injecting the medication.
Correct answer:
The correct answer is C: 'Use a Z-track technique to administer the injection.' When administering IM injections, using a Z-track technique helps prevent medication from leaking into subcutaneous tissues. This technique involves pulling the skin laterally, injecting the medication deeply into the muscle, and then releasing the skin. Choice A is incorrect because massaging the injection site after administering the medication can lead to increased blood flow and potential leakage of the medication. Choice B is incorrect as the needle should typically be inserted at a 90° angle for IM injections to ensure proper delivery into the muscle. Choice D is incorrect as aspirating for blood before injecting the medication is not routinely recommended for IM injections.
A nurse cares for a client after radiation therapy for neck cancer. The client reports extreme dry mouth. What action by the nurse is most appropriate?
A. Ask the client to gargle with mouthwash containing lidocaine.
B. Administer IV fluid boluses every 2 hours.
C. Explain that xerostomia may be a permanent side effect.
D. Assess the client’s neck for redness and swelling.
Correct answer:
Rationale: Option C is correct because xerostomia (dry mouth) is a common side effect of radiation therapy to the head and neck area. It is important for the nurse to educate the client about this potential side effect and provide strategies for managing it. This includes encouraging the client to stay hydrated, suck on sugar-free candy, and avoid alcohol and tobacco.
Option A is incorrect as lidocaine-containing mouthwash may not be appropriate for long-term use and may not effectively address the underlying issue of dry mouth. Option B is also incorrect as IV fluid boluses are not indicated for managing dry mouth. Option D is incorrect as assessing the client's neck for redness and swelling is not directly related to the client's complaint of dry mouth.
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 144 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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