RN exams clinical judgment practice questions, set 158
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 158
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 assessing a newborn immediately following a vaginal birth. For which of the following findings should the nurse intervene?
A. Molding
B. Vernix Caseosa
C. Acrocyanosis
D. Sternal retractions
Show answer and rationale
Correct answer: D — Sternal retractions
The correct answer is D, 'Sternal retractions.' Sternal retractions in a newborn can indicate respiratory distress and difficulty breathing. This is a concerning finding that requires immediate intervention by the nurse. Molding (A) is the elongation of the newborn's head due to passage through the birth canal, which is a normal finding. Vernix Caseosa (B) is a waxy substance on the newborn's skin that provides protection and should be left undisturbed. Acrocyanosis (C) is the bluish discoloration of the extremities, which is a common and temporary condition in newborns. Therefore, the nurse should prioritize addressing sternal retractions to ensure the newborn's respiratory health.
Question 2
The nurse determines that the client demonstrates an understanding of preoperative teaching with which responses? (Select all that apply)
A. I will need to sign a consent form before I am given my medications prior to my surgery
B. Raise bed rails
C. Ensure fluid intake of at least 3L/day
D. Keep an oral airway at the bedside
Show answer and rationale
Correct answer: D — Keep an oral airway at the bedside
The correct responses indicate the client understands preoperative teaching related to safety measures. Keeping an oral airway at the bedside is important to ensure airway patency and assist with maintaining the client's airway during the immediate postoperative period. While signing a consent form is important, it is not directly related to demonstrating understanding of preoperative teaching. Raising bed rails is a safety measure but not specific to preoperative teaching. Ensuring fluid intake of at least 3L/day is a general health recommendation and not specific to preoperative teaching. Therefore, the correct response is D, as it directly relates to preoperative safety measures.
Question 3
A nurse is caring for a client who is at 39 weeks of gestation and is in the active phase of labor. The nurse observes late decelerations in the FHR. Which finding causes late decelerations?
A. Uteroplacental insufficiency
B. Umbilical cord compression
C. Fetal head compression
D. Maternal hypotension
Show answer and rationale
Correct answer: A — Uteroplacental insufficiency
The correct answer is A: Uteroplacental insufficiency. Late decelerations in fetal heart rate are caused by decreased blood flow and oxygen to the fetus, typically due to uteroplacental insufficiency. This condition can occur when the placenta is not functioning optimally, leading to inadequate oxygenation of the fetus. Umbilical cord compression (option B) may cause variable decelerations, fetal head compression (option C) may cause early decelerations, and maternal hypotension (option D) may lead to decreased blood flow but not specifically late decelerations. In this scenario, the nurse should address uteroplacental insufficiency promptly to ensure the well-being of the fetus.
Question 4
Which is an accurate statement about certification in nursing professional development?
A. Certification guarantees that standards of care will be met
B. Certification is a means of licensure and public protection
C. Certification measures the nurse\'s knowledge of the specialty
D. Certification measures the nurse\'s level of education
Show answer and rationale
Correct answer: B — Certification is a means of licensure and public protection
Option B is the correct answer because certification in nursing professional development is not the same as licensure. Certification is a voluntary process that validates a nurse's specialty knowledge and expertise beyond the basic requirements for licensure. It serves to ensure public protection by indicating that the nurse has met specific standards in their area of specialization. Certification does not guarantee that standards of care will be met (Option A), as it focuses on individual competence rather than organizational standards. While certification may involve testing the nurse's knowledge of the specialty (Option C), it is not solely based on education level (Option D).
Question 5
What leadership style is used to maintain a strong control in the department?
A. Laissez-faire
B. Democratic
C. Collegial
D. Autocratic
Show answer and rationale
Correct answer: D — Autocratic
The correct answer is D: Autocratic. An autocratic leadership style is characterized by a leader who maintains strong control and decision-making power in the department. This style is top-down, with the leader making decisions without seeking input from subordinates. It can be effective in situations that require quick decision-making or when clear direction is needed. Laissez-faire (A) is a hands-off approach where the leader provides little guidance or direction. Democratic (B) leadership involves group decision-making and collaboration. Collegial (C) leadership emphasizes teamwork and equal participation in decision-making, which is not focused on maintaining strong control.
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Question 6
.A nurse is evaluating a client who is taking selective serotonin reuptake inhibitors (SSRIs) for depression. Which symptom should the nurse identify as an adverse effect that requires immediate attention?
A. Increased appetite
B. Weight gain
C. Blurred vision
D. Suicidal thoughts
Correct answer:
The correct answer is D: Suicidal thoughts. This is a critical adverse effect that should be addressed immediately due to the increased risk of self-harm or suicide in individuals taking SSRIs. It is important for the nurse to closely monitor the client for any signs of worsening depression or thoughts of self-harm. While increased appetite and weight gain are common side effects of SSRIs, they are not typically considered urgent or life-threatening. Blurred vision is also a potential side effect of SSRIs, but it is not as concerning as suicidal thoughts. Therefore, the nurse should prioritize addressing and monitoring for suicidal thoughts as the top priority in this situation.
The nurse is preparing a care plan for a newly admitted postoperative client. Which nursing intervention is the most important when planning to prevent alveolar collapse?
A. Encouraging hourly coughing and deep breathing
B. I can push the button for my mother if she is too drowsy
C. My mother or I should notify the nurse if her pain is uncontrolled while using PCA
D. My mother will push the PCA button when she is experiencing increased pain
Correct answer:
The correct answer is A: 'Encouraging hourly coughing and deep breathing.' This nursing intervention is crucial for preventing alveolar collapse, also known as atelectasis, in postoperative clients. Deep breathing exercises help to expand the lungs, improve oxygenation, and prevent the collapse of the alveoli. Coughing helps to clear secretions and prevent mucus buildup in the airways, reducing the risk of atelectasis. It is essential to promote lung expansion and prevent respiratory complications in postoperative clients. The other options do not directly address the prevention of alveolar collapse and may not be as effective in supporting respiratory function postoperatively.
Which is the leading cause of death in infants younger than 1 year in the United States?
A. Congenital anomalies
B. Sudden infant death syndrome
C. Disorders related to short gestation and low birth weight
D. Maternal complications specific to the perinatal period
Correct answer:
The leading cause of death in infants younger than 1 year in the United States is congenital anomalies. These are conditions that babies are born with, such as heart defects or genetic disorders. Congenital anomalies are responsible for a significant number of infant deaths each year. While Sudden Infant Death Syndrome (SIDS) and other factors like short gestation and low birth weight or maternal complications can also contribute to infant mortality, congenital anomalies are the primary cause. It is important for healthcare providers and parents to be aware of these risks and take necessary precautions to prevent and manage congenital anomalies to reduce infant mortality rates.
A nurse is reviewing the use of inhalers with a client who has asthma. What is important to include?
A. Shake the inhaler well before use.
B. Use a spacer with the inhaler.
C. Rinse mouth after using the inhaler.
D. Take quick, deep breaths while inhaling.
Correct answer:
The correct answer is C: 'Rinse mouth after using the inhaler.' It is important to include this instruction because some medications in inhalers can cause oral thrush or a sore throat if not rinsed out of the mouth. Rinsing the mouth after using the inhaler helps to prevent these side effects and maintain oral health. Options A and D are not essential steps for using inhalers, although shaking the inhaler well before use can ensure proper medication distribution. Using a spacer (option B) can help improve medication delivery, especially for those who have difficulty coordinating inhalation with the device, but rinsing the mouth is more crucial for oral health in this scenario.
A client has been diagnosed with organic brain pathology. He is presenting with signs and symptoms of total or partial loss of the ability to recognize familiar objects or people through sensory stimulation. The nurse correctly identifies the signs and symptoms as which of the following?
A. Apraxia
B. The surgeon will want me to ambulate as soon as possible after my surgery
C. My nurse will want me to take the deepest breaths I can tolerate following my surgery
D. I may experience some constipation if I am taking much pain medication after my surgery
Correct answer:
The correct answer is B: 'The surgeon will want me to ambulate as soon as possible after my surgery.' The signs and symptoms described in the question are indicative of visual agnosia, a condition where there is a loss of ability to recognize familiar objects or people through sensory stimulation. Apraxia refers to the inability to perform purposeful movements despite the presence of intact motor function. The other options provided do not relate to the specific signs and symptoms described in the scenario. After surgery, early ambulation is crucial to prevent complications such as blood clots and muscle weakness, making option B the most appropriate response in this context.
A nurse is planning to apply a belt restraint to a client who is confused and at risk for falls. Which of the following actions should the nurse make?
A. Apply the belt under the client’s gown.
B. Allow four finger widths between the restraint and the client.
C. Place the belt across the client’s chest.
D. Fasten the client’s restraint using a quick-release tie.
Correct answer:
The correct answer is D: "Fasten the client's restraint using a quick-release tie." This is the appropriate action because using a quick-release tie allows for quick removal in case of an emergency or if the client needs to be repositioned. Options A and C are incorrect as the belt should be applied over the client's clothing, not under a gown, and across the client's waist, not chest. Option B is incorrect because allowing four finger widths between the restraint and the client is not specific guidance for applying the restraint effectively. Overall, using a quick-release tie ensures the safety and well-being of the client while also allowing for easy removal when necessary.
Which is most suggestive that a nurse has a nontherapeutic relationship with a patient and family?
A. Staff assignments to the patient are rotated.
B. Staff and family communication is minimal.
C. The nurse is viewed as intrusive.
D. The nurse shares personal information.
Correct answer:
Option D, 'The nurse shares personal information,' is the most suggestive of a nontherapeutic relationship with a patient and family because it blurs professional boundaries. Sharing personal information can lead to role confusion, lack of trust, and compromised patient care. Nurses should maintain a professional demeanor and focus on the patient's needs rather than sharing personal details that may distract from the therapeutic relationship. Options A, B, and C do not directly indicate a nontherapeutic relationship as staff rotation, minimal communication, and being viewed as intrusive can have various interpretations and may not necessarily indicate a negative relationship.
.A nurse is interviewing a distressed client, who relates being fired after 15 years of loyal employment. Which of the following questions would best assist the nurse to determine the client\'s appraisal of the situation? Select all that apply.
A. What caused the stressful situations?
B. Have you ever experienced a similar stressful situation?
C. Who do you think is to blame for this situation?
D. Why do you think you were fired from your job?
Correct answer:
Option B, 'Have you ever experienced a similar stressful situation?' is the best question to assist the nurse in determining the client's appraisal of the situation because it allows the client to reflect on past experiences and potentially draw parallels or contrasts to the current situation. This question can help the nurse gain insight into how the client typically copes with stress and adversity, as well as how they may be processing the current event in relation to their past experiences. Options A, C, and D may be more focused on assigning blame or causation, which may not be as helpful in understanding the client's emotional response and perspective in this situation.
.A client is experiencing a moderate level of anxiety. Which is an example of an appropriate nursing intervention?
A. Allow the client to pace in a safe environment.
B. Encourage the client to discuss feelings.
C. Help the client identify the cause of anxiety.
D. Provide a distraction for the client.
Correct answer:
Option A, allowing the client to pace in a safe environment, is an appropriate nursing intervention for a client experiencing moderate anxiety. This intervention provides the client with a physical outlet for their anxiety, allowing them to release excess energy and tension in a safe manner. Pacing can help the client to regulate their emotions and reduce feelings of restlessness or agitation. Encouraging the client to pace also promotes movement and physical activity, which can have a calming effect on the individual. By choosing this intervention, the nurse is addressing the client's immediate needs and offering a practical strategy for managing their anxiety effectively.
A nurse is instructing a client on postoperative care after cataract surgery. What should the client avoid?
A. Avoid bending over.
B. Avoid lifting heavy objects.
C. Avoid rubbing the eye.
D. Avoid sunlight exposure.
Correct answer:
The correct answer is B: 'Avoid lifting heavy objects.' After cataract surgery, it is important for the client to avoid lifting heavy objects to prevent strain on the eye and potential complications. Lifting heavy objects can increase intraocular pressure, which may impede the healing process and lead to complications such as bleeding or increased risk of infection. It is crucial for the client to follow this precaution to ensure a smooth recovery and optimal healing. While avoiding bending over, rubbing the eye, and sunlight exposure are also important postoperative care instructions, lifting heavy objects poses a more direct risk to the surgical site and overall recovery.
RN exams clinical judgment practice questions, set 158 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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