RN exams clinical judgment practice questions, set 157
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 157
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 is caring for a client who has hyperemesis gravidarum. Which of the following laboratory tests should the nurse anticipate?
A. Urine Ketones
B. Rapid plasma regain
C. Prothrombin time
D. Urine culture
Show answer and rationale
Correct answer: A — Urine Ketones
The correct answer is A: 'Urine Ketones.' Hyperemesis gravidarum is a severe form of morning sickness that can lead to dehydration and electrolyte imbalances. Urine ketones can indicate the presence of ketosis, a sign of the body breaking down fat for energy due to inadequate food intake. Monitoring urine ketones helps assess the client's nutritional status and hydration level. Rapid plasma regain (B) is not typically indicated for hyperemesis gravidarum. Prothrombin time (C) is a measure of blood clotting function and is not directly related to hyperemesis gravidarum. Urine culture (D) is used to identify the presence of bacteria in the urine and is not a routine test for hyperemesis gravidarum.
Question 2
A nurse is caring for a newborn who has a high bilirubin level and is receiving phototherapy. Which of the following actions should the nurse take?
A. Keep the newborn\'s eyes uncovered during phototherapy.
B. Apply lotion to the newborn\'s skin to prevent dryness.
C. Reposition the newborn every 2 hours.
D. Dress the newborn in warm clothing.
Show answer and rationale
Correct answer: C — Reposition the newborn every 2 hours.
The correct answer is C: 'Reposition the newborn every 2 hours.' Repositioning the newborn every 2 hours helps ensure uniform exposure to the phototherapy light, which is crucial for effective treatment of high bilirubin levels. This rotation prevents uneven skin exposure and reduces the risk of skin breakdown. Keeping the newborn's eyes uncovered during phototherapy (option A) is essential to protect the eyes. Applying lotion to the newborn's skin (option B) is not recommended during phototherapy as it can interfere with the effectiveness of the treatment. Dressing the newborn in warm clothing (option D) is not necessary and may lead to overheating, which can be detrimental during phototherapy.
Question 3
A nurse is planning care for a full-term newborn who is receiving phototherapy. Which of the following actions should the nurse include in the plan of care?
A. Dress the newborn in lightweight clothing.
B. Avoid using lotion or ointment on the newborn skin.
C. Keep the newborn supine throughout treatment
D. Measure the newborn\'s temperature every 8hr
Show answer and rationale
Correct answer: B — Avoid using lotion or ointment on the newborn skin.
The correct answer is B: 'Avoid using lotion or ointment on the newborn skin.' During phototherapy, it is important to avoid applying any lotions or ointments on the newborn's skin as these can interfere with the effectiveness of the light therapy. The skin needs to be exposed to the light to effectively treat jaundice. Dressing the newborn in lightweight clothing (option A) is also important as it allows the skin to be exposed to the light. Keeping the newborn supine throughout treatment (option C) is not necessary and could potentially cause discomfort. Measuring the newborn's temperature every 8 hours (option D) is important but not specifically related to phototherapy treatment for jaundice.
Question 4
A nurse is assessing a pregnant client who is at 28 weeks\' gestation. The nurse would expect to measure the fundal height at which level?
A. at the level of the umbilicus
B. above the symphysis pubis
C. at the xiphoid process
D. below the symphysis pubis
Show answer and rationale
Correct answer: A — at the level of the umbilicus
The correct answer is A: "at the level of the umbilicus." Fundal height measurement is a common way to assess fetal growth and development during pregnancy. At 28 weeks' gestation, the fundal height is typically at the level of the umbilicus. This measurement corresponds to the number of weeks of gestation, so at 28 weeks, the fundal height should be around the umbilicus. Measuring above the symphysis pubis (option B) is more common in the earlier stages of pregnancy, while measuring at the xiphoid process (option C) or below the symphysis pubis (option D) would not be accurate at 28 weeks. Therefore, the correct location to measure the fundal height at 28 weeks is at the level of the umbilicus.
Question 5
A nurse in an acute care center is caring for a client who just died. The client’s family requests to perform the postmortem care. Which of the following is an appropriate response for the nurse to make?
A. “You will have to sign a release form to perform the care yourselfâ€Â
B. “I will assist you in any way I can during this processâ€Â
C. “A licensed health care worker must perform postmortem care.â€Â
D. “This care takes place after the client leaves the facilityâ€Â
Show answer and rationale
Correct answer: B — “I will assist you in any way I can during this processâ€Â
Option B is the correct answer because it demonstrates empathy and support towards the family during this difficult time. The nurse should offer assistance and guidance to the family in performing the postmortem care, ensuring they feel supported and respected. Option A is incorrect because the family's request should be met with compassion rather than administrative requirements. Option C is incorrect as it may come off as dismissive and unhelpful to the family. Option D is also incorrect as postmortem care can be performed in the facility with the family's involvement. Therefore, the most appropriate response is to offer assistance and support to the family during the postmortem care process.
Keep going past these 15 questions
Missed-question review, longer banks, and the rest of 20,000+ nursing practice questions open when you start studying.
Stems and choices stay public so you can still reason. Correct answers and full rationales unlock with the rest of the bank.
Question 6
A nurse is caring for a client who is 2 days postoperative following a below-the-knee amputation. Which of the following statements by the client should the nurse identify as indicating an acceptance of the limb loss?
A. I stay awake at night because I keep thinking about my leg.
B. I need to learn how to perform a dressing change on my leg.
C. I know my family means well, but I don’t want visitors seeing my leg right now.
D. I am going to have to find someone who can take care of my leg at home.
Correct answer:
The correct answer is B because the client expressing a desire to learn how to perform a dressing change on the amputated leg indicates acceptance of the limb loss. This statement shows the client's willingness to participate in self-care and take responsibility for the postoperative care of the residual limb. Option A demonstrates difficulty coping with the loss, as the client is experiencing sleep disturbances due to thoughts about the missing limb. Option C suggests embarrassment or discomfort about the amputation, indicating a lack of acceptance. Option D indicates a dependence on others for care, rather than taking an active role in self-management, which is not indicative of acceptance.
A nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first?
A. Apply a fetal scalp electrode.
B. Increase the rate of the IV infusion.
C. Administer oxygen at 10 L/min via a nonrebreather mask.
D. Change the client\'s position.
Correct answer:
The correct answer is D: "Change the client's position." Late decelerations in the fetal heart rate (FHR) indicate uteroplacental insufficiency, meaning the baby is not getting enough oxygen during contractions. Changing the client's position, particularly to a left lateral position, can help improve placental perfusion and oxygenation to the fetus by relieving pressure on the vena cava and improving blood flow. This intervention is prioritized to address the underlying cause of late decelerations. Applying a fetal scalp electrode, increasing IV infusion rate, or administering oxygen may be necessary interventions but changing the client's position is the first step to take in this scenario.
A nurse receives a verbal order to administer morphine for severe pain as needed. Which entry should the nurse make in the MAR?
A. Morphine 5 mg IV every 4 hours as needed.
B. Morphine 5 mg subcutaneously every 4 hours when in pain.
C. Morphine 5 mg orally every 3 hours as needed for pain.
D. Morphine 5 mg by mouth every 5 hours as needed.
Correct answer:
The correct answer is B: 'Morphine 5 mg subcutaneously every 4 hours when in pain.' This entry accurately reflects the medication, route, dose, frequency, and condition for administration as per the verbal order. Subcutaneous route is appropriate for administering morphine. The dose and frequency align with the prescribed 'as needed' instructions. Option A includes the wrong route (IV instead of subcutaneous). Option C specifies an oral route, which is not suitable for immediate pain relief. Option D has a longer interval between doses, which may not effectively manage severe pain. Selecting option B ensures safe and appropriate administration based on the verbal order received by the nurse.
A nurse is caring for a client who is receiving an epidural block with an opioid analgesic. The nurse should monitor for which of the following findings as an adverse effect of the medication?
A. Hypnosis
B. Polyuria
C. Bilateral crackles
D. Hyperglycemia
Correct answer:
The correct answer is A: "Hypnosis." Opioid analgesics can cause central nervous system depression, which may manifest as sedation or hypnosis. This adverse effect is important for the nurse to monitor because excessive sedation can lead to respiratory depression, a serious complication. Polyuria (B) is increased urine production, not typically associated with opioid analgesics. Bilateral crackles (C) may indicate fluid overload or pulmonary edema, not a direct effect of opioids. Hyperglycemia (D) is not a common adverse effect of opioid analgesics. Therefore, the nurse should prioritize monitoring the client for signs of hypnosis when receiving an epidural block with an opioid analgesic.
A nurse is assessing a client who is at 27 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?
A. Urine protein concentration 200 mg/ 24 hr.
B. Creatinine 0.8 mg/ Dl
C. Hemoglobin 14.8 g/ dL
D. Platelet Count 60.000/ mm3
Correct answer:
The correct answer is D: "Platelet Count 60,000/ mm3." In preeclampsia, a low platelet count (thrombocytopenia) can indicate a risk for severe complications like HELLP syndrome or disseminated intravascular coagulation (DIC). Platelets are essential for blood clotting, and a low count can lead to excessive bleeding. The other options are within normal ranges or expected in pregnancy: A) Urine protein concentration of 200 mg/24 hr is indicative of proteinuria, common in preeclampsia. B) Creatinine level of 0.8 mg/dL is within normal limits. C) Hemoglobin level of 14.8 g/dL is within the normal range for pregnancy and does not directly indicate a complication like low platelet count does.
The nurse suspects early complications of immobility in a 45-year-old patient admitted for multiple stab wounds to the chest. What sign would the nurse most likely find? (Select all that apply.)
A. Increased muscle strength
B. Generalized weakness
C. Moist breath sounds
D. Limited range of motion
Correct answer:
The correct answer is A, 'Increased muscle strength.' Early complications of immobility include muscle weakness, not increased muscle strength. Immobilization can lead to muscle atrophy and weakness due to lack of use. Generalized weakness, moist breath sounds, and limited range of motion are not typically early complications of immobility. Generalized weakness may occur later as muscle mass decreases. Moist breath sounds could indicate respiratory issues unrelated to immobility, and limited range of motion may develop over time with prolonged immobility. Therefore, the nurse is most likely to find increased muscle strength as a sign of early complications of immobility in this patient.
.A nurse is evaluating the effectiveness of medication therapy for a client diagnosed with bipolar disorder. Which outcome should indicate that the medication has been effective?
A. The client reports a decrease in manic episodes.
B. The client experiences fewer mood swings.
C. The client sleeps for 8 hours each night.
D. The client maintains a stable weight.
Correct answer:
The correct answer is A: 'The client reports a decrease in manic episodes.' This outcome is the most indicative of the effectiveness of medication therapy for bipolar disorder because manic episodes are a key symptom of the disorder. By experiencing a decrease in manic episodes, it suggests that the medication is helping to stabilize the client's mood and manage the symptoms of bipolar disorder. Options B, C, and D may be important aspects of overall health and wellness, but they are not specific indicators of the effectiveness of medication therapy for bipolar disorder. It is crucial to focus on managing the core symptoms of the disorder when evaluating the effectiveness of treatment.
As a nurse working in a prenatal clinic, it is important to obtain maternal and fetal assessments. While obtaining fetal assessments, which of the following should be completed for fetal well-being?
A. Fetal movement, maternal vital signs, maternal weight
B. Fetal movement, fetal position, fetal weight
C. Fetal position, fetal heart tone, maternal weight
D. Fetal heart tones, fetal movement, fundal height
Correct answer:
In a prenatal clinic, assessing fetal well-being is crucial for monitoring the health of the fetus. The correct answer, option D, includes key components for fetal assessment. Fetal heart tones provide information about the fetal heart rate, indicating fetal well-being. Fetal movement is also essential as it signifies the activity and vitality of the fetus. Fundal height measurement helps determine fetal growth and position in the uterus, providing valuable insights into fetal development. These assessments collectively offer a comprehensive evaluation of the fetus's health and development, making option D the most appropriate choice for ensuring fetal well-being in a prenatal setting.
A nurse is assessing a client following an amniocentesis. Which of the following findings should the nurse recognize as complications? (Select all that apply).
A. Amnionitis
B. Urinary tract infection
C. Polyhydramnios
D. Leakage of amniotic fluid
Correct answer:
The correct answer is A: "Amnionitis." Amnionitis is a serious complication that can occur following an amniocentesis, where the amniotic fluid becomes infected. This can lead to various issues for both the mother and the fetus, including preterm labor, sepsis, and fetal distress. Urinary tract infection (B) is not a typical complication of amniocentesis, as it involves a different system. Polyhydramnios (C) refers to an excess of amniotic fluid, which is not a direct complication of the procedure. Leakage of amniotic fluid (D) can occur during or immediately after the procedure but is not considered a complication unless it leads to further issues such as infection or preterm labor.
What is the most important nursing intervention to prevent child abandonment by teenage mothers?
A. Providing sexual education and contraception
B. Encouraging the use of adoption agencies
C. Providing community resources for teenage mothers
D. Encouraging family support and involvement
Correct answer:
Providing community resources for teenage mothers is the most important nursing intervention to prevent child abandonment. By offering support services such as counseling, parenting classes, access to healthcare, and social services, teenage mothers are more likely to receive the assistance they need to care for their children. This intervention addresses the root causes of child abandonment by empowering mothers with the resources and skills necessary to raise their children effectively. While sexual education and contraception are essential in preventing unplanned pregnancies, providing community resources directly addresses the issue of child abandonment in this specific scenario.
RN exams clinical judgment practice questions, set 157 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
No. Nursier is independent practice. Register through the official path named on the RN exams exam guide.
The first five questions already include the rationale. Start full practice to unlock the remaining keys, missed-question review, and the rest of the bank.
Keep going past these 15 questions
Missed-question review, longer banks, and the rest of 20,000+ nursing practice questions open when you start studying.
