RN exams clinical judgment practice questions, set 46
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 46
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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 nurse is assessing a patient with anorexia nervosa. Which of the following findings would be a priority for intervention?
A. Weight loss of 2 pounds over the past week.
B. Denial of the need for nutrition rehabilitation.
C. Body image disturbance and self-imposed starvation.
D. Refusal to participate in social activities.
Show answer and rationale
Correct answer: C — Body image disturbance and self-imposed starvation.
The correct answer is C: Body image disturbance and self-imposed starvation. This is a priority because it directly addresses the core issues of anorexia nervosa and poses immediate risks to the patient's health. Body image disturbance contributes to the patient's self-imposed starvation, which can lead to severe malnutrition and other serious complications. Addressing this issue is crucial for the patient's well-being.
A: Weight loss of 2 pounds over the past week is concerning but may not be an immediate priority compared to addressing the underlying psychological issues.
B: Denial of the need for nutrition rehabilitation is important to address but may not pose an immediate threat to the patient's health compared to self-imposed starvation.
D: Refusal to participate in social activities may be a consequence of anorexia nervosa but does not directly address the urgent need to address body image disturbance and self-imposed starvation.
Question 2
A 62-year old client diagnosed with pyelonephritis and possible septicemia has had five urinary tract infections over the past 2 years. She’s fatigued from lack of sleep; urinates frequently, even during the night, and has lost weight recently. Tests reveal the following: sodium level 152mEq/L, osmolarity 340mOsm/L, glucose level 125mg/dl, and potassium level of 3.8mEq/L. Which of the following nursing diagnoses is most appropriate for this client?
A. Deficient fluid volume related to inability to conserve water
B. Imbalanced nutrition: Less than body requirements related to hypermetabolic state
C. Deficient fluid volume related to osmotic diuresis induced by hypernatremia
D. Imbalanced nutrition: Less than body requirements related to catabolic effects of insulin deficiency
Show answer and rationale
Correct answer: C — Deficient fluid volume related to osmotic diuresis induced by hypernatremia
The most appropriate nursing diagnosis for this client is C: Deficient fluid volume related to osmotic diuresis induced by hypernatremia. The client's elevated sodium level of 152mEq/L indicates hypernatremia, which leads to osmotic diuresis and subsequent fluid loss. This results in deficient fluid volume, causing the client to urinate frequently and experience fatigue from lack of sleep. The other choices are incorrect because:
A: Deficient fluid volume related to inability to conserve water is not the most appropriate diagnosis as the primary issue is the osmotic diuresis induced by hypernatremia, not the client's inability to conserve water.
B: Imbalanced nutrition: Less than body requirements related to hypermetabolic state is not the most appropriate diagnosis as the client's weight loss is likely due to fluid loss from osmotic diuresis, not a hypermetabolic state.
D: Imbalanced nutrition: Less than body requirements related to catab
Question 3
A patient at 8 weeks' gestation complains to the nurse, 'I feel sick almost every morning. And I throw up at least two or three times a week.' What is the nurse's best guidance for this patient?
A. Do you like cheese?'
B. Try eating four meals a day instead of three meals a day.'
C. Try eating peanut butter on whole wheat bread right before going to bed.'
D. If you can eat enough throughout the day, you don't have to worry about being sick.'
Show answer and rationale
Correct answer: C — Try eating peanut butter on whole wheat bread right before going to bed.'
The correct answer is C: 'Try eating peanut butter on whole wheat bread right before going to bed.' This recommendation is based on the fact that consuming a small snack high in protein and complex carbohydrates before going to bed can help stabilize blood sugar levels and reduce morning sickness symptoms in pregnant women. Peanut butter provides protein and whole wheat bread provides complex carbohydrates, which can help alleviate nausea and vomiting.
Choice A is incorrect because asking about cheese does not address the patient's symptoms or provide any practical guidance for managing morning sickness.
Choice B is incorrect because increasing the number of meals may not necessarily alleviate morning sickness and could potentially exacerbate symptoms.
Choice D is incorrect because suggesting that eating enough throughout the day will prevent sickness oversimplifies the issue and does not offer targeted advice for managing morning sickness.
Question 4
An older adults unexplained weight loss of 15 pounds over the past 3 months has prompted a thorough o diagnostic workup. What is the nurses rationale for prioritizing biochemical assessment when appraising a persons nutritional status? N
A. It identifies abnormalities in the chemical structure of nutrients.
B. It predicts abnormal utilization ogf nutrients.
C. It reflects the tissue level of a given nutrient. n
D. It predicts metabolic abnormalities in nutritional intak
Show answer and rationale
Correct answer: D — It predicts metabolic abnormalities in nutritional intak
The correct answer is D because prioritizing biochemical assessment in nutritional status appraisal helps predict metabolic abnormalities in nutritional intake. By analyzing blood levels of key nutrients and metabolic markers, the nurse can identify deficiencies or excesses that indicate how well the body is utilizing nutrients. This information can guide interventions to correct imbalances and improve overall health.
Choice A is incorrect as it refers to identifying abnormalities in the chemical structure of nutrients, which is not directly related to predicting metabolic abnormalities in nutritional intake. Choice B is incorrect because predicting abnormal utilization of nutrients does not necessarily directly correlate to metabolic abnormalities. Choice C is incorrect as it refers to reflecting the tissue level of a given nutrient, which is not the primary focus when prioritizing biochemical assessment for nutritional status appraisal.
Question 5
The AGACNP is covering an internal medicine service and is paged by staff to see a patient who has just pulled out his ET tube. After the situation has been assessed, it is clear that the patient will go into respiratory failure and likely die if he is not reintubated. The patient is awake and alert and is adamant that he does not want to be reintubated. The AGACNP is concerned that there is not enough time to establish a DNRthe patient needs to be reintubated immediately and already is becoming obtunded. Which ethical principles are in conflict here?
A. Veracity and beneficence
B. Beneficence and nonmalfeasance
C. Autonomy and beneficence
D. Justice and autonomy
Show answer and rationale
Correct answer: C — Autonomy and beneficence
The correct answer is C: Autonomy and beneficence. Autonomy refers to the patient's right to make their own decisions regarding their healthcare. In this case, the patient is refusing reintubation, exercising his autonomy. However, beneficence, the duty to act in the patient's best interest, also comes into play as the patient's refusal could lead to respiratory failure and death. The conflict arises from balancing the patient's autonomy with the healthcare provider's duty to provide beneficial care.
Choices A, B, and D are incorrect because they do not accurately capture the ethical conflict present in the scenario. Veracity (A) refers to truthfulness, which is not the primary issue here. Nonmalfeasance (B) is the duty to do no harm, which is not directly relevant to the conflict between the patient's autonomy and the need for beneficial care. Justice (D) relates to fairness in resource allocation and is not the primary issue in this case.
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Question 6
Which patient may require more help and understanding when integrating the newborn into the family?
A. A primipara from an upper income family
B. A primipara who comes from a large family
C. A multipara (gravida 2) who has a supportive husband and mother
D. A multipara (gravida 6) who has two children younger than 3 years
Correct answer:
The correct answer is D because a multipara with six pregnancies and two young children may require more help and understanding due to the potential challenges of caring for multiple young children simultaneously. The presence of two children younger than 3 years old indicates that the mother may be experiencing higher levels of stress and demands on her time and energy. This situation could lead to difficulties in integrating the newborn into the family dynamics.
Choice A is incorrect because being from an upper-income family does not necessarily indicate a need for more help and understanding. Choice B is incorrect because coming from a large family does not directly correlate with requiring more assistance when integrating a newborn. Choice C is incorrect because having a supportive husband and mother can provide valuable assistance and may not necessarily indicate a greater need for help compared to the scenario described in choice D.
A woman is being treated for a tumor of the left breast. If the patient and her physician opt for prophylactic treatment, the nurse should prepare the woman for what intervention?
A. More aggressive chemotherapy
B. Left mastectomy
C. Radiation therapy
D. Bilateral mastectomy
Correct answer:
The correct answer is D: Bilateral mastectomy. This intervention involves removing both breasts to reduce the risk of developing breast cancer in the future. For a woman with a history of breast cancer in one breast, opting for bilateral mastectomy can significantly decrease the likelihood of cancer recurrence. This proactive approach is often recommended for individuals with a high risk of developing breast cancer.
Explanation for why the other choices are incorrect:
A: More aggressive chemotherapy - Chemotherapy is typically used to treat existing cancer cells, not as a prophylactic measure to prevent cancer.
B: Left mastectomy - This option only removes the affected breast, not addressing the risk of cancer developing in the other breast.
C: Radiation therapy - While radiation therapy can be used as part of the treatment for breast cancer, it is not a prophylactic measure to prevent future cancer development in the contralateral breast.
A nurse is educating a postpartum person about newborn care. What is the best way to prevent diaper rash?
A. frequent diaper changes
B. use of a barrier cream
C. apply petroleum jelly to the skin
D. change diapers frequently
Correct answer:
The correct answer is C: apply petroleum jelly to the skin. Petroleum jelly acts as a barrier, protecting the baby's skin from moisture and irritants in the diaper. It helps maintain the skin's natural moisture and prevents diaper rash.
Rationale:
1. Petroleum jelly creates a protective barrier on the skin, preventing direct contact with moisture and irritants.
2. It helps to keep the skin moisturized, reducing the risk of irritation.
3. Petroleum jelly is safe and gentle on the baby's skin.
4. It is particularly effective for preventing diaper rash compared to other options.
Summary:
A: Frequent diaper changes are important but may not provide enough protection against moisture and irritants.
B: Barrier creams can be effective, but petroleum jelly is a more commonly recommended option.
D: Changing diapers frequently is essential, but applying petroleum jelly as an additional protective measure is more effective in preventing diaper rash.
A client is being treated for acute congestive heart failure (CHF) and the client's vital signs are as follows: BP 85/50 mm Hg; pulse, 96 bpm; respirations, 26 cpm. The physician prescribes digoxin (Lanoxin). To evaluate a therapeutic effectiveness of this medication, the nurse would expect which of the following changes in the client's vital signs?
A. BP 85/50 mm Hg, pulse 60 bpm, respirations 26 cpm
B. BP 98/60 mm Hg, pulse 80 bpm, respirations 24 cpm
C. BP 130/70 mm Hg, pulse 104 bpm, respirations 20 cpm
D. BP 110/40 mm Hg, 110 bpm, respirations 20 cpm
Correct answer:
Digoxin is a cardiac glycoside used in congestive heart failure to improve heart function. It exerts an inotropic effect, increasing myocardial contractility, which enhances cardiac output and raises blood pressure from a hypotensive state. Simultaneously, it has a negative chronotropic effect, slowing the heart rate by enhancing vagal tone, countering the tachycardia often seen in CHF. Improved cardiac output also reduces respiratory distress by alleviating pulmonary congestion, slightly lowering the respiratory rate. Starting with vital signs of BP 85/50 mm Hg, pulse 96 bpm, and respirations 26 cpm, effective digoxin therapy would show a modest BP increase (e.g., to 98/60 mm Hg), a reduced pulse (e.g., to 80 bpm), and a slight drop in respirations (e.g., to 24 cpm). Extreme changes, like a pulse of 110 bpm or unchanged hypotension, suggest either toxicity or ineffectiveness, making the moderate improvement the expected therapeutic outcome.
The recommended number of chest compressions for neonatal resuscitation is
A. 60 compressions coordinated with 30 breaths per minute
B. 3 compressions coordinated with 1 breath per minute
C. 1 compression coordinated with 3 breaths per minute
D. 90 compressions coordinated with 30 breaths per minute
Correct answer:
The correct answer is A: 60 compressions coordinated with 30 breaths per minute. In neonatal resuscitation, the recommended compression-to-ventilation ratio is 3:1. This means 3 compressions are given followed by 1 breath. With a target compression rate of 120 per minute, this translates to 60 compressions coordinated with 30 breaths per minute. Each compression should be at a depth of about one-third the anterior-posterior diameter of the chest. This ratio and rate are crucial for maintaining adequate circulation and oxygenation during neonatal resuscitation.
Choice B: 3 compressions coordinated with 1 breath per minute is too slow and would not provide enough support for the neonate's circulation.
Choice C: 1 compression coordinated with 3 breaths per minute would not provide sufficient compressions to maintain circulation.
Choice D: 90 compressions coordinated with 30 breaths per minute would result in an incorrect compression-to-vent
A pregnant patient at 30 weeks gestation reports lower back pain and difficulty sleeping. Which of the following is the most appropriate recommendation for the nurse to make?
A. Rest in bed with your legs elevated to reduce back pain.
B. Use a firm mattress and avoid sleeping on your back.
C. Take over-the-counter pain medications as prescribed to alleviate pain.
D. Perform light stretching exercises before bed to relieve discomfort.
Correct answer:
The correct answer is B. Using a firm mattress and avoiding sleeping on the back is the most appropriate recommendation for a pregnant patient at 30 weeks gestation experiencing lower back pain. Here's why:
1. Firm mattress provides better support for the back and helps maintain proper spinal alignment during sleep.
2. Avoiding sleeping on the back reduces pressure on the major blood vessels, preventing potential complications like supine hypotensive syndrome.
3. Resting in bed with legs elevated (choice A) may not address the root cause of back pain and may not be recommended for extended periods during pregnancy.
4. Taking over-the-counter pain medications (choice C) should be avoided unless prescribed by a healthcare provider due to potential risks to the fetus.
5. Performing light stretching exercises (choice D) can be beneficial, but avoiding certain positions like lying on the back is more crucial for back pain relief during pregnancy.
The nurse is caring for a patient diagnosed with Parkinsons disease. The patient is having increasing problems with rising from the sitting to the standing position. What should the nurse suggest to the patient to use that will aid in getting from the sitting to the standing position as well as aid in improving bowel elimination?
A. Use of a bedpan
B. Use of a raised toilet seat
C. Sitting quietly on the toilet every 2 hours
D. Following the outlined bowel program
Correct answer:
Correct Answer: B - Use of a raised toilet seat
Rationale: A raised toilet seat helps the patient with Parkinson's disease by providing additional height, making it easier for them to transition from sitting to standing. This aids in improving mobility and reducing the risk of falls. Furthermore, the raised seat can also promote proper positioning for bowel elimination, making the process more comfortable and effective.
Incorrect Choices:
A: Using a bedpan does not address the issue of transitioning from sitting to standing, nor does it aid in improving bowel elimination for the patient.
C: Sitting quietly on the toilet every 2 hours may not directly address the physical challenges the patient is facing in transitioning from sitting to standing.
D: Following the outlined bowel program is important, but it does not specifically address the physical support needed to transition from sitting to standing for a patient with Parkinson's disease.
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 27-year-old patient presents with injuries sustained in a motor vehicle accident. She was wearing her seatbelt and has multiple bruises and scrapes along her abdomen. She complains of pain 3/10 in her abdomen. She is G1P0 and is at 14 weeks’ gestation. A bedside ultrasound scan confirms that the fetus is stable and not in any distress. The patient is Rh negative, and her husband is Rh positive. What do you anticipate being the next step?
A. Obtain a urinalysis.
B. Administer Rh(D) immune globulin (RhoGAM).
C. Confirm with the provider that she can be discharged home.
D. Schedule a follow-up ultrasound.
Correct answer:
The correct answer is B: Administer Rh(D) immune globulin (RhoGAM). In this scenario, the patient is Rh negative and her husband is Rh positive, which puts her at risk for Rh isoimmunization. Administration of Rh(D) immune globulin (RhoGAM) helps prevent the mother's immune system from developing antibodies against the Rh-positive fetus's blood, thereby protecting future pregnancies. This intervention is crucial in preventing hemolytic disease of the newborn.
Choice A: Obtaining a urinalysis is not indicated in this case as the patient's main concern is her abdominal pain and pregnancy status, not related to her urinalysis.
Choice C: Discharging the patient without administering Rh(D) immune globulin would be inappropriate as it puts future pregnancies at risk of complications due to Rh incompatibility.
Choice D: Scheduling a follow-up ultrasound is not the immediate next step. Administering Rh(D) immune globulin is the priority to
Which measure is critical to achieving desired outcomes in the nurse-client relationship? The nurse:
A. develops trust in the client.
B. uses autodiagnosis.
C. relies on the client liking the nurse rather than limit-setting to achieve structure.
D. analyzes the relationships among biologic, familial, and sociocultural factors that contributed to the client's disorder.
Correct answer:
The correct answer is B: uses autodiagnosis. Autodiagnosis is critical in the nurse-client relationship as it involves self-awareness and reflection by the nurse to understand their own biases, emotions, and reactions. This self-awareness allows the nurse to effectively manage their responses, maintain professionalism, and provide quality care to the client. By being aware of their own thoughts and feelings, nurses can better empathize with the client, build trust, and communicate effectively. This approach helps prevent potential conflicts and misunderstandings, leading to better outcomes in the nurse-client relationship.
Summary:
A: Developing trust in the client is important but not the most critical measure.
C: Relying on the client liking the nurse is not professional and may compromise boundaries.
D: Analyzing biologic, familial, and sociocultural factors is important but not as critical as self-awareness through autodiagnosis.
RN exams clinical judgment practice questions, set 46 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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