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RN exams clinical judgment practice questions, set 153

RN exams · clinical judgment

RN exams clinical judgment practice questions set 153

You notice cues, form a hypothesis, act, and evaluate — the same loop Next Generation items reward. Five of the 15 questions include the correct answer and rationale. The other ten keep answers in the study hub. Continue with the RN exams exam guide or more RN exams practice questions.

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 has just admitted a client who has been diagnosed with major depressive disorder. Which of the following interventions should the nurse implement first?

  1. A. Administer an antidepressant medication.
  2. B. Establish a trusting relationship with the client.
  3. C. Develop a plan of care with the client.
  4. D. Teach the client about the importance of medication compliance.
Show answer and rationale

Correct answer: B — Establish a trusting relationship with the client.

The correct answer is B: Establish a trusting relationship with the client. Building a trusting relationship is the first step in providing effective care for a client with major depressive disorder. It is essential for the nurse to establish a therapeutic alliance with the client to promote communication, trust, and engagement in the treatment process. This will help the nurse understand the client's needs, concerns, and preferences, which are crucial for developing a personalized plan of care. Administering medication or teaching about compliance should come after establishing trust and understanding the client's individual needs. Therefore, building a trusting relationship is the priority intervention in this situation.

Question 2

.A nurse is caring for a client who has been diagnosed with borderline personality disorder. The client has been admitted to the psychiatric unit after a suicide attempt. Which of the following actions should the nurse take first?

  1. A. Encourage the client to express feelings about the suicide attempt.
  2. B. Place the client on one-to-one observation.
  3. C. Discuss the client\'s feelings about the suicide attempt.
  4. D. Encourage the client to participate in group therapy.
Show answer and rationale

Correct answer: B — Place the client on one-to-one observation.

The correct answer is B: 'Place the client on one-to-one observation.' When a client with borderline personality disorder is admitted to the psychiatric unit after a suicide attempt, the priority is to ensure their safety. Placing the client on one-to-one observation allows the nurse to closely monitor the client's behavior and prevent further harm. While encouraging the client to express feelings or discussing their emotions is important therapeutic interventions, ensuring immediate safety takes precedence. Group therapy may be beneficial for the client in the future, but the immediate concern is preventing any further harm. Therefore, placing the client on one-to-one observation is the first action the nurse should take.

Question 3

After failure of less restrictive measures, the nurse decides to apply physical restraints to a confused older adult man. Which measure(s) must the nurse include to ensure safe use of physical restraints? (Select one that does not apply.)

  1. A. Promptly attend to the toileting needs of the patient.
  2. B. Reevaluate use of the restraints every shift.
  3. C. Ensure adequate nutrition and hydration.
  4. D. Administer scheduled doses of sedative-hypnotics.
Show answer and rationale

Correct answer: D — Administer scheduled doses of sedative-hypnotics.

Administering scheduled doses of sedative-hypnotics is not a measure that should be included when ensuring safe use of physical restraints. Sedative-hypnotics can worsen confusion and increase the risk of falls and other adverse effects in older adults. Instead, the nurse should promptly attend to the toileting needs of the patient to prevent discomfort and maintain dignity, reevaluate the use of restraints every shift to assess the ongoing need for their use, and ensure adequate nutrition and hydration to support the patient's overall well-being while restrained. By avoiding sedative-hypnotics and focusing on these other measures, the nurse can promote the safe and appropriate use of physical restraints in this situation.

Question 4

A nurse is caring for a client who has a closed head injury with intracranial pressure (ICP) readings between 16 and 22 mm Hg. Which of the following actions should the nurse take to decrease the potential for raising the client\'s ICP? (Select all that apply)

  1. A. Suction the endotracheal tube frequently
  2. B. Decrease the noise in the client\'s room
  3. C. Elevate the client\'s head on two pillows
  4. D. Administer a stool softener
Show answer and rationale

Correct answer: A — Suction the endotracheal tube frequently

Suctioning the endotracheal tube frequently is an appropriate action to decrease the potential for raising the client's ICP in the context of a closed head injury. Secretions accumulating in the airway can lead to increased intracranial pressure. By maintaining a clear airway through suctioning, the nurse helps ensure adequate oxygenation and ventilation, which can help prevent complications and further elevate ICP. Decreasing noise in the room and elevating the client's head on two pillows are also measures to promote a conducive environment for the client, but they do not directly impact ICP. Administering a stool softener does not directly relate to managing ICP in the scenario described, making it an incorrect option.

Question 5

A nurse is preparing a teaching plan for a client with migraine headaches who has been prescribed a beta blocker daily to help manage this disorder. Which instructions would be appropriate to relay to this client?

  1. A. Take this drug only when you have prodromal symptoms indicating the onset of a migraine headache.
  2. B. Take this drug as ordered even when feeling well, to prevent vascular changes associated with migraine headaches.
  3. C. This drug will relieve the pain during the aura phase soon after a headache has started.
  4. D. This medication is prescribed for migraines; you won\'t experience any effect on your heart rate or blood pressure.
Show answer and rationale

Correct answer: B — Take this drug as ordered even when feeling well, to prevent vascular changes associated with migraine headaches.

Option B is the correct answer because beta blockers are used as a preventive treatment for migraine headaches by helping to regulate blood vessel constriction and dilation. It is important for the client to take the medication as prescribed even when they are not experiencing symptoms to maintain a consistent level of the drug in their system. This helps in preventing vascular changes that can trigger migraines. Options A, C, and D are incorrect because beta blockers are not meant to be taken only when prodromal symptoms appear, they do not relieve pain during the aura phase, and they can indeed have effects on heart rate and blood pressure as they work by blocking the action of adrenaline on the heart and blood vessels.

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Question 6

The client received a preoperative dose of lorazepam 20 minutes ago. Which of the following is the priority intervention the nurse should take to promote safety for this client?

  1. A. Monitor respiratory status
  2. B. Parkinson\'s disease
  3. C. Alzheimer\'s disease
  4. D. Epilepsy
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Question 7

A nurse is reviewing the side effects of a newly prescribed medication with a client. What is important to monitor?

  1. A. Monitor for nausea.
  2. B. Monitor for dizziness.
  3. C. Monitor for rash.
  4. D. Monitor for insomnia.
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Question 8

A nurse is caring for a newborn immediately following delivery. What actions should the nurse take first?

  1. A. Place the newborn directly on the client\'s chest.
  2. B. Dry the newborn and provide warmth.
  3. C. Perform a physical assessment.
  4. D. Initiate breastfeeding.
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Question 9

A nurse is teaching a parent of a newborn about the correct technique for bottle feeding. Which of the following instructions should the nurse include?

  1. A. Hold the bottle at a 45-degree angle.
  2. B. Burp the newborn halfway through feeding.
  3. C. Feed the newborn every 6 hours.
  4. D. Place the newborn in the crib after feeding.
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Question 10

A client has been admitted to the neurological department because of a seizure of unknown cause. What is the priority intervention?

  1. A. Placing the client in protective restraints
  2. B. Being sure padded side rails are present
  3. C. Suggesting that the family monitor the client
  4. D. Placing the client with one-on-one nursing service
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Question 11

Which of the following is not related to a drug toxicity of Atenolol?

  1. A. CHF
  2. B. Tachycardia
  3. C. AV block
  4. D. Sedative appearance
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Question 12

The nurse manager generally uses a stepwise method to arrive at decisions that are logical and that is used to maximize the achievement of the desired objective. Which decision-making model does this manager use?

  1. A. Political decision-making model
  2. B. Experimentation process
  3. C. Rational decision-making model
  4. D. Trial-and-error method
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Question 13

Which of the following factors will influence the types of structures groups create?

  1. A. Member characteristics and preferences
  2. B. The nature of the group\'s task
  3. C. The interplay between important value
  4. D. All of the above
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Question 14

A patient receives an analgesic. Several hours later, the patient develops hives and itching. Which action is essential for the LPN/LVN to take immediately?

  1. A. Report the finding.
  2. B. Administer an antihistamine.
  3. C. Apply a cold compress.
  4. D. Monitor the patient\'s vital signs.
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Question 15

A nurse is preparing a client who is in active labor for an epidural analgesia. Which of the following actions should the nurse take?

  1. A. Have the client stand at the bedside with her arms at her side.
  2. B. Administer a 500mL bolus of 5% dextrose in water prior to induction.
  3. C. Inform the client the anesthetic effect will last for approximately 6hr.
  4. D. Obtain a 30min electronic fetal monitoring (EFM) strip prior to induction.
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About these RN exams clinical judgment questions

RN exams clinical judgment practice questions, set 153 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.

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