RN exams clinical judgment practice questions, set 167
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 167
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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
A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations should the nurse expect?
A. 2+ deep tendon reflex
B. Proteinuria of 200mg in a 24-hr specimen
C. Polyuria
D. Blurred vision
Show answer and rationale
Correct answer: D — Blurred vision
The correct answer is D: "Blurred vision." Blurred vision is a common manifestation of severe preeclampsia due to increased intracranial pressure and retinal edema. It is caused by vasospasms affecting the blood vessels in the eyes. Deep tendon reflexes (option A) are typically brisk in preeclampsia, so 2+ deep tendon reflexes may not be indicative of severe preeclampsia. Proteinuria of 200mg in a 24-hr specimen (option B) is a sign of preeclampsia, but not specifically severe preeclampsia. Polyuria (option C) is not typically associated with preeclampsia, as it is more commonly related to other conditions like diabetes mellitus. Therefore, the nurse should expect blurred vision as a manifestation of severe preeclampsia.
Question 2
A nurse is providing teaching to the parents of a newborn about how to care for his circumcision at home. What instructions should the nurse include in the teaching?
A. Encourage nonnutritive sucking for pain relief.
B. Apply alcohol to the circumcision site.
C. Wash the circumcision site with soap and water.
D. Remove the circumcision clamp after 24 hrs.
Show answer and rationale
Correct answer: A — Encourage nonnutritive sucking for pain relief.
The correct answer is A: 'Encourage nonnutritive sucking for pain relief.' Nonnutritive sucking, such as using a pacifier, can help soothe the baby and provide pain relief after circumcision. Answer B is incorrect because alcohol should not be applied to the circumcision site as it can cause irritation and delay healing. Answer C is incorrect as soap and water should not be used on the circumcision site; instead, gentle cleaning with warm water is recommended. Answer D is incorrect because the circumcision clamp should not be removed by the parents; it will fall off on its own within a few days. Therefore, the best instruction for caring for a circumcision at home is to encourage nonnutritive sucking for pain relief.
Question 3
A nurse is planning care for a newborn who has neonatal abstinence syndrome. Which of the following interventions should the nurse include in the plan of care?
A. Increase the newborn\'s visual stimulation
B. Weigh the newborn every other day
C. Discourage parental interaction until after a social evaluation
D. Swaddle the newborn in a flexed position
Show answer and rationale
Correct answer: D — Swaddle the newborn in a flexed position
The correct answer is D: 'Swaddle the newborn in a flexed position.' Neonatal abstinence syndrome results from the sudden discontinuation of substances that the baby was exposed to in utero. Swaddling the newborn in a flexed position provides comfort and security, mimicking the snug environment of the womb. This can help to reduce symptoms of withdrawal and promote calmness in the newborn. Increasing visual stimulation (option A) may overwhelm the baby, and weighing the newborn every other day (option B) is important but not directly related to managing neonatal abstinence syndrome. Discouraging parental interaction (option C) is not recommended, as parental bonding and care are crucial for the baby's well-being.
Question 4
A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn?
A. Apply a cool back for 10 minutes to the heel prior to the puncture
B. Request a prescription for IM analgesic
C. Use a manual lace blade to pierce the skin
D. Place the newborn skin to skin on the mother’s chest
Show answer and rationale
Correct answer: D — Place the newborn skin to skin on the mother’s chest
Placing the newborn skin to skin on the mother's chest is an effective technique to help minimize the pain of a heel stick procedure. This method, known as kangaroo care, promotes bonding, warmth, and comfort for the newborn, which can reduce stress and pain perception during the procedure. The close contact with the mother's skin also helps regulate the newborn's body temperature and heart rate. Using a cool pack, requesting an IM analgesic, or using a manual lace blade are not recommended practices for minimizing pain during a heel stick procedure in a newborn. Therefore, placing the newborn skin to skin on the mother's chest is the most appropriate and beneficial technique in this scenario.
Question 5
A nurse is assessing a newborn upon admission to the nursery. Which of the following should the nurse expect?
A. Bulging fontanels
B. Nasal flaring
C. Length from head to heel of 40 cm (15.7 in)
D. Chest circumference 2 cm (0.8 in) smaller than the head circumference
Show answer and rationale
Correct answer: D — Chest circumference 2 cm (0.8 in) smaller than the head circumference
The correct answer is D: 'Chest circumference 2 cm (0.8 in) smaller than the head circumference.' This is an expected finding in a newborn as the chest is typically smaller in circumference compared to the head. The head circumference is usually larger than the chest circumference in newborns due to the proportionate growth of the head in relation to the rest of the body. Bulging fontanels (option A) may indicate increased intracranial pressure, nasal flaring (option B) could be a sign of respiratory distress, and a length of 40 cm (15.7 in) (option C) is within the normal range for a newborn but is not specifically related to the assessment of chest circumference in this context.
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Question 6
A nurse is caring for a client who is 4 hr postpartum and is experiencing hypovolemic shock. Which of the following actions should the nurse take?
A. Administer indomethacin
B. Insert a second using a 22-gauge IV catheter.
C. Insert an indwelling urinary catheter.
D. Administer oxygen at 4 L/min via nasal cannula.
Correct answer:
The correct answer is C: 'Insert an indwelling urinary catheter.' In hypovolemic shock, the body is experiencing a significant volume loss which can lead to decreased urine output. Inserting an indwelling urinary catheter will help monitor the client's urine output closely, which is crucial in assessing the client's fluid status and response to treatment. Administering indomethacin (A) is not indicated in hypovolemic shock. Inserting a second IV using a 22-gauge catheter (B) may be necessary for fluid resuscitation, but monitoring urine output is a priority. Administering oxygen (D) is important, but assessing and managing fluid volume status is the priority in hypovolemic shock.
The nurse explains which of the following is a purpose of preconception care?
A. Ensure that pregnancy complication will not occur
B. Ensure the woman knows about prenatal care
C. Encourage health lifestyle for families desiring pregnancy
D. Identify women who should not become pregnant
Correct answer:
The purpose of preconception care is to encourage healthy lifestyle practices for individuals or families desiring pregnancy. This includes optimizing health before conception to improve pregnancy outcomes and reduce the risk of complications. Preconception care focuses on factors such as nutrition, physical activity, managing chronic conditions, and avoiding harmful substances. It aims to ensure that both partners are in optimal health before attempting to conceive, which can have a positive impact on the health of the mother, baby, and family overall. Therefore, option C is the correct answer as it best reflects the main goal of preconception care.
A nurse is providing teaching about terbutaline to a client who is experiencing preterm labor. Which of the following statements by the client indicates an understanding of the teaching?
A. The medication could cause me to experience heart palpitations.
B. This medication could cause me to experience blurred vision.
C. This medication could cause me to experience ringing in my ears.
D. This medication could cause me to experience frequent urination.
Correct answer:
The correct answer is A: 'The medication could cause me to experience heart palpitations.' Terbutaline is a beta-2 adrenergic agonist used to relax the uterine smooth muscle and delay preterm labor. One of the common side effects of terbutaline is tachycardia or heart palpitations due to its effect on beta-2 receptors in the heart. It is important for the client to be aware of this potential side effect to monitor their symptoms and report any concerning changes to their healthcare provider. Blurred vision (option B), ringing in the ears (option C), and frequent urination (option D) are not typically associated with terbutaline use in preterm labor.
.Vitamin deficiencies, especially the B-complex vitamins, seldom occur in isolation. Folate, a B-complex vitamin, is the exception because it functions separately from other vitamins.
A. Both statements are true.
B. Both statements are false.
C. The first statement is true; the second is false.
D. The first statement is false; the second is true.
Correct answer:
The first statement, 'Vitamin deficiencies, especially the B-complex vitamins, seldom occur in isolation,' is true because B-complex vitamins often work together in various metabolic pathways, so a deficiency in one may indicate a deficiency in others. The second statement, 'Folate, a B-complex vitamin, is the exception because it functions separately from other vitamins,' is false. Folate actually works closely with other B-complex vitamins, especially vitamin B12, in processes like DNA synthesis and red blood cell formation. Therefore, option C is correct because the first statement is true, but the second statement is false.
The nurse is caring for a patient with peptic ulcer disease. Which finding is most concerning?
A. Epigastric pain relieved by eating
B. Nausea and vomiting
C. Melena
D. Heartburn
Correct answer:
The correct answer is C: 'Melena.' Melena is a concerning finding in a patient with peptic ulcer disease as it indicates upper gastrointestinal bleeding. Melena is characterized by black, tarry stools due to the presence of digested blood. This finding suggests that there is active bleeding in the gastrointestinal tract, which can be a serious complication of peptic ulcer disease and requires immediate medical attention. Epigastric pain relieved by eating (A), nausea and vomiting (B), and heartburn (D) are common symptoms associated with peptic ulcer disease but are not as concerning as melena, which signifies active bleeding.
The nurse is assessing a group of patients. Which patient would most likely qualify for Medicaid?
A. A 35-year-old unemployed single mother with diabetes
B. A 70-year-old Medicare recipient with retirement income who needs to be in a long-term care facility
C. An 80-year-old blind woman living in her own home who has inadequate private insurance
D. A 67-year-old stroke victim with Medicare Part A and an income from investments
Correct answer:
The correct answer is A because Medicaid is a government program that provides healthcare coverage to low-income individuals and families. Given that the patient is an unemployed single mother, she is more likely to qualify for Medicaid due to her low income status. The other options mention Medicare, which is a federal health insurance program for people aged 65 and older, and individuals with certain disabilities. The 80-year-old blind woman may also qualify for Medicaid due to her inadequate private insurance and age, but the most likely candidate based on the given information is the unemployed single mother with diabetes.
The nurse is assessing a patient with dehydration. Which finding is expected?
A. Increased blood pressure
B. Decreased skin turgor
C. Weight gain
D. Bradycardia
Correct answer:
The correct answer is B: Decreased skin turgor. Dehydration leads to a decrease in the body's fluid volume, causing the skin to lose elasticity and turgor. This results in the skin appearing less firm and slower to return to its normal position when pinched. Increased blood pressure (choice A) is not typically associated with dehydration as the body tries to conserve fluid. Weight gain (choice C) is unlikely in dehydration as it involves fluid loss. Bradycardia (choice D) is not a common finding in dehydration; instead, tachycardia may occur as the body compensates for the decreased fluid volume by increasing the heart rate.
.Each has cariostatic properties, except one. Which is the exception?
A. Eggs
B. Instant oatmeal
C. Cheese
D. Seafood
Correct answer:
The correct answer is B: Instant oatmeal. Instant oatmeal is not typically considered to have cariostatic properties, as it often contains added sugars that can contribute to tooth decay. Eggs, cheese, and seafood are all examples of foods that have cariostatic properties. Eggs contain protein and essential nutrients that can help promote oral health. Cheese is rich in calcium and phosphorus, which can remineralize tooth enamel. Seafood, such as fish and shellfish, contain minerals like fluoride and phosphorus that can strengthen teeth and prevent decay. Therefore, instant oatmeal is the exception among the options provided.
A nurse is teaching a client about proper nutrition. What should be included for a balanced diet?
A. High protein intake
B. Low carb intake
C. Variety of fruits and vegetables
D. Increase in dietary fats
Correct answer:
The correct answer is C: 'Variety of fruits and vegetables.' A balanced diet should include a variety of fruits and vegetables to ensure the intake of essential vitamins, minerals, and fiber necessary for overall health. Fruits and vegetables provide antioxidants and phytochemicals that help prevent chronic diseases. High protein intake (A) is important but should be balanced with other food groups. Low carb intake (B) may not be suitable for all individuals and can lead to nutrient deficiencies. Increasing dietary fats (D) should be done with caution, focusing on healthy fats like those found in nuts, seeds, and avocados.
Pain receptors in the skin, connective tissue, bone, joints, and muscles are classified as __________.
A. nociceptors
B. mechanoreceptors
C. thermoreceptors
D. nociceptors
Correct answer:
Pain receptors in the skin, connective tissue, bone, joints, and muscles are classified as nociceptors. Nociceptors are specialized nerve endings that respond to potentially damaging stimuli by sending signals to the brain, which are interpreted as pain. These receptors help us detect harmful or potentially harmful stimuli, triggering a protective response. Mechanoreceptors, on the other hand, respond to mechanical stimuli such as touch or pressure. Thermoreceptors detect changes in temperature. Therefore, in this scenario, the correct classification for the pain receptors in the mentioned areas is nociceptors (Option A).
RN exams clinical judgment practice questions, set 167 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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