RN exams clinical judgment practice questions, set 39
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 39
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
The nurse identifies a client's needs and formulates the nursing problem of, 'Imbalanced nutrition: less than body requirements, related to mental impairment and decreased intake, as evidenced by increasing confusion and weight loss of more than 30 pounds over the last 6 months.' Which short-term goal is best for this client?
A. Verbalize understanding of plan and of intention to eat meals.
B. Eat 50% of six small meals each day by the end of one week.
C. Meals prepared during hospitalization will be fed by the nurse.
D. Demonstrate progressive weight gain toward the ideal weight.
Show answer and rationale
Correct answer: B — Eat 50% of six small meals each day by the end of one week.
The correct short-term goal for the client with imbalanced nutrition is choice B: Eat 50% of six small meals each day by the end of one week. This goal is specific, measurable, achievable, relevant, and time-bound (SMART). By setting a goal for the client to eat a specific amount of meals within a defined timeframe, it allows for objective monitoring of progress. This goal also addresses the client's decreased intake and aims to improve their nutritional status gradually.
Choice A is incorrect as verbalizing understanding does not directly address the client's nutritional needs. Choice C is not appropriate as it does not promote independence in meal consumption. Choice D is not the best short-term goal as it focuses on the outcome of weight gain rather than the process of increasing food intake. Overall, choice B is the most appropriate short-term goal as it targets the client's specific nutritional needs and provides a clear direction for intervention.
Question 2
A pregnant patient at 32 weeks gestation reports swelling in the feet and hands. What should the nurse do first?
A. Monitor the patient's blood pressure and assess for signs of preeclampsia.
B. Encourage the patient to elevate her feet and rest for 30 minutes.
C. Recommend that the patient drink more water and reduce sodium intake.
D. Assess the patient for signs of a blood clot or deep vein thrombosis.
Show answer and rationale
Correct answer: A — Monitor the patient's blood pressure and assess for signs of preeclampsia.
The correct answer is A: Monitor the patient's blood pressure and assess for signs of preeclampsia. At 32 weeks gestation, swelling in the feet and hands can be a sign of preeclampsia, a serious condition characterized by high blood pressure and protein in the urine. Monitoring blood pressure is crucial as elevated blood pressure is a key indicator of preeclampsia. Assessing for other signs of preeclampsia such as headache, visual disturbances, or upper abdominal pain is important for early detection and management. Prompt intervention is necessary to prevent complications for both the mother and the baby.
Choices B, C, and D are incorrect because while elevation of feet, rest, hydration, and reducing sodium intake are important in managing mild swelling during pregnancy, in this case, the priority is to rule out preeclampsia which can lead to severe complications if left untreated. Assessing for blood clots or deep vein thrombosis is also important but
Question 3
The nurse is educating the pregnant patient with a body mass index (BMI) of 33. The nurse knows that teaching has been effective when the patient states which of the following?
A. My child may be at increased risk for birth injury.
B. My child may have a decreased risk of developing childhood diabetes.
C. I will probably give birth vaginally.
D. I have a lower risk of developing gestational hypertension.
Show answer and rationale
Correct answer: A — My child may be at increased risk for birth injury.
The correct answer is A: "My child may be at increased risk for birth injury." This is correct because a pregnant patient with a BMI of 33 is considered obese, which can increase the risk of birth injury to the baby due to complications such as macrosomia (large birth weight).
Explanation:
1. Obesity in pregnancy can lead to complications such as macrosomia, shoulder dystocia, and birth trauma.
2. Higher BMI can also increase the risk of cesarean delivery, which may be necessary to prevent birth injuries.
3. Childhood diabetes risk is not decreased with maternal obesity.
4. Mode of delivery (vaginal or cesarean) is not solely determined by BMI.
5. Gestational hypertension risk is actually higher in women with obesity.
In summary, choice A is correct because it directly relates to the increased risk of birth injury associated with maternal obesity, while the other choices are not directly linked to the patient's BMI and pregnancy complications.
Question 4
The __________ is the first measurement of blood pressure
A. when the heart is at work
B. Diastolic
C. Orthostatic
D. Systolic
Show answer and rationale
Correct answer: C — Orthostatic
The correct answer is C: Orthostatic. Orthostatic blood pressure measurement is the first measurement taken when assessing blood pressure. This measurement is done with the individual in a standing position after resting for a few minutes. It helps to evaluate for postural changes in blood pressure, which can indicate conditions like orthostatic hypotension.
Explanation for other choices:
A: when the heart is at work - This is not the first measurement taken for blood pressure assessment. It refers to blood pressure measurement during physical activity or stress.
B: Diastolic - Diastolic blood pressure is the second number in a blood pressure reading, representing the pressure in the arteries when the heart is at rest.
D: Systolic - Systolic blood pressure is the first number in a blood pressure reading, representing the pressure in the arteries when the heart contracts. It is not the first measurement taken in a standard blood pressure assessment.
Question 5
An experienced nurse is supervising a student nurse in an acute care setting. Which statement, if made by the experienced nurse, would be most appropriate to help the student nurse establish credibility with other nurses on the unit?
A. "It is impossible to be credible when you are a student because you lack experience."
B. "Try to hide your feelings of inadequacy and portray a sense of confidence."
C. "Be honest with the nurses about your strengths and about areas that need improvement."
D. "It would help if you bring special treats for the nurses so that they will like you."
Show answer and rationale
Correct answer: C — "Be honest with the nurses about your strengths and about areas that need improvement."
The correct answer is C: "Be honest with the nurses about your strengths and about areas that need improvement." This statement is the most appropriate because it emphasizes the importance of being transparent and authentic in one's interactions. By acknowledging both strengths and areas for improvement, the student nurse shows humility, self-awareness, and a willingness to learn. This approach fosters trust and respect from other nurses, as it demonstrates a commitment to personal and professional growth.
Option A is incorrect because it discourages the student nurse by implying that credibility is unattainable due to lack of experience. Option B is incorrect as it suggests hiding feelings of inadequacy, which can lead to inauthenticity and hinder genuine connections with colleagues. Option D is incorrect as it promotes a superficial and transactional approach to building relationships, rather than focusing on genuine communication and mutual respect.
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Question 6
A nurse is caring for an 8-year-old patient whois embarrassed about urinating in bed at night. Which intervention should the nurse suggest to reduce the frequency of this occurrence?
A. “Set your alarm clock to wake you every 2 hours, so you can get up to void.”
B. “Line your bedding with plastic sheets to protect your mattress.”
C. “Drink your nightly glass of milk earlier in the evening.”
D. “Empty your bladder completely before going to bed.”
Correct answer:
The correct answer is C: “Drink your nightly glass of milk earlier in the evening.” By suggesting the patient to drink milk earlier, it allows more time for the body to process and excrete the fluids before bedtime, reducing the likelihood of bedwetting. This intervention targets the root cause of the issue by addressing the timing of fluid intake.
Explanation for why the other choices are incorrect:
A: “Set your alarm clock to wake you every 2 hours, so you can get up to void.” This intervention disrupts the patient's sleep pattern and may not address the underlying cause of bedwetting.
B: “Line your bedding with plastic sheets to protect your mattress.” This intervention focuses on managing the consequences of bedwetting rather than preventing it.
D: “Empty your bladder completely before going to bed.” While important, this suggestion alone may not be sufficient to address the timing of fluid intake, which is crucial in reducing bedwetting frequency.
While obtaining history for a 1-year-old from the mother, the nurse notices that the baby has had a bottle in his mouth the entire time. The mother states that"it makes a great pacifier." The best response by the nurse would be:
A. "You're right, bottles make very good pacifiers."
B. "Use of a bottle is better for the teeth than thumb-sucking."
C. "It's okay to do this as long as the bottle contains milk and not juice."
D. "Prolonged use of a bottle can increase the risk for tooth decay and ear infections."
Correct answer:
The correct answer is D: "Prolonged use of a bottle can increase the risk for tooth decay and ear infections." This response is the best because it addresses the potential consequences of prolonged bottle use, which include tooth decay and ear infections. It educates the mother on the risks associated with using a bottle as a pacifier for an extended period.
Rationale:
1. Tooth decay: Prolonged exposure to sugary liquids in the bottle can lead to tooth decay, as the sugar feeds bacteria in the mouth.
2. Ear infections: Bottle-feeding while lying down can increase the risk of ear infections due to fluid entering the Eustachian tube.
3. Education: The response educates the mother on the specific risks associated with prolonged bottle use, promoting informed decision-making.
4. Health promotion: By highlighting the potential negative outcomes, the nurse is advocating for the baby's health and well-being.
Incorrect Choices:
A: "You're right, bottles make
A 33 year old patient was delivered to the infectious diseases department on the 7-th day of disease. He complained about great weakness, high temperature, pain in the lumbar area and leg muscles, icteritiousness, dark color of urine, headache. The acute disease started with chill, body temperature rise up to 40oC, headache, pain in the lumbar area and sural muscles. Icterus turned up on the 4th day, nasal and scleral haemorrhages came on the 5th day. Fever has lasted for 6 days. Diuresis - 200 ml. What is the most probable diagnosis?
A. Leptospirosis
B. Typhoid fever
C. Virus A hepatitis
D. Sepsis
Correct answer:
The most probable diagnosis is Leptospirosis. The symptoms described align with the classic presentation of Leptospirosis, such as fever, muscle pain, headache, jaundice, and hemorrhages. The initial symptoms of chills, high fever, and muscle pain followed by jaundice and hemorrhages are characteristic of Leptospirosis. The presence of dark urine and low diuresis also point towards kidney involvement, which is common in Leptospirosis due to renal failure. Additionally, the patient's history of potential exposure to contaminated water or soil supports the diagnosis, as Leptospirosis is commonly transmitted through contact with infected animal urine.
Summary of other choices:
- Typhoid fever typically presents with sustained fever, abdominal pain, and constipation, not matching the symptoms described.
- Virus A hepatitis usually presents with jaundice, but other symptoms such as muscle pain and hemorrhages are not typical.
- Sepsis is a systemic response
A 32-year-old woman was brought to the emergency department because of a generalized tonic-clonic seizure. Her husband stated that his wife had been suffering from epilepsy since childhood, but the seizures were only partially controlled by medication. Which of the following pairs of neurotransmitters are thought to be most involved in seizure disorders?
A. GABA and serotonin
B. GABA and glutamate
C. GABA and acetylcholine
D. Serotonin and glutamate
Correct answer:
The correct answer is B: GABA and glutamate. GABA is an inhibitory neurotransmitter that helps regulate neuronal excitability, while glutamate is an excitatory neurotransmitter that enhances neuronal activity. In seizure disorders, an imbalance between these two neurotransmitters can lead to excessive neuronal firing and seizures. GABAergic drugs are commonly used to increase inhibition and reduce seizure activity.
A: GABA and serotonin - While serotonin plays a role in mood regulation and certain aspects of seizure disorders, it is not as directly involved in the mechanisms of seizures as glutamate.
C: GABA and acetylcholine - Acetylcholine is involved in various functions such as muscle movement and memory but is not as central to seizure disorders as glutamate.
D: Serotonin and glutamate - While both serotonin and glutamate have roles in the central nervous system, glutamate is more directly implicated in seizure disorders compared to serotonin.
The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain. Which of the following would be the next appropriate action?
A. Establishing priorities
B. Identifying expected outcomes
C. Evaluating the individual's condition and comparing actual outcomes with expected outcomes
D. Interpreting data, identifying clusters of cues, and making inferences
Correct answer:
The next appropriate action is to evaluate the individual's condition and compare actual outcomes with expected outcomes (Choice C). This step is crucial in determining the effectiveness of the implemented interventions in addressing the nursing diagnosis of acute pain. By evaluating the individual's condition, the nurse can assess whether the interventions have been successful in alleviating the pain. Comparing actual outcomes with expected outcomes helps in identifying any discrepancies and adjusting the plan of care accordingly to ensure optimal patient outcomes.
Establishing priorities (Choice A) is important but would come before implementing interventions. Identifying expected outcomes (Choice B) is necessary before implementing interventions but does not directly address the need for evaluation. Interpreting data and making inferences (Choice D) is part of the assessment phase and not the next appropriate action after implementing interventions.
Expectant parents ask a prenaNtal RnursIe eGducaBto.rC, “WMhich setting for childbirth limits the U S N T O amount of parent–infant interaction?†Which answer should the nurse provide for these parents in order to assist them in choosing an appropriate birth setting?
A. Birth center
B. Home birth
C. Traditional hospital birth
D. Labor, birth, and recovery room
Correct answer:
Rationale:
1. Traditional hospital birth setting often involves medical interventions that can limit parent-infant interaction, such as continuous fetal monitoring and medication administration.
2. These interventions may restrict movement and bonding opportunities between the parent and infant during labor and immediately after birth.
3. In contrast, birth center and home birth settings typically prioritize natural childbirth experiences with minimal interventions to encourage bonding and parent-infant interaction.
4. Labor, birth, and recovery room, while providing a more private setting than a traditional hospital, may still involve medical interventions that can impact parent-infant interaction.
Summary:
A: Birth center and B: Home birth promote parent-infant interaction. D: Labor, birth, and recovery room may still involve interventions. C: Traditional hospital birth setting often limits parent-infant interaction due to medical interventions.
A school nurse wants to decrease the incidence of obesity in elementary school children. Which of the following describes a secondary prevention intervention that the nurse could implement?
A. Giving a presentation on the importance of exercise and physical fitness
B. Designing a game in which students select healthy food choices
C. Weighing students to identify those who are overweight
D. Putting students on a diet if they weigh greater than 20% of their ideal weight
Correct answer:
The correct answer is C because weighing students to identify those who are overweight is a secondary prevention intervention. This intervention focuses on early detection and intervention for individuals who already have risk factors for a health condition, in this case, obesity. By identifying overweight students early on, the nurse can provide targeted interventions and support to prevent further weight gain and related health issues.
A, giving a presentation on the importance of exercise, is more of a primary prevention strategy aimed at educating all students to prevent obesity from occurring in the first place. B, designing a game for healthy food choices, is also a primary prevention strategy that promotes healthy behaviors for all students. D, putting students on a diet if they are overweight, is more of a tertiary prevention approach focusing on treatment after the condition has already developed, rather than early detection and prevention.
The client has been taking danazol for endometriosis for 3 years. She tells you that she would like to have a baby and wants to stop taking this medication. She wants to know what will happen when she stops. Which is the nurse’s best response?
A. Nothing, your endometriosis will not return.
B. If you stop taking danazol, it could increase your blood pressure.
C. Once you stop any medication for endometriosis, your symptoms may return in 1 to 5 years.
D. Once you stop the medication, the growths from endometriosis will return in 2 to 3 months.
Correct answer:
Rationale for Correct Answer (C): The nurse should explain to the client that once she stops any medication for endometriosis, her symptoms may return in 1 to 5 years. This is the best response because endometriosis is a chronic condition, and stopping the medication can lead to a recurrence of symptoms over time. It is important for the client to be aware of this possibility to make informed decisions about her health and fertility. By mentioning the timeframe of 1 to 5 years, the nurse provides a general idea of when symptoms may return, allowing the client to plan accordingly.
Summary of Incorrect Choices:
A: Nothing, your endometriosis will not return - This is incorrect because endometriosis is a chronic condition that can recur when medication is stopped.
B: If you stop taking danazol, it could increase your blood pressure - This is incorrect as danazol is not typically associated with blood pressure changes upon discontinuation.
D: Once you stop
The nurse is taking vital signs of a pregnant woman during her first prenatal visit. The patient asks the nurse if she has to have an HIV test. Which of the following is the nurse’s best response?
A. “Yes, all pregnant women must have the test.”
B. “If you do not have multiple sex partners or inject drugs, it is not necessary.”
C. “Governmental guidelines require an HIV test for all pregnant woman.”
D. “After voluntary pretest counseling, you decide whether HIV testing should be done.”
Correct answer:
Rationale for Correct Answer (A): The nurse's best response is to inform the pregnant woman that all pregnant women must have an HIV test. This is because HIV testing is a standard part of prenatal care to prevent mother-to-child transmission. It is crucial to detect HIV early to provide appropriate treatment and prevent transmission to the baby.
Summary of Incorrect Choices:
B: This response could lead to misinformation and potentially harm the patient and her baby. HIV testing is recommended for all pregnant women regardless of risk factors.
C: While governmental guidelines may vary, it is essential for all pregnant women to undergo HIV testing to ensure the health of both the mother and the baby.
D: While it is important to provide counseling and involve the patient in decision-making, in the case of HIV testing during pregnancy, it is a standard procedure that should be offered to all pregnant women to safeguard their health and that of their baby.
The nurse is assessing a client who is 2 days post-op following abdominal surgery. The client reports feeling something 'give way' in the incision site and there is a small amount of bowel protruding from the wound. What action should the nurse take first?
A. Apply a sterile saline dressing to the wound
B. Notify the healthcare provider
C. Administer pain medication
D. Cover the wound with an abdominal binder
Correct answer:
The correct action for the nurse to take first is to apply a sterile saline dressing to the wound. This is because the client is experiencing evisceration, which is a medical emergency requiring immediate attention to prevent infection and further complications. By applying a sterile saline dressing, the nurse can protect the exposed bowel from contamination, maintain moisture, and promote healing. This action helps to reduce the risk of infection and provides a temporary barrier until further interventions can be implemented.
Summary of Incorrect Choices:
B: Notifying the healthcare provider is important, but immediate action to protect the exposed bowel is the priority.
C: Administering pain medication does not address the primary concern of protecting the exposed bowel.
D: Covering the wound with an abdominal binder does not provide the necessary protection and could potentially exacerbate the situation by applying pressure to the protruding bowel.
RN exams clinical judgment practice questions, set 39 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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