RN exams clinical judgment practice questions, set 163
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 163
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
Preparing the client for abdominal surgery, the nurse delegates which tasks to the unlicensed assistive personnel (UAP)? (Select all that apply)
A. Vital signs
B. Insertions of Nasogastric tube (NGT)
C. Height and weight
D. Obtain operative consent
Show answer and rationale
Correct answer: D — Obtain operative consent
The nurse should delegate obtaining operative consent to the unlicensed assistive personnel (UAP) because it does not require specialized nursing knowledge or skills. UAP can assist with tasks that do not involve interpretation, assessment, or interventions that require nursing judgment. Vital signs and height/weight measurements may require interpretation and assessment by a licensed nurse. Insertion of a nasogastric tube (NGT) is a skilled procedure that requires specialized training and should be performed by a licensed healthcare provider. Therefore, the correct task to delegate to the UAP in this scenario is obtaining operative consent.
Question 2
A nurse is collecting data about a client’s oral care. The client wears dentures and reports having mouth sores. The nurse should identify which of the following oral care practices by the client as a possible cause of the mouth sores?
A. Soaks dentures in water after removal.
B. Applies an adhesive to seal dentures in place.
C. Wears dentures while sleeping at night.
D. Rinses dentures after meals.
Show answer and rationale
Correct answer: C — Wears dentures while sleeping at night.
The correct answer is C: 'Wears dentures while sleeping at night.' Wearing dentures continuously, especially while sleeping, can lead to a lack of exposure to saliva and air, creating a warm and moist environment that promotes bacterial growth and can cause mouth sores. Removing dentures at night allows the oral tissues to rest and recover. Soaking dentures in water, applying adhesive, and rinsing dentures after meals are all common and appropriate oral care practices that should not directly cause mouth sores. Therefore, the client wearing dentures while sleeping at night is the oral care practice that could potentially lead to mouth sores.
Question 3
A nurse is teaching a client about proper foot care with diabetes. What advice is crucial?
A. Soak feet in hot water daily.
B. Wear tight-fitting shoes.
C. Inspect feet daily.
D. Walk barefoot as much as possible.
Show answer and rationale
Correct answer: C — Inspect feet daily.
The correct answer is C. Inspecting feet daily is crucial for individuals with diabetes as they are at higher risk of developing foot problems. Regular foot inspections can help identify any issues like cuts, sores, blisters, or signs of infection early on, allowing for prompt treatment and prevention of complications. Soaking feet in hot water daily (A) can actually increase the risk of skin damage and infection. Tight-fitting shoes (B) can lead to pressure points and increase the risk of foot ulcers. Walking barefoot (D) can also increase the risk of injury and infection for individuals with diabetes due to decreased sensation in the feet.
Question 4
.A nurse is assessing a client who has been diagnosed with schizoid personality disorder. Which of the following behaviors should the nurse expect?
A. Preference for solitary activities
B. Detachment from social relationships
C. Indifference to praise or criticism
D. Anxiety in social situations
Show answer and rationale
Correct answer: C — Indifference to praise or criticism
The correct answer is C: 'Indifference to praise or criticism.' Schizoid personality disorder is characterized by a pattern of detachment from social relationships and a limited range of emotional expression. Individuals with this disorder typically prefer solitary activities and tend to be indifferent to both positive and negative feedback from others. This behavior reflects the core features of schizoid personality disorder, such as emotional coldness and a lack of desire for close relationships. Options A, B, and D are not as characteristic of schizoid personality disorder as the indifference to praise or criticism described in option C.
Question 5
After teaching a group of adolescents about female reproductive anatomy, the nurse determines that the teaching was successful when the adolescents identify which structure as the site of fertilization?
A. vagina
B. uterus
C. fallopian tubes
D. vestibule
Show answer and rationale
Correct answer: C — fallopian tubes
The correct answer is C: 'fallopian tubes.' The fallopian tubes are the structures where fertilization typically occurs in the female reproductive system. After ovulation, an egg is released from the ovary and travels through the fallopian tube, where it may be fertilized by sperm. The fertilized egg then continues its journey to the uterus for implantation. The vagina is not the site of fertilization but is the birth canal and a part of the reproductive system. The uterus is where a fertilized egg implants and grows into a fetus during pregnancy. The vestibule is the entrance to the vagina and does not play a direct role in fertilization.
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Question 6
When assessing a patient who is experiencing acute pain and comparing the findings with the patient\'s baseline, what can the LPN/LVN expect to find?
A. Increase in blood pressure
B. Decrease in respiratory rate
C. No change in vital signs
D. No change in behavior
Correct answer:
When a patient is experiencing acute pain, the sympathetic nervous system is activated, leading to physiological responses such as increased heart rate and blood pressure. Therefore, the LPN/LVN can expect to find an increase in blood pressure when assessing a patient with acute pain compared to their baseline. Acute pain can trigger a 'fight or flight' response in the body, causing an elevation in vital signs. Respiratory rate may also increase due to stress and anxiety associated with pain. However, a decrease in respiratory rate or no change in vital signs or behavior would not typically be expected in a patient experiencing acute pain.
.A nurse is assessing a client who has been diagnosed with antisocial personality disorder. Which of the following behaviors should the nurse expect the client to exhibit?
A. A lack of remorse for wrongdoing
B. A fear of gaining weight
C. A need for constant reassurance
D. A willingness to take responsibility for actions
Correct answer:
The correct answer is A: 'A lack of remorse for wrongdoing.' Individuals with antisocial personality disorder typically display a pervasive pattern of disregard for and violation of the rights of others. They often demonstrate a lack of empathy and remorse for their actions, leading to behaviors such as deceitfulness, impulsivity, and aggression. This lack of remorse is a key characteristic of this disorder and can manifest in various harmful actions towards others without feeling guilt or regret. Options B, C, and D are less likely behaviors associated with antisocial personality disorder, making them incorrect choices for this question.
What is the major cause of death for children older than 1 year in the United States?
A. Heart disease
B. Childhood cancer
C. Unintentional injuries
D. Congenital anomalies
Correct answer:
The major cause of death for children older than 1 year in the United States is unintentional injuries. These include accidents such as drowning, car accidents, falls, burns, and poisoning. Children are naturally curious and may not always be aware of potential dangers, making them more susceptible to unintentional injuries. While heart disease and childhood cancer are serious health concerns, unintentional injuries are the leading cause of death in this age group due to the risks associated with everyday activities. Congenital anomalies refer to birth defects and are not typically the primary cause of death in children older than 1 year.
You are asked by your instructor to discuss about Contingency Theory. What should you include in your discussion?
A. It is a theory in leadership that views the pattern of leader behavior as dependent on the interaction of the personality and the needs of the situation.
B. It considers that leaders must provide followers the sense of security and approval and discipline to succeed in an output.
C. It emphasizes that both leaders and followers should act on one another to raise their motivation.
D. It states that leadership qualities inspire followers to be motivated by what they do.
Correct answer:
The correct answer is A. Contingency Theory in leadership posits that the effectiveness of a leader is contingent upon the interplay between the leader's traits and the characteristics of the situation. This theory acknowledges that different situations may require different leadership styles for optimal results. By understanding this theory, leaders can adapt their behaviors to suit the needs of specific circumstances, ultimately leading to improved outcomes. Therefore, it is essential to include this key concept in your discussion on Contingency Theory to demonstrate an understanding of how leadership effectiveness is context-dependent.
A client was recently treated for toxic shock syndrome. Based on her history. what contraceptive method should the client and her partner avoid?
A. Diaphragm (cap)
B. Oral progestin(minipill)
C. Vaginal sheath
D. Condom
Correct answer:
The correct answer is A: Diaphragm (cap). Toxic shock syndrome is a rare but serious condition caused by bacterial toxins. Since the diaphragm is inserted into the vagina and can potentially introduce bacteria, it may increase the risk of toxic shock syndrome in individuals who have a history of the condition. It is important for the client and her partner to avoid using the diaphragm as a contraceptive method to prevent any potential complications. The other contraceptive methods listed, such as the oral progestin (minipill), vaginal sheath, and condom, do not pose the same risk of exacerbating toxic shock syndrome as the diaphragm does.
To ensure homogenization when diluting powdered medication in a vial, the nurse should:
A. Shake the vial vigorously
B. Roll the vial gently between the palms
C. Invert the vial and let it stand for 1 minute
D. Do nothing after adding the solution to the vial
Correct answer:
The correct answer is B: 'Roll the vial gently between the palms.' When diluting powdered medication in a vial, shaking the vial vigorously may create air bubbles and uneven mixing. Rolling the vial gently between the palms helps to ensure thorough homogenization without introducing air bubbles. Inverting the vial and letting it stand for 1 minute may not be sufficient to completely mix the medication. Doing nothing after adding the solution to the vial will not ensure proper mixing. Therefore, rolling the vial gently between the palms is the most appropriate method to ensure homogenization when diluting powdered medication in a vial.
The nurse is caring for a post-stroke client with expressive (Broca\'s) aphasia. Which nursing intervention is appropriate for the nurse to communicate with the client?
A. Refer the client to the speech-language pathologist
B. Monitor for signs of infection in the surgical wound
C. Administration of bronchodilators via nebulizer
D. Applying supplemental O2/2L via nasal cannula
Correct answer:
The correct answer is C. Administration of bronchodilators via nebulizer is the appropriate nursing intervention for a post-stroke client with expressive (Broca's) aphasia. Bronchodilators help in managing respiratory issues, which are common post-stroke complications. Clients with expressive aphasia may have difficulty speaking but can understand others. Options A, B, and D are not relevant to communicating with a client with expressive aphasia or addressing their immediate needs post-stroke. Referring the client to a speech-language pathologist (option A) would be appropriate for addressing communication challenges in the long term.
A nurse is caring for a client who is primigravida, at term, and having contractions but is statins that she is \"not really sure if she is in labor or not.\" Which of the following should the nurse recognize as a sign of true labor?
A. Rupture of the membranes
B. Changes in the cervix
C. Station of the presenting part
D. Pattern of contractions
Correct answer:
The correct answer is B: "Changes in the cervix." True labor is characterized by progressive changes in the cervix, such as effacement (thinning) and dilation (opening). These changes indicate that the body is preparing for childbirth. Rupture of the membranes (A) can occur before or during labor but is not a definitive sign of true labor. Station of the presenting part (C) refers to the position of the baby's head in the pelvis and is important during the birth process but is not a specific sign of true labor. The pattern of contractions (D) is essential, but alone it does not confirm true labor without accompanying cervical changes.
A patient is catheterized with a #16 indwelling urinary (Foley) catheter to determine if:
A. Trauma has occurred
B. His 24-hour output is adequate
C. He has a urinary tract infection
D. Residual urine remains in the bladder after voiding
Correct answer:
The correct answer is B: "His 24-hour output is adequate." When a patient is catheterized with an indwelling urinary catheter, it allows for accurate measurement of urine output over a 24-hour period. This can help healthcare providers assess the patient's renal function, fluid balance, and overall health status. Options A, C, and D are not typically reasons for catheterization with an indwelling urinary catheter. Trauma assessment may involve other diagnostic procedures, urinary tract infections are usually diagnosed through urine analysis, and residual urine can be assessed through other methods such as ultrasound or bladder scans.
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.' When receiving a verbal order for administering medication, it is crucial to document the exact route of administration specified by the healthcare provider. In this scenario, the order specifies subcutaneous administration, making option B the correct choice. Options A, C, and D suggest different routes of administration (IV, orally, and by mouth) than what was specified in the order, which could lead to medication errors or improper dosing. It is essential for nurses to accurately document medication orders to ensure safe and effective patient care.
RN exams clinical judgment practice questions, set 163 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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