RN exams clinical judgment practice questions, set 148
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 148
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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 is caring for a patient with a history of hypertension and diabetes. The nurse should monitor for which of the following complications?
A. Hyperglycemia.
B. Stroke.
C. Hypokalemia.
D. Hypoglycemia.
Show answer and rationale
Correct answer: B — Stroke.
Step 1: The patient has a history of hypertension and diabetes, putting them at risk for cardiovascular complications.
Step 2: Among the choices, stroke is a common complication associated with uncontrolled hypertension and diabetes.
Step 3: Monitoring for signs of stroke is crucial to prevent serious consequences in this patient population.
Step 4: Hyperglycemia (A) is a common complication of diabetes, but it is not directly related to the patient's hypertension.
Step 5: Hypokalemia (C) is an electrolyte imbalance that can occur in some conditions but is not as directly linked to the patient's history.
Step 6: Hypoglycemia (D) is a potential complication in diabetic patients but is not as common as hyperglycemia and is not directly related to hypertension.
Question 2
It is important for the nurse teaching the patient regarding secobarbital to include which information about the drug?
A. It is a short-acting drug that may cause one to awaken early in the morning.
B. It is an intermediate-acting drug that frequently causes rapid eye movement rebound.
C. It is an intermediate-acting drug that frequently causes a hangover effect.
D. It is a long-acting drug that is frequently associated with dependence.
Show answer and rationale
Correct answer: C — It is an intermediate-acting drug that frequently causes a hangover effect.
Rationale for Correct Answer C: The nurse should include information about secobarbital causing a hangover effect because it is an important side effect to be aware of. This effect may lead to drowsiness, dizziness, and impaired cognitive function the morning after taking the drug, impacting the patient's ability to function normally. Educating the patient about this potential consequence is crucial for promoting safe and effective medication use.
Summary of Incorrect Choices:
A: Incorrect because secobarbital is an intermediate-acting drug, not short-acting.
B: Incorrect because rapid eye movement rebound is not a common side effect of secobarbital.
D: Incorrect because secobarbital is not a long-acting drug and is not typically associated with dependence.
Question 3
A nurse is caring for a client who is in active labor with 7cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client\'s amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse take?
A. Assist the client into a comfortable position.
B. Observe the perineum for signs of crowning.
C. Have the client pant during the next contractions.
D. Help the client to the bathroom to void.
Show answer and rationale
Correct answer: B — Observe the perineum for signs of crowning.
The correct answer is B: 'Observe the perineum for signs of crowning.' When a client in active labor suddenly feels the need to push, it may indicate that the baby is descending rapidly. Observing the perineum for signs of crowning will help the nurse assess if the baby is moving down the birth canal. This information is crucial for determining the stage of labor and the need for immediate delivery assistance. Assisting the client into a comfortable position (option A) may be appropriate after confirming the need to push. Having the client pant during contractions (option C) is not recommended if the urge to push is strong. Helping the client to the bathroom (option D) is not appropriate in this situation as it may delay necessary interventions for delivery.
Question 4
A nurse is caring for a client who has a chest tube. Which of the following findings should the nurse report to the provider?
A. Intermittent bubbling in the water seal chamber
B. Drainage of 80 mL of fluid in the past hour
C. Tidaling in the water seal chamber with respiration
D. Fluctuation in the drainage tubing with breathing
Show answer and rationale
Correct answer: B — Drainage of 80 mL of fluid in the past hour
The correct answer is B: Drainage of 80 mL of fluid in the past hour. This finding indicates excessive drainage, which could be a sign of hemorrhage or other complications requiring immediate medical attention.
A: Intermittent bubbling in the water seal chamber is expected and indicates proper functioning of the chest tube system.
C: Tidaling in the water seal chamber with respiration is a normal finding that indicates the system is functioning correctly.
D: Fluctuation in the drainage tubing with breathing is also a normal finding that shows the chest tube is working properly.
In summary, choice B is the correct answer as it signals a potentially serious issue, while the other choices are normal findings associated with a functioning chest tube system.
Question 5
A 30-year-old man notices a firm, 2-cm mass under his areola. He has no other symptoms and no diagnosis of breast cancer in his first-degree relatives. What is the most likely diagnosis?
A. Breast tissue
B. Fibrocystic disease
C. Breast cancer
D. Lymph node
Show answer and rationale
Correct answer: A — Breast tissue
In a 30-year-old man with a firm, 2-cm mass under his areola and no other symptoms, the most likely diagnosis is breast tissue. Gynecomastia is a common condition in males where there is proliferation of breast tissue. It typically presents as a firm subareolar mass and can occur due to hormonal imbalances, medication use, or underlying medical conditions. Given the lack of family history of breast cancer, absence of other symptoms, and the age of the patient, breast tissue is the most probable diagnosis in this case. Breast cancer is less likely in this scenario, especially without any additional concerning findings or family history. Fibrocystic disease and lymph node involvement are also less likely given the presentation of a firm mass under the areola.
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Question 6
The daily patrons of a local town restaurant became ill with nausea, vomiting, and diarrhea. Without knowing the cause, which action should be taken immediately to help avoid future problems?
A. Establish a series of cooking classes for all citizens
B. Have a citywide campaign to cover your mouth when sneezing
C. Use bleach to clean the entire restaurant
D. Strongly emphasize the importance of proper hand washing to staff
Correct answer:
Agents leave the human host through a portal of exit and invade through a portal of entry. Portals of exit include respiratory secretions, vaginal secretions, semen, saliva, lesion exudates, blood, and feces. Portals of entry are associated with the portal of exit and include the respiratory passages, mucous membranes, skin and blood vessels, oral cavity, and the placenta. Because it was food poisoning of some sort, until the cause is known, it can be assumed to probably be a fecal-oral transmission. Thus, the interventions of cooking classes, covering your mouth when sneezing, and using bleach to clean the entire restaurant would be ineffective. Therefore, staff need to again be reminded of the importance of careful hand washing after using the facilities.
Which of the following activities is an example of building social capital?
A. Volunteering at the local community center
B. Attending parent-teacher conferences at the school
C. Composting in your own backyard
D. Utilizing the library to check out movies
Correct answer:
The correct answer is A: Volunteering at the local community center. This activity builds social capital by fostering relationships, trust, and reciprocity within the community. By volunteering, individuals contribute to the common good, strengthen social networks, and create a sense of belonging. This increases social cohesion and cooperation.
Summary of why other choices are incorrect:
B: Attending parent-teacher conferences is important for education but does not directly build social capital.
C: Composting in your own backyard is environmentally friendly but does not involve engaging with others to build social connections.
D: Utilizing the library for personal entertainment is beneficial but does not actively contribute to social capital development.
The nurse identifies that a patient with immobility is at risk for the development of urolithiasis. What should the nurse include when planning this patient’s care?
A. Monitor urine pH
B. Administer calcium supplements
C. Maintain an indwelling urinary catheter
D. Increase fluid intake to 3000 mL/day
Correct answer:
Immobility can contribute to the development of urolithiasis (the formation of urinary calculi or stones) due to decreased mobility leading to stagnant urine flow, which can result in the concentration of crystal-forming substances in the urine. Increasing fluid intake helps prevent urinary stasis and dilutes the urine, reducing the risk of stone formation. Adequate hydration can also help flush out any existing crystals or small stones before they grow larger. Therefore, increasing fluid intake to 3000 mL/day is essential in preventing urolithiasis in patients with immobility. Monitoring urine pH, administering calcium supplements, or maintaining an indwelling urinary catheter are not appropriate interventions for preventing urolithiasis in this situation.
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 client reports difficulty breathing, stating, 'I can’t catch my breath.' What is the most appropriate action for the nurse to take?
A. Validate the client’s statement by measuring oxygen saturation.
B. Encourage the client to perform deep breathing exercises.
C. Document the client’s statement and continue with the assessment.
D. Provide oxygen immediately without further assessment.
Correct answer:
The correct answer is A because measuring oxygen saturation will provide objective data to assess the client's respiratory status accurately. This step is crucial in identifying the severity of the client's breathing difficulty and determining the appropriate intervention. Encouraging deep breathing exercises (B) may worsen the client's condition if there is an underlying respiratory problem. Simply documenting the client's statement (C) without immediate action can delay necessary interventions. Providing oxygen without further assessment (D) can be harmful if the client's oxygen saturation is already high. Overall, option A is the most appropriate as it involves a proactive and evidence-based approach to address the client's reported breathing difficulty.
A patient with a history of type 1 diabetes and an eating disorder is found unconscious. In the emergency department, the following lab values are obtained: Glucose: 648 mg/dL pH: 88 P CO : 20 mm Hg a 2 P O : 95 mm Hg a 2 HCO ¯: undetectable Anion gap: >31 Na+: 127 mEq/L K+: 5 mEq/L Creatinine: 8 mg/dL After the patient’s airway and ventilation have been established, the next priority for this patient is:
A. administration of a 1-L normal saline fluid bolus.
B. administration of 0.1 unit of regular insulin IV push followed by an insulin infusion.
C. administration of 20 mEq KCl in 100 mL.
D. IV push administration of 1 amp of sodium bicarbonate.
Correct answer:
The correct answer is A: administration of a 1-L normal saline fluid bolus. In this scenario, the patient is likely experiencing diabetic ketoacidosis (DKA) due to the extremely high glucose levels, low bicarbonate, and anion gap metabolic acidosis. The priority is to correct the dehydration and electrolyte imbalances through fluid resuscitation with normal saline to improve perfusion and reverse the metabolic derangements. Options B, C, and D do not address the immediate need for volume resuscitation and correction of dehydration. Administering insulin or potassium without first addressing the fluid deficit could lead to further complications. Sodium bicarbonate is not recommended in DKA as it can worsen acidosis and has not been shown to improve outcomes.
The patient is admitted with complaints of general malaise and fatigue, along with a decreased urinary output. The patient’s urinalysis shows coarse, muddy brown granular casts and hematuria. The nurse determines that the patient has:
A. acute kidney injury from a prerenal condition.
B. acute kidney injury from postrenal obstruction.
C. intrarenal disease, probably acute tubular necrosis.
D. a urinary tract infection.
Correct answer:
The correct answer is C: intrarenal disease, probably acute tubular necrosis. The presence of coarse, muddy brown granular casts and hematuria in the urinalysis indicates damage to the renal tubules, which is characteristic of acute tubular necrosis. This condition is a type of intrarenal disease where there is direct damage to the kidney tubules, leading to decreased urinary output and symptoms like malaise and fatigue. Prerenal and postrenal conditions do not typically present with granular casts and hematuria, making choices A and B incorrect. Urinary tract infection is also unlikely to cause the specific findings seen in this case, ruling out choice D. Therefore, choice C is the most appropriate based on the urinalysis results and clinical presentation.
Nurse Fely is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that the catheter insertion site appears reddened. Which of the following assessment findings is the MOST ALARMING?
A. Temperature: 38.1 C
B. Expiration date is next month
C. Dressing change due today
D. Tight tubing connections
Correct answer:
The correct answer is A: Temperature: 38.1 C. A fever is the most alarming finding as it indicates a potential systemic infection, especially in a client with a central line and redness at the insertion site. Fever can be a sign of sepsis which requires immediate intervention.
Choice B: Expiration date is next month is not relevant to the current situation and does not indicate an immediate threat to the client's health.
Choice C: Dressing change due today, while important for infection prevention, is not the most alarming finding in this scenario as it can be addressed promptly.
Choice D: Tight tubing connections can lead to complications but are not as urgent or life-threatening as a fever in a client with a central line and redness at the site.
A soldier in a combat zone tells the nurse, "I saw a child get blown up over a year ago, and I still keep seeing bits of flesh everywhere. I see something red, and the visions race back to my mind." Which phenomenon associated with PTSD is the soldier describing?
A. Reexperiencing
B. Hyperarousal
C. Avoidance
D. Psychosis
Correct answer:
The correct answer is A: Reexperiencing. The soldier's description aligns with the reexperiencing symptom of PTSD, where traumatic memories intrude into consciousness causing distress. This is evident as the soldier vividly recalls the traumatic event and experiences flashbacks triggered by red objects. Hyperarousal (B) involves heightened sensitivity to potential threats, not the vivid recall of traumatic events. Avoidance (C) refers to efforts to avoid reminders of the trauma, which is not the case here. Psychosis (D) involves a loss of touch with reality, such as hallucinations or delusions, which are not described in the scenario. In summary, the soldier's experience of intrusive memories and flashbacks corresponds to the reexperiencing symptom of PTSD.
You readmitted a client who was in another department a month ago. Since you will need the previous chart, from whom do you request the old chart?
A. Central supply section
B. Previous doctor's clinic
C. Department where the patient was previously admitted
D. Medical records section
Correct answer:
The correct answer is D, Medical records section. This is because the medical records section is responsible for maintaining and storing all patient records, including previous charts. Requesting the old chart from the medical records section ensures accuracy and completeness of the client's medical history.
A: Central supply section - Incorrect, as this department is responsible for providing medical supplies and equipment, not maintaining patient records.
B: Previous doctor's clinic - Incorrect, as the clinic may not have the complete medical history if the patient has been seen in multiple departments.
C: Department where the patient was previously admitted - Incorrect, as they may not have access to the complete medical records from other departments.
RN exams clinical judgment practice questions, set 148 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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