RN exams clinical judgment practice questions, set 155
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 155
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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
Which medications will the nurse administer to the client who is experiencing status epilepticus?
A. Phenobarbital
B. Lorazepam
C. Chlordiazepoxide
D. Phenytoin
Show answer and rationale
Correct answer: B — Lorazepam
The correct answer is B: Lorazepam. Status epilepticus is a medical emergency characterized by prolonged seizures or multiple seizures without regaining consciousness in between. Lorazepam is the first-line medication for treating status epilepticus due to its fast onset of action and effectiveness in stopping seizures. Phenobarbital (A) and Phenytoin (D) are also antiepileptic medications, but they are not typically used as first-line treatments for status epilepticus. Chlordiazepoxide (C) is not commonly used in the acute management of seizures. Therefore, the nurse should administer Lorazepam to the client experiencing status epilepticus to quickly control the seizures and prevent further complications.
Question 2
A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take?
A. Apply fundal pressure.
B. Observe for the presence of a nuchal cord.
C. Observe for crowning.
D. Prepare to administer oxytocin.
Show answer and rationale
Correct answer: C — Observe for crowning.
The correct answer is C: 'Observe for crowning.' In active labor, when the fetal head is at 3+ station, it means the head is descending into the birth canal but has not yet reached the perineum for delivery. Observing for crowning is crucial as it indicates that the baby's head is visible at the vaginal opening, signaling imminent delivery. This allows the nurse to prepare for the actual birth, ensuring a safe delivery for both the mother and the baby. Applying fundal pressure (A) is not recommended as it can cause complications. Observing for a nuchal cord (B) is important but not the immediate priority in this scenario. Administering oxytocin (D) is not indicated as the client is already in active labor.
Question 3
A nurse is caring for a newborn immediately following birth and notes a large amount of mucus in the newborn\'s mouth and nose. Identify the sequence the nurse should follow when performing suction with a bulb syringe. (Move the steps into the box on the placing them in the selected order of performance. Use all the steps.)
A. Compress the bulb syringe
B. Place the bulb syringe in the newborn\'s mouth.
C. Use the bulb syringe to suction the newborn\'s nose.
D. Assess the newborn for reflex bradycardia.
Show answer and rationale
Correct answer: A — Compress the bulb syringe
The correct sequence for performing suction with a bulb syringe on a newborn is to first compress the bulb syringe. This action creates a vacuum that allows for effective suctioning. Placing the bulb syringe in the newborn's mouth or nose without compressing it would not effectively clear the mucus. After compressing the bulb syringe, the nurse should then use it to suction the newborn's nose to remove any excess mucus. Assessing the newborn for reflex bradycardia is not directly related to the suctioning process and should be done separately. Therefore, step A, compressing the bulb syringe, is the initial and most crucial step in the correct sequence of performing suction with a bulb syringe on a newborn.
Question 4
A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?
A. Assess the pain level of a client who has received acetaminophen.
B. Measure the intake and output of a client who has received furosemide.
C. Check a client’s peripheral IV site for redness or swelling.
D. Reinforce teaching with a client about crutch-gait walking.
Show answer and rationale
Correct answer: B — Measure the intake and output of a client who has received furosemide.
The correct answer is B because measuring intake and output is a task that can be safely and appropriately delegated to an assistive personnel (AP). This task involves documenting the client's fluid intake and output, which is a basic nursing skill that does not require advanced knowledge or decision-making. Option A involves assessing pain, which requires clinical judgment and interpretation of the client's response to medication, making it more appropriate for a licensed nurse. Option C involves assessing for signs of complications at an IV site, which requires nursing knowledge and skills. Option D involves client teaching, which also requires the expertise and communication skills of a licensed nurse.
Question 5
To apply the nursing process, the LPN/LVN must understand which principle?
A. The nursing process is the only way for nurses to solve problems.
B. The patient has to follow the care plan as the nurse designed it.
C. The physician has to approve the care plan.
D. Each patient is a unique individual.
Show answer and rationale
Correct answer: D — Each patient is a unique individual.
The correct answer is D because the nursing process is a systematic method that involves assessing, diagnosing, planning, implementing, and evaluating patient care. Understanding that each patient is a unique individual is crucial for tailoring care plans to meet their specific needs. This principle emphasizes the importance of personalized care and recognizing that patients have different backgrounds, preferences, and responses to treatment. It also highlights the patient-centered approach in nursing practice, which focuses on individualized care to achieve the best outcomes for each patient. Therefore, recognizing the uniqueness of each patient is fundamental in applying the nursing process effectively.
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Question 6
A nurse is collecting data from a client who is immobile and has a potential deep-vein thrombosis. Which of the following findings should the nurse report to the provider?
A. Bradycardia.
B. Calf swelling.
C. Tortuous veins.
D. Clammy skin.
Correct answer:
The correct answer is B: Calf swelling. In a client with potential deep-vein thrombosis (DVT), calf swelling is a significant finding that should be reported to the provider. DVT occurs when a blood clot forms in a deep vein, often in the legs, due to immobility. Calf swelling can indicate the presence of a clot obstructing blood flow, leading to potential complications like pulmonary embolism. Bradycardia (A) refers to a slow heart rate and is not directly related to DVT. Tortuous veins (C) and clammy skin (D) can be seen in various conditions but are not specific to DVT. Therefore, the nurse should prioritize reporting calf swelling to ensure timely intervention and prevention of further complications.
In addition to injuries, what are the leading causes of death in adolescents ages 15 to 19 years?
A. Suicide and cancer
B. Suicide and homicide
C. Drowning and cancer
D. Homicide and heart disease
Correct answer:
The correct answer is B: "Suicide and homicide." In adolescents aged 15 to 19 years, the leading causes of death, in addition to injuries, are suicide and homicide. This age group is particularly vulnerable to mental health issues, leading to a higher incidence of suicide. Homicide also poses a significant risk due to factors like violence in communities or relationships. While cancer and heart disease are major causes of death in older age groups, they are less common in adolescents. Drowning, although a concern, is not a leading cause of death in this age group. Therefore, understanding the prevalence of suicide and homicide in adolescents is crucial for addressing and preventing these tragic outcomes.
A women at 36 weeks of gestation is placed in a supine position for an ultrasound. She begins to complain about feeling dizzy and nauseated. Her skin feels damp and cool. what would be the nurse’s first action?
A. Obtain vital signs
B. Provide the woman with emesis basin
C. Turn the woman on her side
D. Assess the woman’s respiratory rate and effort
Correct answer:
The correct answer is C: 'Turn the woman on her side.' This action is essential as the woman is experiencing symptoms of hypotension due to supine hypotensive syndrome, which occurs when the weight of the uterus compresses the inferior vena cava in the supine position, leading to decreased venous return and subsequent hypotension. Turning the woman onto her side helps alleviate this pressure and improves blood flow, relieving the symptoms. Providing an emesis basin (B) or assessing the woman's respiratory rate and effort (D) may be important but addressing the hypotension by repositioning the woman is the priority. Obtaining vital signs (A) can be done after repositioning the woman to monitor her status.
A nurse is planning care for a client who is at 33 weeks of gestation and is experiencing preterm labor. Which of the following actions should the nurse include?
A. Administer betamethasone.
B. Perform a cervical exam.
C. Insert an indwelling urinary catheter.
D. Place the client in a Trendelenburg position.
Correct answer:
The correct answer is A: "Administer betamethasone." Betamethasone is a corticosteroid given to promote fetal lung maturity in cases of preterm labor. It helps reduce the risk of respiratory distress syndrome in the newborn. Performing a cervical exam (B) can increase the risk of infection and should be avoided in preterm labor unless necessary. Inserting an indwelling urinary catheter (C) may not be indicated unless there are specific medical reasons. Placing the client in a Trendelenburg position (D) is contraindicated in preterm labor as it can worsen the condition by increasing pressure on the cervix. Administering betamethasone is crucial in this scenario to improve outcomes for the preterm infant.
A nurse is caring for a client who has active genital herpes simplex virus type 2. Which of the following medications should the nurse plan to administer?
A. Metronidazole
B. Penicillin
C. Acyclovir
D. Gentamicin
Correct answer:
The correct answer is C: Acyclovir. Acyclovir is an antiviral medication commonly used to treat herpes simplex virus infections, including genital herpes caused by herpes simplex virus type 2. It works by inhibiting the replication of the virus within the body. Metronidazole (A) is an antibiotic used to treat bacterial infections, not viral infections like herpes. Penicillin (B) is also an antibiotic effective against certain bacterial infections but not herpes. Gentamicin (D) is an antibiotic used to treat bacterial infections and is not effective against viral infections like herpes. Therefore, the nurse should plan to administer Acyclovir to the client with active genital herpes simplex virus type 2.
.A nurse is providing discharge instructions to a client who has been prescribed lithium for the treatment of bipolar disorder. Which of the following instructions should the nurse include?
A. Avoid driving until you know how the medication affects you.
B. Take the medication with food to avoid stomach upset.
C. You may experience mild nausea when you first start taking the medication.
D. If you miss a dose, double the next dose to catch up.
Correct answer:
The correct answer is A. Lithium is known to cause side effects such as dizziness and drowsiness, which can impair one's ability to drive safely. It is important for the client to avoid driving or operating heavy machinery until they know how the medication affects them. Option B is incorrect because lithium should be taken on an empty stomach to maximize absorption. Option C is incorrect as nausea is a common side effect of lithium, especially when starting the medication. Option D is incorrect because it is dangerous to double the dose if a dose is missed, as it can lead to toxicity. The nurse should emphasize the importance of taking the medication as prescribed and never doubling up on missed doses.
.A teenage boy is attracted to a female teacher. Without objective evidence, a school nurse overhears the boy state, \'I know she wants me.\' This statement reflects which defense mechanism?
A. Displacement
B. Projection
C. Rationalization
D. Sublimation
Correct answer:
The correct answer is B: Projection. Projection is a defense mechanism where one attributes their own unacceptable or unwanted thoughts, feelings, or motives to others. In this scenario, the teenage boy is projecting his own desires onto the female teacher by assuming she wants him, despite no evidence supporting this claim. Displacement (A) involves redirecting emotions from a threatening target to a less threatening one. Rationalization (C) is when one justifies their actions with logical reasoning. Sublimation (D) is channeling unacceptable impulses into socially acceptable behaviors. In this case, the boy's statement best aligns with projection as he is projecting his own feelings onto the teacher.
A nurse is administering blood to a client who had a severe hemorrhage. What should the nurse monitor?
A. Monitor for allergic reactions.
B. Monitor for hypertension.
C. Monitor for infection signs.
D. Monitor for anaphylactic shock.
Correct answer:
The correct answer is A: 'Monitor for allergic reactions.' When administering blood, the nurse should closely monitor the client for signs of an allergic reaction, such as itching, hives, or difficulty breathing. This is important because some individuals may have allergic reactions to blood components. Monitoring for hypertension (B) is not a priority in this situation. While monitoring for signs of infection (C) is important in general, it is not the most immediate concern when administering blood. Anaphylactic shock (D) is a severe allergic reaction that can occur quickly and requires immediate intervention, so the nurse should monitor for signs of anaphylaxis and be prepared to respond accordingly.
.A nurse is assessing a client who has been diagnosed with body dysmorphic disorder. Which of the following findings should the nurse expect?
A. Preoccupation with a perceived physical defect
B. Fear of gaining weight
C. Excessive worry about physical symptoms
D. Persistent depressive mood
Correct answer:
The correct answer is A: 'Preoccupation with a perceived physical defect.' Body dysmorphic disorder is characterized by an obsessive preoccupation with a perceived flaw in one's physical appearance that is not observable or appears slight to others. Individuals with this disorder often engage in compulsive behaviors like excessive grooming, seeking reassurance, or avoiding social situations. Fear of gaining weight (B) is more indicative of an eating disorder such as anorexia nervosa or bulimia. Excessive worry about physical symptoms (C) may suggest hypochondriasis or somatic symptom disorder. Persistent depressive mood (D) is a common symptom of depression but not specific to body dysmorphic disorder.
.A nurse is providing care for a client experiencing alcohol withdrawal. Which intervention should be included in the plan of care?
A. Administer benzodiazepines as prescribed.
B. Monitor the client\'s vital signs every 4 hours.
C. Provide a high-protein diet.
D. Encourage the client to drink plenty of fluids.
Correct answer:
The correct answer is A: Administer benzodiazepines as prescribed. Benzodiazepines are commonly used in the management of alcohol withdrawal symptoms due to their ability to reduce anxiety, agitation, and prevent seizures. Monitoring vital signs (option B) is important, but administering benzodiazepines takes priority to address the client's withdrawal symptoms. Providing a high-protein diet (option C) and encouraging plenty of fluids (option D) are not directly related to managing alcohol withdrawal symptoms. Therefore, the priority intervention for a client experiencing alcohol withdrawal is to administer benzodiazepines as prescribed to ensure their safety and manage withdrawal symptoms effectively.
RN exams clinical judgment practice questions, set 155 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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