RN exams clinical judgment practice questions, set 42
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 42
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Five clinical judgment questions with answers
Cover the key. Write the first action. Then open the rationale and name why the other choices fail.
Question 1
A 36-year-old woman is beaten about the head and face and is brought to the local community hospital in full spinal immobilization. Her BP is 130/88, HR 70/min, and RR 18/min. Pulse oximetry indicated 98% while she was given 100% O2 via a non-rebreather mask. Her airway is clear. She has marked swellings on her face and several lacerations of her scalp that are not actively bleeding. She does not respond to verbal stimuli, but localizes to painful stimuli and opens her eyes. She moves all extremities equally. The remainder of her physical exam is normal. There is no neurosurgeon at the local hospital. After ensuring the patient's airway, the most appropriate course of action is to:
A. "Admit the patient to the hospital for observation"
B. Obtain x-ray of her facial bones prior to transfer
C. Obtain complete x-ray evaluation of the cervical spine
D. Transfer the patient to a neurosurgeon without performing a CT-scan
Show answer and rationale
Correct answer: D — Transfer the patient to a neurosurgeon without performing a CT-scan
The correct answer is D: Transfer the patient to a neurosurgeon without performing a CT-scan.
Rationale:
1. The patient has sustained significant head trauma with neurological symptoms.
2. The patient is not responding to verbal stimuli but localizes to painful stimuli, indicating altered mental status.
3. There is no neurosurgeon at the local hospital, suggesting the need for transfer to a facility with neurosurgical capabilities.
4. Performing a CT-scan may delay necessary intervention, and in this case, immediate neurosurgical evaluation is crucial.
Summary:
A: Admitting the patient for observation is not appropriate as she requires specialized care.
B: Obtaining x-ray of facial bones is not a priority in this scenario and does not address the potential neurological injury.
C: While a complete x-ray evaluation of the cervical spine is important, neurosurgical evaluation takes precedence in this case to assess for possible intracranial injuries.
Question 2
The home care nurse is assigned to make the first home visit to a new client who has been discharged from the hospital. After initial introductions, the nurse should take which action to convey respect?
A. Ask the client to develop a list of needs to discuss at the next visit.
B. Wear a name badge that clearly identifies the home care agency.
C. Provide contact information for several other clients who can serve as references.
D. Tell the client that information obtained will not be shared with others.
Show answer and rationale
Correct answer: B — Wear a name badge that clearly identifies the home care agency.
The correct answer is B: Wear a name badge that clearly identifies the home care agency. This action conveys professionalism, credibility, and respect for the client by clearly identifying the nurse's affiliation and role. It helps establish trust and ensures transparency.
A: Asking the client to develop a list of needs for the next visit may be premature and could come across as insensitive or overwhelming for the client during the initial meeting. It does not directly convey respect.
C: Providing contact information for other clients as references is inappropriate and breaches confidentiality. It can also violate the client's privacy and trust. This action does not convey respect.
D: Assuring the client of confidentiality is important, but it may not directly convey respect in the same way as wearing a name badge does. It is an essential aspect of professionalism but does not establish credibility or respect as visibly as wearing a name badge.
Question 3
A nurse cares for a client with chronic obstructive pulmonary disease (COPD) who appears thin and disheveled. Which question would the nurse ask first?
A. “Do you have a strong support system?â€
B. “What do you understand about your disease?â€
C. “Do you experience shortness of breath with basic activities?â€
D. “What medications are you prescribed to take each day?â€
Show answer and rationale
Correct answer: C — “Do you experience shortness of breath with basic activities?â€
The correct question to ask first is "Do you experience shortness of breath with basic activities?" because it directly assesses the client's current health status related to COPD, which is essential for immediate care. By prioritizing this question, the nurse can quickly evaluate the severity of the client's symptoms and determine the need for urgent intervention or adjustment of the care plan. This information is crucial for addressing the client's immediate respiratory needs and ensuring their safety.
Choice A is incorrect because assessing the client's support system is important but not as urgent as evaluating their respiratory status. Choice B is also incorrect as understanding the disease is important but not as time-sensitive as assessing the client's current symptoms. Choice D is incorrect as knowing the medications the client is prescribed is important for overall care but does not address the immediate need for respiratory assessment.
Question 4
A 45-year-old woman is at the clinic for a mental health assessment. When giving her the Four Unrelated Words Test, the nurse would be concerned if the patient:
A. Could not give four unrelated words within 5 minutes.
B. Could not give four unrelated words within 30 seconds.
C. Could not recall four unrelated words after a 30-minute delay.
D. Could not recall four unrelated words after a 60-minute delay.
Show answer and rationale
Correct answer: C — Could not recall four unrelated words after a 30-minute delay.
The correct answer is C because the inability to recall four unrelated words after a 30-minute delay indicates potential issues with short-term memory retention, which is concerning for cognitive impairment or memory disorders. This delay allows for the consolidation of memory, so failure at this point suggests a more significant problem compared to immediate recall.
A: Not being able to give four unrelated words within 5 minutes may indicate some difficulty, but it does not necessarily indicate a severe issue as more time is typically allowed for this task.
B: Inability to give four unrelated words within 30 seconds could be due to various factors such as anxiety or processing speed, but it does not necessarily indicate a memory issue.
D: Not being able to recall four unrelated words after a 60-minute delay is expected to be more challenging than a 30-minute delay, so this alone does not raise as much concern as failing the 30-minute delay test.
Question 5
What are the two essential components of transitional care discharge model that is used in Canada and Scotland?
A. Peer support and bridging staff
B. Collaboration and funding
C. Relapse and hospitalization
D. Poverty and entitlements
Show answer and rationale
Correct answer: A — Peer support and bridging staff
Two essential components of the transitional care discharge model are peer support and bridging staff. Peer support is provided by a consumer now living successfully in the community. Bridging staff refers to an overlap between hospital and community careâ€â€hospital staff do not terminate their therapeutic relationship with the client until a therapeutic relationship has been established with the community care provider. This model requires collaboration, administrative support, and adequate funding to effectively promote the patient's health and well-being and prevent relapse and rehospitalization. Poverty among people with mental illness is a significant barrier to maintaining housing. Mentally ill persons often rely on government entitlements for their income which forces people to have to choose continuation of the entitlement and dependence versus working inconsistently in unskilled, part-time, and low-paying jobs with no health insurance.
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Question 6
An older adult client receiving medication for hypertension had a recent fall at home. Which intervention should the nurse include in this client's plan of care?
A. Monitor serum sodium levels
B. Assess postural blood pressures
C. Monitor serum creatinine levels
D. Monitor blood pressure every 2 hours
Correct answer:
Assessing postural blood pressures is important in determining if the client may be experiencing orthostatic hypotension, which could have contributed to the fall. Orthostatic hypotension is a sudden drop in blood pressure that can occur when a person stands up from a sitting or lying position. Older adults on antihypertensive medications are at increased risk for orthostatic hypotension. By monitoring postural blood pressures, the nurse can identify fluctuations in blood pressure that may put the client at risk for falls and implement appropriate interventions to prevent future falls. Monitoring serum sodium levels and creatinine levels are important for detecting electrolyte imbalances or kidney dysfunction but do not directly address the issue of orthostatic hypotension related to falls. Monitoring blood pressure every 2 hours may not provide valuable information on postural blood pressure changes that are associated with orthostatic hypotension.
A patient declared brain dead is an organ donor. The following events occur: 1300 Diagnostic tests for brain death are completed. 1330 primary care provider reviews diagnostic test results and writes in the progress note that the patient is brain deaadb.i r1b.4co0m0/ tePsat tient is taken to the operating room for organ retrieval. 1800 All organs have b een retrieved for donation. The ventilator is discontinued. 1810 Cardiac monitor shows fla tline. What is the official time of death recorded in the medical record?
A. 1300
B. 1330
C. 1400
D. 1800
Correct answer:
The correct answer is not provided, but based on the events described, the official time of death recorded in the medical record should be 1810 (Choice D). At this time, the cardiac monitor shows flatline, indicating the cessation of cardiac activity, which is the universally accepted point of declaring death.
Choice A (1300) is incorrect because that is when diagnostic tests for brain death were completed, but the patient was not officially declared dead at that time.
Choice B (1330) is incorrect as this is when the primary care provider reviewed the test results and documented brain death in the progress note, but the patient was not officially declared dead at this time either.
Choice C (1400) is incorrect as there is no significant event occurring at this time that signifies the patient's death.
Therefore, the most appropriate and official time of death recorded in the medical record would be 1810 when the cardiac monitor shows flatline.
While giving a history, a patient reports having a weak urinary stream and feeling that his bladder is not empty after urination. Based on these data, what finding does the nurse anticipate upon examination?
A. An enlarged prostate gland palpated on the anterior wall of the rectum
B. An indirect hernia palpated through the inguinal ring when the patient coughs
C. The foreskin of the penis cannot be returned to position after retraction behind the glans
D. A nodular prostate gland palpated on the posterior wall of the rectum
Correct answer:
The correct answer is A: An enlarged prostate gland palpated on the anterior wall of the rectum. In this case, the patient's weak urinary stream and feeling of incomplete bladder emptying are classic symptoms of benign prostatic hyperplasia (BPH). During a rectal examination, an enlarged prostate gland can be felt as a smooth, rubbery, and symmetrically enlarged mass on the anterior wall of the rectum. This finding correlates with the patient's urinary symptoms, indicating obstruction of the urethra by the enlarged prostate.
Choice B is incorrect because an indirect hernia is not typically associated with urinary symptoms. Choice C is incorrect as it describes paraphimosis, a condition where the foreskin cannot be returned to its original position. Choice D is incorrect as a nodular prostate gland palpated on the posterior wall of the rectum is more characteristic of prostate cancer rather than BPH, which is typically felt on the anterior wall.
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.
The nurse is caring for a patient who sustained a head injury and is unresponsive to painful stimuli. Which intervention is most appropriate while bathaibnirgb. ctohme/ tpesatt ient?
A. Ask a family member to help you bathe the patient, and discuss the family structure with the family member during the procedure .
B. Because the patient is unconscious, complete care as q uickly and quietly as possible.
C. Inform the patient of the day and time, and what kind o f care you are providing.
D. Turn the television on to the evening news so that you and the patient can be updated to current events.
Correct answer:
The correct answer is B: Because the patient is unconscious, complete care as quickly and quietly as possible. This is the most appropriate intervention as it prioritizes the patient's comfort and minimizes unnecessary stimulation. Performing care quickly reduces the time the patient is exposed to potentially uncomfortable procedures. Being quiet also helps create a calming environment for the patient, which is important for someone who is unresponsive.
Explanation for other choices:
A: Asking a family member to help and discussing family structure is not appropriate as it can be intrusive and may not be relevant or beneficial to the patient's care.
C: Informing the patient of the day and time is unnecessary as the patient is unresponsive. Providing care is more crucial than updating the patient.
D: Turning on the television is inappropriate as it introduces unnecessary noise and distraction, which can be overwhelming for an unresponsive patient.
A 6-year-old boy is brought to the pediatrician by his mother, who complains of low-grade fever, chronic cough and night sweats in her child. She describes the cough as productive, producing white sputum that is sometimes streaked with blood. She also says that her son has lost some weight in the last month. His vital signs include blood pressure of 115/75 mm Hg, heart rate of 110/min., respiratory rate of 18/min. and temperature of 36,6°C. On physical examination, the patient is ill looking. Pulmonary auscultation reveals some fine crackles in the right upper lobe. The pediatrician suspects an active infection and performs Mantoux test. Intradermal injection of which of the following substances has been most likely used by pediatrician for screening test in this clinical case?
A. Tuberculin
B. Measles
C. Tetanus and diphtheria toxoids vaccine (Td)
D. Bacillus Calmette-Guerin (BCG) vaccine
Correct answer:
The correct answer is A: Tuberculin. In this clinical scenario, the patient presents with symptoms suggestive of tuberculosis, including chronic cough, night sweats, weight loss, and hemoptysis. The Mantoux test, also known as the tuberculin skin test, is used to screen for tuberculosis. Tuberculin, a purified protein derivative (PPD) derived from Mycobacterium tuberculosis, is injected intradermally. The test elicits a delayed-type hypersensitivity reaction in individuals who have been exposed to the organism in the past. A positive Mantoux test indicates exposure to tuberculosis and does not differentiate between active infection and prior exposure.
Explanation for other choices:
B: Measles - Measles is a viral infection that presents with a characteristic rash and fever, not consistent with the symptoms described in the case.
C: Tetanus and diphtheria toxoids vaccine (Td) - Td vaccine is not used for tuberculosis screening and does not elicit
The correct answer is A: Frank breech presentation. This is because the frank breech presentation is the most common type of breech presentation, accounting for about 50-70% of all breech births. In a frank breech presentation, the baby's buttocks are presenting first with the legs extended up towards the head. This position is considered the most favorable for a vaginal delivery compared to the other types of breech presentations.
Summary of incorrect choices:
B: Complete breech presentation - This type of breech presentation occurs when the baby's buttocks are presenting first with the knees bent and the feet near the buttocks. It is less common than the frank breech presentation.
C: Incomplete breech presentation - In this type, one or both of the baby's legs are presenting first instead of the buttocks. It is less common than the frank breech presentation.
D: Footling breech presentation - This type occurs when one or both of the baby's feet
A nurse is working in a Level 4 hospital. What type of patient would the nurse expect to see?
A. a first-time pregnant person with good fetal movement
B. a pregnant person who needs neurosurgery
C. a postpartum person with asthma
D. a pregnant person who plans to birth in a birth center
Correct answer:
The correct answer is B: a pregnant person who needs neurosurgery. In a Level 4 hospital, which is a facility capable of providing the highest level of care, the nurse can expect to see patients with complex and critical medical conditions like a pregnant person requiring neurosurgery. This level of hospital is equipped with advanced medical technology and specialists to handle such cases.
A: a first-time pregnant person with good fetal movement - This choice is incorrect as it does not specify any complex medical condition that would require the services of a Level 4 hospital.
C: a postpartum person with asthma - While asthma can be a serious condition, it does not necessarily require the highest level of care provided by a Level 4 hospital.
D: a pregnant person who plans to birth in a birth center - This choice is incorrect as it suggests a low-risk pregnancy that can be managed in a less intensive care setting than a Level 4 hospital.
A nurse cares for a client with chronic obstructive pulmonary disease (COPD) who appears thin and disheveled. Which question would the nurse ask first?
A. “Do you have a strong support system?”
B. “What do you understand about your disease?”
C. “Do you experience shortness of breath with basic activities?”
D. “What medications are you prescribed to take each day?”
Correct answer:
The correct question to ask first is "Do you experience shortness of breath with basic activities?" because it directly assesses the client's current health status related to COPD, which is essential for immediate care. By prioritizing this question, the nurse can quickly evaluate the severity of the client's symptoms and determine the need for urgent intervention or adjustment of the care plan. This information is crucial for addressing the client's immediate respiratory needs and ensuring their safety.
Choice A is incorrect because assessing the client's support system is important but not as urgent as evaluating their respiratory status. Choice B is also incorrect as understanding the disease is important but not as time-sensitive as assessing the client's current symptoms. Choice D is incorrect as knowing the medications the client is prescribed is important for overall care but does not address the immediate need for respiratory assessment.
A nurse believes a new mouth care procedure (MCP) is causing more mouth problems than it
A. Which of the following must be present for the nurse to go to administration with confidence that the MCP is causing problems? (Select all that apply.)
B. A plausible explanation of how the new MCP could cause harm
C. A strong feeling that the MCP is the cause
D. Consistently seeing mouth inflammation in many of the patients who have received the MCP
Correct answer:
Rationale for Correct Answer (B): A plausible explanation of how the new MCP could cause harm is crucial for the nurse to confidently present concerns to administration. Without understanding how the MCP could be causing issues, it would be challenging to convince administration of the need for changes. This step ensures that the nurse has a solid basis for their argument and can clearly articulate the potential risks associated with the new procedure.
Summary of Incorrect Choices:
A: While having specific criteria present can strengthen the case, it is not the primary factor for determining if the MCP is causing problems.
C: Relying solely on personal feelings or intuition is not sufficient evidence to support the claim that the MCP is causing harm.
D: Observing consistent mouth inflammation is important but does not provide a clear causal relationship between the MCP and the issues, lacking the necessary explanation of how harm is being caused.
RN exams clinical judgment practice questions, set 42 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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