RN exams clinical judgment practice questions, set 17
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 17
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
An elderly client was well until 12 hours ago, when she reported to her family that during the evening she saw strange faces peering in her windows and in the middle of the night awakened to see a man standing at the foot of her bed. She admits to being very frightened. She is presently pacing and somewhat agitated in the examining room. The client's family reports that the client has recently been to the doctor, who made some medication changes, although they are unsure what the changes were. Which nursing intervention should the nurse implement at the time of this client's admission?
A. Interact with the client on an adult to child level.
B. Place the client in a safe, nonstimulating environment.
C. Ask client why she thinks someone would be trying to frighten her.
D. Explain to the family that the client will be restrained for her own good.
Show answer and rationale
Correct answer: B — Place the client in a safe, nonstimulating environment.
The correct answer is B: Place the client in a safe, nonstimulating environment. This is the most appropriate nursing intervention because the client is experiencing hallucinations and agitation, which could be due to the recent medication changes. Placing the client in a safe, calm environment can help reduce stimulation and provide a sense of security. This intervention addresses the client's immediate needs by ensuring her safety and promoting a sense of comfort.
Incorrect answers:
A: Interact with the client on an adult to child level - This is not appropriate as it does not address the client's current state of distress and could potentially worsen the situation.
C: Ask client why she thinks someone would be trying to frighten her - This is not the priority at this time, as the client is experiencing hallucinations and agitation that need to be managed first.
D: Explain to the family that the client will be restrained for her own good - Restraints should only be used as a last resort and should not be considered
Question 2
An adult is diagnosed with disseminated intravascular coagulation. The nurse should identify that the client is at risk for which of the following nursing diagnosis?
A. Risk for increased cardiac output related to fluid volume excess
B. Disturbed sensory perception related to bleeding into tissues
C. Alteration in tissue perfusion related to bleeding and diminished blood flow
D. Risk for aspiration related to constriction of the respiratory musculature
Show answer and rationale
Correct answer: C — Alteration in tissue perfusion related to bleeding and diminished blood flow
The correct answer is C: Alteration in tissue perfusion related to bleeding and diminished blood flow. Disseminated intravascular coagulation (DIC) is a condition where blood clots form throughout the body, leading to both bleeding and clotting. This can result in decreased blood flow to tissues, causing tissue perfusion issues.
Explanation:
1. Option A: Risk for increased cardiac output related to fluid volume excess is incorrect because DIC can lead to bleeding, causing a decrease in blood volume and potentially decreasing cardiac output.
2. Option B: Disturbed sensory perception related to bleeding into tissues is incorrect as DIC primarily affects blood clotting and bleeding, not sensory perception.
3. Option D: Risk for aspiration related to constriction of the respiratory musculature is incorrect as DIC does not directly cause constriction of respiratory muscles, but rather impacts the clotting and bleeding processes in the body.
In summary, the correct answer is C because DIC can lead to altered tissue perfusion
Question 3
After fasting from 10 p.m. the previous evening, a client finds out that the blood test has been canceled. The client swears at the nurse and states, "You are incompetent!" Which is the nurse's best response?
A. "Do you believe that I was the cause of your blood test being canceled?"
B. "I see that you are upset, but I feel uncomfortable when you swear at me."
C. "Have you ever thought about ways to express anger appropriately?"
D. "I'll give you some space. Let me know if you need anything."
Show answer and rationale
Correct answer: B — "I see that you are upset, but I feel uncomfortable when you swear at me."
The correct answer is B: "I see that you are upset, but I feel uncomfortable when you swear at me." This response acknowledges the client's emotion, sets a boundary against inappropriate behavior, and expresses the nurse's discomfort without being confrontational. It maintains a professional and therapeutic communication while addressing the client's behavior.
Choice A: "Do you believe that I was the cause of your blood test being canceled?" This response can come off as defensive and may escalate the situation by questioning the client's perception.
Choice C: "Have you ever thought about ways to express anger appropriately?" This response may be perceived as patronizing or dismissive of the client's feelings, potentially leading to further frustration.
Choice D: "I'll give you some space. Let me know if you need anything." While giving space can be helpful, this response does not directly address the client's inappropriate behavior or set boundaries, missing an opportunity to address the behavior constructively.
Question 4
Which of the following types of study should the nurse researcher choose if the goal is to identify the long-term benefits and risks of a particular nursing intervention for senior citizens living in the community?
A. Cross-sectional study
B. Ecological study
C. Clinical trial
D. Retrospective analysis
Show answer and rationale
Correct answer: C — Clinical trial
The correct answer is C: Clinical trial. A clinical trial is the most appropriate type of study to identify the long-term benefits and risks of a nursing intervention in senior citizens. Clinical trials involve controlled experimentation with participants assigned to different groups, allowing for comparison of outcomes over time. This design enables researchers to assess the effectiveness and safety of interventions in a systematic and rigorous manner.
Explanation of why other choices are incorrect:
A: Cross-sectional study - This type of study provides a snapshot of a population at a specific point in time and does not allow for the assessment of long-term benefits and risks.
B: Ecological study - Focuses on group-level data rather than individual-level data, making it less suitable for assessing individual outcomes over time.
D: Retrospective analysis - Involves looking back at historical data, which may not provide the necessary controlled environment to evaluate the long-term effects of a nursing intervention.
Question 5
Which action should be performed first when assessing a hospitalized patient with shortness of breath?
A. Examine only the body areas related to the problem.
B. Obtain a thorough history and physical assessment from the family.
C. Obtain baseline information first, then do a complete assessment.
D. Examine the entire body to determine if the problem is linked to something else.
Show answer and rationale
Correct answer: C — Obtain baseline information first, then do a complete assessment.
The correct action is to obtain baseline information first, then do a complete assessment (Choice C). This is important as it allows the healthcare provider to gather initial vital signs and key information before proceeding with a thorough assessment. By obtaining baseline information first, the healthcare provider can assess the patient's current status and identify any urgent needs requiring immediate attention. This approach helps in prioritizing the assessment and subsequent interventions.
Examining only the body areas related to the problem (Choice A) may lead to missing important clues to the patient's condition. Obtaining a thorough history and physical assessment from the family (Choice B) can provide valuable information but should not be the first step in assessing the patient's immediate needs. Examining the entire body to determine if the problem is linked to something else (Choice D) is not the most efficient approach as it may delay identifying and addressing the primary issue causing shortness of breath.
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Question 6
A community in the New Madrid fault zone experiences an earthquake resulting in injuries from propelled objects and abrasions for many victims. The local supply of antibiotics is quickly exhausted. Local authorities would contact the:
A. Commissioned Corps Readiness Force.
B. Strategic National Stockpile.
C. Department of Homeland Security.
D. local Young Men's Christian Association (YMCA).
Correct answer:
The correct answer is B: Strategic National Stockpile. This is because the Strategic National Stockpile is a federal repository of antibiotics, medical supplies, and equipment to respond to public health emergencies. In this scenario, the local supply of antibiotics is exhausted, so contacting the Strategic National Stockpile would provide the necessary antibiotics to treat the injured victims.
Explanation for why other choices are incorrect:
A: The Commissioned Corps Readiness Force is a team of health professionals who can be deployed during public health emergencies, but they do not specifically store or distribute medical supplies like antibiotics.
C: The Department of Homeland Security focuses on national security and disaster response, but they do not directly handle the distribution of medical supplies like antibiotics.
D: The local Young Men's Christian Association (YMCA) is a community organization that is not equipped to provide medical supplies for emergency response situations like this earthquake scenario.
The nurse is caring for a pregnant patient who is at 25 weeks gestation and is concerned about gestational diabetes. Which of the following symptoms should the nurse educate the patient to watch for?
A. Increased thirst and frequent urination
B. Severe leg cramps and dizziness
C. Constant fatigue and swollen feet
D. Shortness of breath and dizziness upon standing
Correct answer:
The correct answer is A: Increased thirst and frequent urination. These symptoms are indicative of gestational diabetes due to elevated blood sugar levels. Increased thirst is a result of the body trying to dilute the excess glucose through increased fluid intake, leading to frequent urination. This occurs because the kidneys work to eliminate the excess glucose from the blood by excreting it in the urine. Therefore, educating the patient to watch for these symptoms is crucial for early detection and management of gestational diabetes.
Choices B, C, and D are incorrect as they do not directly correlate with the symptoms of gestational diabetes. Severe leg cramps and dizziness (Choice B) may be related to other factors such as dehydration or electrolyte imbalance. Constant fatigue and swollen feet (Choice C) could be common symptoms during pregnancy but are not specific to gestational diabetes. Shortness of breath and dizziness upon standing (Choice D) are more likely to be related to issues such as anemia or changes
Researchers of a bacteriological laboratory examine tinned meat for botulinic toxin. For this purpose a group of mice was injected with an extract of the material under examination and antitoxic antibotulinic serum of A, B, E types. A control group of mice was injected with the same extract but without antibotulinic serum. What serological reaction was applied?
A. Neutralization
B. Precipitation
C. Complement binding
D. Double immune diffusion
Correct answer:
The correct answer is A: Neutralization. In this experiment, the researchers used antitoxic antibotulinic serum of different types to neutralize the botulinic toxin in tinned meat extract injected into mice. Neutralization is the process of rendering a toxin harmless by combining it with specific antibodies. The purpose of injecting the antitoxic serum was to neutralize the toxin and prevent it from causing harm to the mice. This serological reaction of neutralization directly aligns with the objective of the experiment.
Summary of other choices:
B: Precipitation - Precipitation involves the formation of a visible insoluble complex when an antigen reacts with its corresponding antibody. This process was not described in the scenario.
C: Complement binding - Complement binding involves the activation of the complement system by antigen-antibody complexes. This was not the main focus of the experiment described.
D: Double immune diffusion - This technique is used to detect the presence of specific antigens or antibodies
Which statement best describes how working on a farm is different from working in a factory?
A. Factories have more dangerous dust than farming dust
B. Farm chemicals are more immediately fatal than most industrial chemicals
C. The worksite and the home are the same
D. Workers on farms, unlike those in factories, can bring dangerous substances home on their clothing, which expose their families
Correct answer:
The correct answer is C: The worksite and the home are the same. This is because on a farm, the workers typically live on the farm itself or in close proximity, blurring the lines between work and home. This can lead to longer working hours and less separation between personal and work life compared to factory workers who typically commute to a separate worksite.
Explanation for why the other choices are incorrect:
A: Factories have more dangerous dust than farming dust - This statement is not directly related to the difference between working on a farm and in a factory.
B: Farm chemicals are more immediately fatal than most industrial chemicals - While farm chemicals can be dangerous, this statement does not address the difference in worksite environment.
D: Workers on farms, unlike those in factories, can bring dangerous substances home on their clothing, which expose their families - This statement focuses on the potential impact on families but does not directly address the difference in worksite environment.
A client with polycystic kidney disease (PKD) is being discharged. Which statements should the nurse include in this client's discharge teaching? (Select all that apply.)
A. Take your blood pressure every morning.
B. Weigh yourself at the same time each day.
C. Contact your provider if you have visual disturbances.
D. All of the above
Correct answer:
A client with polycystic kidney disease (PKD) should be educated on monitoring their blood pressure daily and weighing themselves consistently to detect any changes promptly. It is essential to contact the healthcare provider if visual disturbances occur, as this could indicate a complication such as a berry aneurysm associated with PKD. Foul-smelling or bloody urine should also prompt notification to the provider as they could signify urinary tract infections or glomerular injury. Choices A, B, and C are correct as they address crucial aspects of managing PKD and its potential complications. Choices A and B help in monitoring for changes in blood pressure and fluid status, while choice C focuses on detecting possible neurological complications. Choices A, B, and C are relevant to PKD management and should be included in the client's discharge teaching. Choices that mention diarrhea and renal stones are not directly associated with PKD; therefore, teaching related to these conditions would be irrelevant in this context.
An 86-year-old female comes to your office for a wellness visit. Her blood pressure is 125/70 mmHg, pulse 69 beats per minute, and respiratory rate 18 breaths per minute. She is well-appearing and reports she is up to date on her routine vaccinations. She introduces her partner of 35 years, whom she would like to make medical decisions for her in case she becomes unable to make decisions for herself. She reports that she and her partner are not married. She asks if she needs any further documentation to ensure her goals of care are followed.
A. Advise them to complete a POLST.
B. Advise them that they have adequate documentation to be recognized legally.
C. Advise them to file an advanced directive.
D. Respond that although they lack documentation, her partner will be recognized de facto.
Correct answer:
The correct answer is C: Advise them to file an advanced directive. An advanced directive is a legal document that allows individuals to specify their healthcare preferences in advance, including who they want to make medical decisions for them if they are unable to do so. In this scenario, since the patient and her partner are not married, it is important for her to have an advanced directive in place to ensure that her partner is legally recognized as the decision-maker. This documentation will help ensure her goals of care are followed in case she becomes incapacitated.
Choice A (Advise them to complete a POLST) is incorrect because a POLST (Physician Orders for Life-Sustaining Treatment) form is used to specify a patient's wishes for end-of-life care, not for designating a medical decision-maker.
Choice B (Advise them that they have adequate documentation to be recognized legally) is incorrect because without an advanced directive, there may be legal challenges to the partner's authority to make medical decisions
You are caring for a patient, a 42-year-old mother of two children, with a diagnosis of ovarian cancer. She has just been told that her ovarian cancer is terminal. When you admitted this patient, you did a spiritual assessment. What question would it have been most important for you to evaluate during this assessment?
A. Is she able to tell her family of negative test results?
B. Does she have a sense of peace of mind and a purpose to her life?
C. Can she let go of her husband so he can make a new life?
D. Does she need time and space to bargain with God for a cure?
Correct answer:
The correct answer is B: Does she have a sense of peace of mind and a purpose to her life? This question is crucial during a spiritual assessment because it addresses the patient's emotional well-being and coping mechanisms in the face of a terminal diagnosis. It helps assess the patient's spiritual beliefs, values, and sources of strength, which can impact their ability to find meaning and comfort during difficult times. It also provides insights into the patient's resilience and ability to navigate their emotions and find peace amidst uncertainty.
Choice A is incorrect because it focuses on the patient's ability to deliver negative news to her family, which is important but not as central to the patient's spiritual well-being in this context. Choice C is incorrect as it assumes the patient needs to let go of her husband, which may not be relevant to her spiritual assessment. Choice D is incorrect as it centers on bargaining with God for a cure, which may not be reflective of the patient's spiritual beliefs or needs.
As the American population ages, nurses expect see more patients admitted to long-term care facilities in need of palliative care. Regulations now in place that govern how the care in these facilities is both organized and reimbursed emphasize what aspect of care?
A. Ongoing acute care
B. Restorative measures
C. Mobility and socialization
D. Incentives to palliative care
Correct answer:
The correct answer is D: Incentives to palliative care. Palliative care focuses on improving the quality of life for patients with serious illnesses by addressing their physical, emotional, and spiritual needs. As the American population ages, the emphasis on palliative care in long-term care facilities is crucial. Regulations emphasizing incentives for palliative care ensure that patients receive appropriate symptom management, comfort care, and support to enhance their overall well-being.
Choice A: Ongoing acute care is not the correct answer because palliative care is different from acute care, which focuses on treating the underlying medical condition.
Choice B: Restorative measures are not the correct answer as palliative care aims to improve quality of life rather than focusing on restoring physical function.
Choice C: Mobility and socialization are important aspects of care in long-term facilities, but palliative care goes beyond these aspects to provide holistic support for patients facing serious illnesses.
The new nurse is caring for six patients in this shift. After completing their assessments, the nurse asks where to begin in developing care plans for these patients. Which statement is an appropriate suggestion by another nurse?
A. “Choose all the interventions and perform them in order of time needed for each one.”
B. “Make sure you identify the scientific rationale for each intervention first.”
C. “Decide on goals and outcomes you have chosen for the patients.”
D. “Begin with the highest priority diagnoses, then select appropriate interventions.”
Correct answer:
The correct answer is D: "Begin with the highest priority diagnoses, then select appropriate interventions."
Rationale:
1. Start with the highest priority diagnoses: Prioritizing care based on the patients' most critical needs ensures their safety and well-being.
2. Identify appropriate interventions: Select interventions that directly address the priority diagnoses to promote effective care delivery.
3. Tailor interventions to individual needs: By focusing on high-priority diagnoses, the nurse can personalize care plans for each patient.
4. Ensure efficient use of resources: Addressing critical issues first optimizes time and resources for the most impactful outcomes.
Summary:
A: Incorrect. Performing interventions based on time needed may not address the most critical patient needs.
B: Incorrect. While scientific rationale is important, it should come after identifying priority diagnoses.
C: Incorrect. Setting goals and outcomes should follow the identification of high-priority diagnoses for effective care planning.
Which intervention would best address the nursing diagnosis of Imbalanced nutrition for elderly patients in stages 2 to 3 of Alzheimer's disease?
A. Monitor the frequency and characteristics of bowel movements.
B. Offer finger foods the patient can take away from the table.
C. Monitor intake and output, and take patient weights each week.
D. Provide protein-dense foods to provide for neurological regrowth.
Correct answer:
The correct answer is B: Offer finger foods the patient can take away from the table. This intervention is best suited for elderly patients in stages 2 to 3 of Alzheimer's disease as it promotes independent eating, encourages increased food intake, and addresses potential behavioral issues related to Alzheimer's. By offering finger foods that the patient can take away from the table, it allows for easier access to food, enhances the patient's ability to feed themselves, and reduces frustration or confusion that may arise during meal times. This approach supports the patient's autonomy and dignity while also addressing the nursing diagnosis of Imbalanced nutrition.
Choice A is incorrect because monitoring bowel movements does not directly address the nutritional needs of the patient. Choice C focuses more on fluid balance rather than nutrition intake. Choice D is incorrect as providing protein-dense foods does not specifically target the challenges faced by elderly patients with Alzheimer's disease in stages 2 to 3.
RN exams clinical judgment practice questions, set 17 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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