RN exams clinical judgment practice questions, set 30
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 30
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 caring for a patient diagnosed with anorexia nervosa. The patient states, 'I need to lose more weight.' What is the priority nursing diagnosis for this patient?
A. Imbalanced nutrition: Less than body requirements
B. Ineffective coping
C. Disturbed body image
D. Risk for injury
Show answer and rationale
Correct answer: C — Disturbed body image
The correct answer is C: Disturbed body image. This is the priority nursing diagnosis because the patient's statement indicates a distorted perception of their own body, which is a core issue in anorexia nervosa. Addressing the patient's distorted body image is crucial in promoting positive self-perception and working towards recovery.
Incorrect choices:
A: Imbalanced nutrition: Less than body requirements - While this is a common concern in anorexia nervosa, the patient's statement about needing to lose more weight indicates a deeper psychological issue that needs immediate attention.
B: Ineffective coping - While coping strategies are important, the primary focus should be on addressing the distorted body image in this case.
D: Risk for injury - While anorexia nervosa can lead to physical complications, the patient's statement does not directly suggest an immediate risk for injury, making this option less of a priority compared to addressing the distorted body image.
Question 2
A nurse is investigating a bacterial illness that has caused a health problem in the community. Only some of the people exposed to the bacteria have become ill. Which of the following factors best explains why this would have happened?
A. Chemical agent factors
B. Environmental factors
C. Host factors
D. Physical agent factors
Show answer and rationale
Correct answer: C — Host factors
The correct answer is C: Host factors. Host factors refer to individual characteristics that influence susceptibility to a particular disease. In this scenario, the variation in illness among those exposed to the same bacteria suggests that host factors play a crucial role. Factors such as immune status, genetic predisposition, age, and overall health can affect an individual's ability to combat the bacterial illness. This explains why only some of the exposed individuals became ill.
A: Chemical agent factors - This choice refers to agents like toxic chemicals, which are not directly relevant to the scenario described.
B: Environmental factors - While environmental factors can play a role in disease transmission, the question specifically focuses on why only some individuals became ill despite exposure to the same bacteria.
D: Physical agent factors - This choice relates to physical agents like radiation or trauma, which are not applicable to a bacterial illness scenario.
Question 3
Which vaccines should be emphasized to prevent diseases?
A. HPV, genital herpes, measles
B. pneumonia, HIV, mumps
C. syphilis, gonorrhea, pneumonia
D. polio, pertussis, measles
Show answer and rationale
Correct answer: D — polio, pertussis, measles
The correct answer is D because polio, pertussis, and measles are highly infectious diseases that can have severe consequences if not prevented through vaccination. Polio can cause paralysis, pertussis can be fatal in infants, and measles can lead to complications like pneumonia and encephalitis. Emphasizing these vaccines can significantly reduce the risk of outbreaks and protect public health.
Choice A is incorrect because HPV and genital herpes are sexually transmitted infections, and although important, they are not typically prevented through vaccines like polio, pertussis, and measles.
Choice B is incorrect because pneumonia, HIV, and mumps, while serious diseases, do not have vaccines that are as universally recommended for prevention as polio, pertussis, and measles.
Choice C is incorrect because syphilis and gonorrhea are sexually transmitted infections, and pneumonia is not typically prevented through vaccination as effectively as polio, pertussis, and measles.
Question 4
As the newborn nursery nurse, you are assessing your patients. Which assessment warrants further investigation?
A. Irregular patterns of breathing with periods of apnea lasting 5 seconds
B. Periodic episodes of grunting during expiration
C. Breathing at a rate of 45 breaths per minute
D. Mild sternal retractions
Show answer and rationale
Correct answer: B — Periodic episodes of grunting during expiration
The correct answer is B: Periodic episodes of grunting during expiration. This warrants further investigation as grunting during expiration is a sign of respiratory distress in newborns, indicating potential respiratory compromise. It can be a sign of underlying lung pathology or inadequate oxygenation. It is important to assess and address this promptly to prevent further deterioration.
Incorrect choices:
A: Irregular patterns of breathing with periods of apnea lasting 5 seconds - While apnea can be concerning, it is common in newborns. This alone may not warrant immediate further investigation.
C: Breathing at a rate of 45 breaths per minute - A respiratory rate of 45 breaths per minute can be within normal range for a newborn. It may not be abnormal unless accompanied by other signs of distress.
D: Mild sternal retractions - Sternal retractions can be a sign of increased work of breathing, but mild retractions alone may not be as concerning as grunting during expiration.
Question 5
A 32-year-old female patient arrives to the emergency department with heavy uterine bleeding. The nurse finds that the patient had a positive pregnancy test 1 month prior to the visit. What is the potential medical management for this patient's issue?
A. Endometrial biopsy
B. Dilation and curettage
C. Colposcopy
D. Laparoscopy
Show answer and rationale
Correct answer: B — Dilation and curettage
The correct answer is B: Dilation and curettage. This procedure is indicated for heavy uterine bleeding in the setting of a positive pregnancy test to diagnose and treat conditions such as incomplete miscarriage or ectopic pregnancy. Dilation and curettage involves dilating the cervix and scraping the uterine lining to remove any remaining products of conception. It is important in this case to rule out any potential sources of bleeding that could be life-threatening.
A: Endometrial biopsy is not the appropriate initial management in this scenario as it is primarily used to assess endometrial pathology such as cancer.
C: Colposcopy is a procedure used to examine the cervix and vagina for abnormalities, not typically indicated for heavy uterine bleeding in the setting of a positive pregnancy test.
D: Laparoscopy is a minimally invasive surgical procedure used to view the abdominal organs, not typically indicated for uterine bleeding related to a positive pregnancy test.
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Question 6
When assessing pupillary light reflex, which of the following techniques should the nurse use?
A. Shine a penlight from directly in front of the patient, and inspect for pupillary constriction.
B. Ask the patient to follow the penlight in eight directions, and observe for bilateral pupil constriction.
C. Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction.
D. Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to about 7 cm (2¾ in.) from the nose.
Correct answer:
The correct answer is C because shining a light across the pupil from the side allows for both direct (ipsilateral) and consensual (contralateral) pupillary constriction to be observed. This technique helps to assess the integrity of the cranial nerves involved in the pupillary light reflex (CN II and III). Direct constriction occurs in the eye exposed to the light, while consensual constriction occurs in the opposite eye. This comprehensive assessment ensures that both pupils are responding appropriately to light stimulation, providing a more accurate evaluation of the reflex.
Choice A is incorrect because inspecting for pupillary constriction from directly in front may not adequately assess for consensual constriction in the opposite eye. Choice B is incorrect as asking the patient to follow the penlight in eight directions does not specifically target the pupillary light reflex. Choice D is incorrect as it focuses on accommodation rather than the pupillary light reflex.
The correct answer is B: To improve, restore, or maintain health. The purpose of a healthcare system is primarily focused on enhancing the health and well-being of individuals. It aims to provide medical services, preventive care, and treatments to improve health outcomes. This choice aligns with the fundamental goal of healthcare systems worldwide.
Choice A: To reduce healthcare costs - While cost reduction is a consideration in healthcare systems, it is not the primary purpose. The main focus is on providing quality care to individuals.
Choice C: To expand healthcare facilities - While expanding healthcare facilities may be a part of improving the healthcare system, it is not the primary purpose. The primary goal is to enhance health outcomes.
Choice D: To promote government-funded healthcare - While government funding is a crucial aspect of many healthcare systems, it is not the sole purpose. The primary goal is to improve, restore, or maintain health for individuals.
A client who has been diagnosed as having paranoid schizophrenia is highly suspicious and delusional. He hears voices telling him terrorists are plotting to assassinate him. He refuses to eat, saying the food is poisoned. The nursing action that best addresses his needs is to:
A. Explain that others eat the food and are not harmed
B. Allow client to select food from vending machines
C. Assist client with personal hygiene and grooming
D. Not allow client to verbalize delusional thoughts
Correct answer:
The correct answer is B: Allow client to select food from vending machines. This option respects the client's autonomy and addresses his delusion about the food being poisoned. By allowing the client to choose food from vending machines, it acknowledges his concerns and promotes a sense of control over his environment. This approach can help build trust and rapport with the client, as forcing him to eat regular hospital food might exacerbate his paranoia and resistance.
A: Explaining that others eat the food and are not harmed may not be effective as it disregards the client's beliefs and could further alienate him.
C: Assisting with personal hygiene and grooming is important but does not directly address the client's primary concern of refusing to eat due to delusional beliefs.
D: Not allowing the client to verbalize delusional thoughts is counterproductive as it suppresses communication and does not address the underlying issue of the client's fear of being poisoned.
Which of the following has a higher resistance to environmental stresses than the others?
A. Bacterial endospores
B. Fungal spores
C. Enveloped viruses
D. Vegetative bacterial cells
Correct answer:
The correct answer is A: Bacterial endospores. Bacterial endospores have a higher resistance to environmental stresses due to their unique structure, which includes a tough outer layer that protects the spore from harsh conditions such as heat, chemicals, and radiation. This protective layer allows endospores to remain dormant and survive in unfavorable environments until conditions improve.
Summary:
B: Fungal spores - While fungal spores can also survive in harsh conditions, they are generally not as resistant as bacterial endospores due to differences in their protective structures.
C: Enveloped viruses - Enveloped viruses are susceptible to environmental stresses as their lipid envelope can easily be damaged by heat, chemicals, and other factors.
D: Vegetative bacterial cells - Vegetative bacterial cells are more susceptible to environmental stresses compared to endospores, as they do not have the same level of protective mechanisms to survive in unfavorable conditions.
In which stage of disease progression would the nurse classify a client who has elevated blood pressure but no symptoms?
A. Susceptibility stage
B. Subclinical stage
C. Clinical stage
D. Carrier stage
Correct answer:
The correct answer is B: Subclinical stage. In this stage, the client has elevated blood pressure but no symptoms are present. This stage is characterized by the presence of the disease without noticeable symptoms. It is important for the nurse to identify and monitor clients in the subclinical stage to prevent progression to more severe stages.
Choice A: Susceptibility stage refers to the stage where the client is at risk of developing the disease but has not yet been affected. Elevated blood pressure without symptoms indicates that the disease has already manifested, ruling out the susceptibility stage.
Choice C: Clinical stage would involve the presence of symptoms, which is not the case with the client in question. Therefore, this choice is incorrect.
Choice D: Carrier stage typically refers to individuals who harbor a pathogen without showing symptoms themselves, which is not applicable to a client with elevated blood pressure. Hence, this choice is incorrect.
A nurse is assessing a pregnant patient who is at 34 weeks gestation and reports swelling in the legs and feet. What is the nurse's priority action?
A. Monitor the patient's blood pressure and assess for signs of preeclampsia.
B. Encourage the patient to rest with her feet elevated.
C. Administer a diuretic to reduce swelling.
D. Instruct the patient to reduce fluid intake to decrease swelling.
Correct answer:
The correct answer is A: Monitor the patient's blood pressure and assess for signs of preeclampsia. At 34 weeks gestation, swelling in the legs and feet can be a sign of preeclampsia, a serious condition characterized by high blood pressure and protein in the urine. The priority action is to assess for signs of preeclampsia, as it can lead to severe complications for both the mother and the baby. Monitoring blood pressure is crucial in identifying preeclampsia early.
Choice B is incorrect because while elevating the feet may provide some relief from swelling, it does not address the potential underlying issue of preeclampsia. Choice C is incorrect because administering a diuretic without assessing for preeclampsia can be dangerous and potentially harmful to the patient and the baby. Choice D is incorrect because reducing fluid intake can lead to dehydration, which is not a recommended approach in pregnancy without proper assessment and guidance from healthcare providers.
Lori, who is 32 years old, is taking clomiphene citrate to induce ovulation and presents to the office for a vaginal ultrasound. As the nurse is walking Lori to ultrasound, Lori mentions that over the past 12 hours she has experienced abdominal bloating, nausea, and weight gain of 5 pounds. The nurse recognizes these signs and symptoms to be associated with what condition?
A. Ovulation
B. Premenstrual syndrome
C. Ovarian hyperstimulation syndrome
D. Failed ovulation induction
Correct answer:
The correct answer is C: Ovarian hyperstimulation syndrome (OHSS). OHSS is a potential complication of ovulation induction with medications like clomiphene citrate. The symptoms Lori is experiencing (abdominal bloating, nausea, and weight gain) are classic signs of moderate OHSS. The mechanism involves excessive response to the ovulation induction medication leading to enlarged ovaries and fluid accumulation in the abdomen. It is crucial to monitor patients on ovulation induction therapy for signs of OHSS to prevent severe complications.
Choice A: Ovulation - This is incorrect because the symptoms described are not typical of ovulation itself.
Choice B: Premenstrual syndrome - This is incorrect because the symptoms are not specific to premenstrual syndrome and are more indicative of a complication related to medication.
Choice D: Failed ovulation induction - This is incorrect because the symptoms suggest a response to the medication rather than a failure of ovulation.
A nurse and unlicensed assistive personnel (UAP) are helping a client during a hysterosalpingogram. Which action by the nurse is best delegated to the UAP?
A. Witnessing of the consent form
B. Assisting the client into a lithotomy position
C. Asking about allergies to iodine or shellfish
D. Assessing for pelvic or shoulder pain after the study
Correct answer:
The correct answer is B: Assisting the client into a lithotomy position. This task can be safely delegated to the UAP as it involves physically assisting the client into a specific position and does not require specialized nursing knowledge or assessment skills. The nurse should be available to provide guidance and supervision to ensure the safety and comfort of the client during the procedure.
Choices A, C, and D involve tasks that require nursing assessment and critical thinking skills, which should be performed by the nurse. Witnessing the consent form (choice A) ensures proper documentation and understanding of the procedure. Asking about allergies to iodine or shellfish (choice C) is crucial to prevent adverse reactions during the procedure. Assessing for pelvic or shoulder pain after the study (choice D) is important to monitor for any potential complications post-procedure. These tasks are within the scope of nursing practice and should not be delegated to a UAP.
The primigravida is admitted to the birthing and labor unit, but
A. The initial response from the nurse will be to:
B. Take health history
C. Perform vaginal exam
D. Review prenatal record
Correct answer:
The correct answer is B: Take health history. This is the initial response because obtaining the patient's health history provides crucial information about the primigravida's medical background, current health status, any complications, and helps in assessing the risk factors for labor and delivery. This information guides the nurse in providing appropriate care and making informed decisions during the labor process.
Choice A (The initial response from the nurse will be to) is vague and not specific enough to address the immediate needs of the patient.
Choice C (Perform vaginal exam) is not appropriate as the first action because it can be invasive and should only be performed after obtaining the health history to determine the necessity and timing of the exam.
Choice D (Review prenatal record) is important but should come after taking the health history to supplement the information obtained and provide a comprehensive understanding of the patient's pregnancy course.
The team leader is teaching the nursing student about emergency respiratory equipment that should be available for Mr. L (tracheostomy and partial laryngectomy). Which piece of equipment is the most important to show to the student?
A. Adult-sized endotracheal tube
B. Laryngeal scope with blades of several sizes
C. Bag-valve mask with extension tubing
D. Tracheostomy insertion tray
Correct answer:
The correct answer is C: Bag-valve mask with extension tubing. This is the most important equipment to show to the student because it is essential for providing immediate ventilation support in case of respiratory distress for a patient with a tracheostomy or partial laryngectomy. The bag-valve mask allows for manual ventilation by delivering oxygen to the patient's lungs, and the extension tubing ensures easy access to the patient's airway.
A: An adult-sized endotracheal tube is not the most important equipment in this scenario as the patient already has a tracheostomy in place.
B: A laryngeal scope with blades of several sizes is used for visualizing the larynx and not essential for immediate respiratory support.
D: A tracheostomy insertion tray is used for performing tracheostomy procedures and not required for routine emergency respiratory support.
In summary, the bag-valve mask with extension tubing is the most critical equipment for immediate ventilation support
RN exams clinical judgment practice questions, set 30 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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