RN exams clinical judgment practice questions, set 18
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 18
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 17-year-old client is admitted to the ED after being alternately hyperalert and difficult to arouse. His symptoms all started within the last few hours, during which time he became disoriented and confused. His behavior was agitated and restless, and his memory was impaired, especially for recent events. The client displayed some delusions and misinterpretations of his surroundings. The nurse knows she needs to assess the client further for:
A. Dementia
B. Depression
C. Delirium
D. Amnesia
Show answer and rationale
Correct answer: C — Delirium
The correct answer is C: Delirium. Delirium is characterized by acute and fluctuating changes in cognition, attention, and awareness. The client's sudden onset of symptoms, including disorientation, confusion, agitation, restlessness, impaired memory, delusions, and misinterpretations of surroundings, align with the hallmark features of delirium. The nurse needs to further assess the client for delirium to determine the underlying cause and provide appropriate interventions promptly.
Incorrect choices:
A: Dementia - Dementia is a chronic, progressive condition characterized by gradual cognitive decline. The client's acute onset of symptoms is not consistent with dementia.
B: Depression - Depression typically presents with persistent feelings of sadness, hopelessness, and loss of interest, which are different from the acute and fluctuating cognitive changes seen in delirium.
D: Amnesia - Amnesia refers to memory loss, which is only one aspect of the client's presentation. Delirium involves a broader range of cognitive
Question 2
The nurse evaluates a pattern on the fetal monitor that appears similar to early decelerations. The deceleration begins near the acme of the contraction and continues well beyond the end of the contraction. Which nursing action indicates the proper evaluation of this situation?
A. This pattern reflects variable decelerations. No interventions are necessary at this time
B. Document this Category I fetal heart rate pattern and decrease the rate of the
C. Continue to monitor these early decelerations, which occur as the fetal head is
compressed during a contraction
D. This deceleration pattern is associated with uteroplacental insufficiency. The nurse
Show answer and rationale
Correct answer: D — This deceleration pattern is associated with uteroplacental insufficiency. The nurse
Step-by-step rationale for why answer D is correct:
1. The deceleration pattern described, beginning near the acme of the contraction and extending beyond, is associated with uteroplacental insufficiency.
2. Uteroplacental insufficiency indicates a potential problem with oxygen and nutrient delivery to the fetus.
3. This situation requires immediate intervention to improve oxygenation to the fetus.
4. Monitoring alone is not sufficient; action is needed to address the underlying issue.
5. Therefore, the correct nursing action in this situation is to recognize the potential uteroplacental insufficiency and take appropriate measures to address it.
Summary of why other choices are incorrect:
A: This pattern reflects variable decelerations - Incorrect because the described pattern is not characteristic of variable decelerations.
B: Document this Category I fetal heart rate pattern and decrease the rate of the - Incorrect because immediate action is needed in the presence of potential uteroplacental insufficiency.
Question 3
After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? Administer scheduled medications assuming that the NAP would have reported
A. abnormal vital signs. Have the patient transported to the radiology department for a scheduled x-ray, and
B. review vital signs upon return.
C. Ask the NAP to record the patient’s vital signs before administering medications.
D. Omit the vital signs because the patient is presently in no distress.
Show answer and rationale
Correct answer: C — Ask the NAP to record the patient’s vital signs before administering medications.
Rationale for Correct Answer (C):
1. Safety first: Patient safety is the top priority in healthcare. Vital signs provide crucial information about the patient's condition.
2. Accountability: The nurse is responsible for ensuring accurate vital sign documentation. Asking the NAP to record vital signs before medication administration ensures accountability.
3. Communication: Clear communication between healthcare team members is essential to provide quality care. Asking the NAP to record vital signs promotes effective communication.
Summary of Incorrect Choices:
A (abnormal vital signs): Administering medications without knowing the patient's vital signs, especially if abnormal, can be dangerous and potentially harmful.
B (review upon return): Delaying vital sign assessment until later can lead to missed opportunities for timely intervention if the patient's condition changes.
D (omit vital signs): Neglecting vital signs based on assumption risks overlooking potential issues that could impact patient care and outcomes.
Question 4
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
Show answer and rationale
Correct answer: A — Increased thirst and frequent urination
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
Question 5
A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient?
A. Ask the patient to lie down for complete a full physical assessment.
B. Complete the health history and check for allergies before treatment.
C. Briefly ask specific questions about this episode of respiratory distress.
D. Delay the physical assessment to first complete pulmonary function tests.
Show answer and rationale
Correct answer: C — Briefly ask specific questions about this episode of respiratory distress.
The correct answer is C because during an acute episode of respiratory distress, it is essential to quickly gather specific information about the current situation. This allows the nurse to assess the severity of the issue, identify potential causes, and provide immediate interventions. Asking specific questions about the episode helps in determining the onset, triggers, associated symptoms, and any previous similar episodes. This information guides the nurse in prioritizing care and initiating appropriate interventions promptly.
Choice A is incorrect because asking the patient to lie down for a full physical assessment is not appropriate during acute respiratory distress as it delays crucial information gathering. Choice B is incorrect as completing the health history and checking for allergies can be done after addressing the immediate respiratory distress. Choice D is incorrect because delaying the physical assessment for pulmonary function tests is not indicated in the acute management of respiratory distress.
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
During the implementation phase of the nursing process for medication administration, which procedure is considered essential?
A. Monitor the patient's response to the drug therapy
B. Following the five rights of medication administration
C. Establishing measurable and realistic outcomes
D. Use NANDA nursing diagnoses to plan care delivery
Correct answer:
In the nursing process, the implementation phase focuses on carrying out the planned interventions, such as administering medications to the patient. A critical aspect of this phase is ensuring safety and accuracy during medication administration. The five rights ensuring the correct patient receives the correct drug, in the correct dose, via the correct route, at the correct time serve as a universal standard to minimize errors and promote patient safety. Monitoring the patient's response is important but typically occurs in the evaluation phase, not implementation. Establishing outcomes is part of the planning phase, while using NANDA diagnoses aids in identifying problems during assessment and planning, not directly during implementation. The emphasis on the five rights directly aligns with the hands-on action of giving medication, making it essential to this phase. This structured approach reduces the risk of adverse events, ensures therapeutic effectiveness, and upholds professional standards in nursing practice.
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.
Correct answer:
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
A client admitted with delusions, hallucinations, and thought disorder has the admitting diagnosis schizophreniform disorder R/O organic pathology. Based on this information, the nurse can expect that the client will:
A. Undergo an MRI test
B. Have psychological testing
C. Have an immunologic assay performed
D. Participate in a dexamethasone suppression test
Correct answer:
Step 1: The client is admitted with symptoms suggestive of a psychotic disorder, specifically schizophreniform disorder.
Step 2: The admitting diagnosis includes ruling out organic pathology, indicating a need to investigate potential physical causes.
Step 3: An MRI test is a non-invasive imaging procedure that can help identify any structural abnormalities in the brain.
Step 4: This test is appropriate in ruling out organic causes of the symptoms presented by the client.
Step 5: Psychological testing (Choice B) is more focused on assessing cognitive and emotional functioning, not ruling out organic pathology.
Step 6: Immunologic assay (Choice C) is used to detect antibodies or antigens in the blood, not typically relevant in this context.
Step 7: Dexamethasone suppression test (Choice D) is used to assess for abnormalities related to cortisol levels in conditions like depression, not specific to ruling out organic pathology in psychotic disorders.
Summary: Choice A is correct because an MRI test is the most relevant
You are on-scene with a patient who was struck by a car on her bicycle. She is conscious and alert but has a possible closed right mid-shaft femur fracture. The patient advises you that she is sixteen but does not need parental consent to be treated. Which of the following situations would make this statement true?
A. She can be treated under implied consent because her injury may become life-threatening
B. She is not an American citizen, visiting on a student visa
C. She is an emancipated minor granted by the court
D. She is an orphaned minor who lives alone
Correct answer:
The correct answer is C: She is an emancipated minor granted by the court. An emancipated minor is legally considered an adult and can make medical decisions without parental consent. This situation would make the statement true because an emancipated minor has the legal authority to consent to their own treatment.
Rationale:
1. Emancipated minors are legally recognized as adults in terms of making medical decisions.
2. Emancipation grants the minor the right to make healthcare choices independently.
3. In this scenario, the patient being an emancipated minor means she can consent to treatment without involving her parents.
Summary of other choices:
A: Implied consent does not apply in this scenario as the patient is conscious and alert, and the injury is not immediately life-threatening.
B: Immigration status is not relevant to the patient's ability to consent to treatment without parental consent.
D: Being an orphaned minor does not automatically grant the ability to consent to treatment without parental consent.
Jasmine is a 31-year-old female who presents with neck pain. She has a long history of injection drug use and admits to injecting opiates into her neck. Physical examination reveals diffuse tracking and scarring. Today Jasmine has a distinct inability to turn her neck without pain, throat pain, and a temperature of 102.1F. She appears ill and has foul breath. In order to evaluate for a deep neck space infection, the AGACNP orders
A. Anteroposterior neck radiography
B. CT scan of the neck
C. White blood cell (WBC) differential
D. Aspiration and culture of fluid
Correct answer:
The correct answer is D: Aspiration and culture of fluid. Given Jasmine's history of injection drug use, neck pain, inability to turn her neck, elevated temperature, and foul breath, there is a high suspicion of a deep neck space infection. Aspiration and culture of fluid from the affected area will help identify the causative organism and guide appropriate antibiotic therapy. This procedure is essential for definitive diagnosis and management of deep neck infections.
A: Anteroposterior neck radiography is not the most appropriate initial diagnostic test for evaluating deep neck space infections as it may not provide detailed information on the extent or nature of the infection.
B: CT scan of the neck may provide valuable information regarding the extent of the infection, but aspiration and culture of fluid are crucial for identifying the causative organism.
C: White blood cell (WBC) differential may show signs of inflammation, but it does not provide specific information on the causative organism of the infection.
A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?
A. Ineffective breathing pattern related to pneumonia
B. Risk for infection related to chest x-ray procedure NursingStoreRN
C. Risk for deficient fluid volume related to dehydration
D. Impaired gas exchange related to alveolar-capillary membrane changes
Correct answer:
The correct answer is D: Impaired gas exchange related to alveolar-capillary membrane changes. This nursing diagnosis is appropriate for a patient with pneumonia and lower lobe infiltrates as it directly addresses the underlying physiological issue of impaired gas exchange due to alveolar-capillary membrane changes. The infiltrates indicate infection and inflammation in the lower lobes, leading to difficulty in oxygen and carbon dioxide exchange. This diagnosis aligns with the patient's medical condition and helps guide nursing interventions focused on improving oxygenation.
Choice A is incorrect because ineffective breathing pattern is a broad diagnosis that does not specifically address the gas exchange issue seen in pneumonia. Choice B is incorrect as the risk for infection is already present with the diagnosis of pneumonia and does not directly address the patient's current respiratory status. Choice C is incorrect as dehydration is not the primary concern in a patient with pneumonia and lower lobe infiltrates.
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
Correct answer:
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.
Several clients are members of a therapy group for clients with eating disorders. Of what particular use is this type of group therapy for treatment of eating disorders?
A. Spending time in a group setting helps the client focus on things other than food.
B. Interacting with clients who have similar problems helps prevent secondary gains related to being different.
C. Focusing on problems experienced by other group members helps the client avoid having to deal with personal concerns.
D. None of the above.
Correct answer:
The correct answer is B because interacting with clients who have similar problems in a therapy group for eating disorders helps prevent secondary gains related to feeling different or unique in their struggles. This interaction can offer a sense of validation, support, and understanding, which can be crucial for individuals with eating disorders. It fosters a sense of belonging and reduces the feelings of isolation that often accompany these disorders.
Choice A is incorrect because the primary focus of group therapy for eating disorders is to address and work through issues related to food and body image, rather than distracting clients from these concerns.
Choice C is incorrect because the purpose of group therapy is to provide a safe space for clients to explore and address their personal concerns within a supportive group setting, not to avoid dealing with them.
Choice D is also incorrect as interacting with similar others in a therapy group has specific benefits for individuals with eating disorders.
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."
Correct answer:
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.
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 18 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.
