RN exams clinical judgment practice questions, set 53
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 53
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
It is mandatory to have maternal signed consent before administering which newborn drug?
A. Erythromycin eye ointment
B. Phytonadione (Vitamin K1)
C. Hepatitis B vaccine series
D. Betamethasone injection
Show answer and rationale
Correct answer: C — Hepatitis B vaccine series
Step 1: Maternal consent is required for Hepatitis B vaccine series as it involves administering a vaccine to the newborn, which may have potential risks.
Step 2: The Hepatitis B vaccine series is given as a preventive measure against Hepatitis B infection.
Step 3: Maternal consent ensures that the mother is informed about the benefits and risks of the vaccine for her newborn.
Step 4: Without maternal consent, healthcare providers cannot administer the Hepatitis B vaccine series to the newborn.
Summary: Choice A (Erythromycin eye ointment) is typically administered routinely without requiring maternal consent. Choice B (Phytonadione) is a vitamin supplement given to newborns to prevent bleeding disorders, usually without the need for maternal consent. Choice D (Betamethasone injection) is a medication given to pregnant women to help fetal lung development and does not require maternal consent for administration to the newborn.
Question 2
The breastfeeding patient should be taught a safe method to remove her breast from the baby's mouth. Which suggestion by the nurse is most appropriate?
A. Break the suction by inserting your finger into the corner of the infant's mouth.
B. A popping sound occurs when the breast is correctly removed from the infant's mouth.
C. Slowly remove the breast from the baby's mouth when the infant has fallen asleep and the jaws are relaxed.
D. Elicit the Moro reflex in the baby to wake the baby up, and remove the breast when the baby cries.
Show answer and rationale
Correct answer: A — Break the suction by inserting your finger into the corner of the infant's mouth.
Rationale for correct answer (A):
1. Breaking the suction by inserting a finger into the corner of the infant's mouth is the most appropriate method to remove the breast safely.
2. This technique prevents trauma to the nipple and helps the baby release the latch gently.
3. It allows for a smooth and painless disengagement of the baby from the breast.
4. By breaking the suction first, the risk of causing discomfort or injury to both the mother and the baby is minimized.
Summary of why other choices are incorrect:
B. A popping sound is not a reliable indicator of correct breast removal and may lead to abrupt disengagement, causing pain and potential injury.
C. Removing the breast slowly while the baby is asleep can disrupt the baby's sleep and may not be gentle or safe.
D. Eliciting the Moro reflex is unnecessary and may startle the baby, leading to an abrupt disengagement that can cause discomfort and potential injury.
Question 3
A nurse is caring for a patient with a history of stroke. What is the priority nursing intervention?
A. Assist the patient with a swallowing assessment.
B. Monitor the patient for changes in neurological status.
C. Ensure the patient has a family member to assist with rehabilitation.
D. Provide medication to improve swallowing.
Show answer and rationale
Correct answer: B — Monitor the patient for changes in neurological status.
The correct answer is B: Monitor the patient for changes in neurological status. This is the priority intervention because patients with a history of stroke are at risk for complications such as recurrent strokes or worsening neurological status. Monitoring for changes allows for early detection and timely intervention.
A: Assisting with a swallowing assessment is important, but monitoring neurological status takes precedence as it directly assesses the patient's brain function.
C: Having a family member for rehabilitation is beneficial but not the priority over monitoring neurological status for immediate complications.
D: Providing medication for swallowing improvement may be necessary, but monitoring neurological status is crucial for detecting any emergent issues.
In summary, monitoring neurological status is the priority as it directly assesses the patient's brain function and allows for early detection of complications.
Question 4
A 40-year-old primiparous woman who is 38 weeks pregnant has been on the labor unit for an hour when she starts to complain of feeling dizzy, light-headed, and nauseous. Her blood pressure is 90/60. What should be the first response of the nurse?
A. Give the patient a bolus of intravenous fluid.
B. Turn the patient to her left side.
C. Call the obstetrician or nurse midwife.
D. Give the patient an antiemetic medication for the nausea.
Show answer and rationale
Correct answer: B — Turn the patient to her left side.
The correct answer is B: Turn the patient to her left side.
Rationale:
1. The patient's symptoms of dizziness, light-headedness, and low blood pressure (90/60) suggest hypotension, which could be due to supine hypotensive syndrome in pregnancy.
2. Turning the patient to her left side can help alleviate pressure on the vena cava, improving blood flow back to the heart and subsequently increasing blood pressure.
3. This immediate action can help prevent further complications such as decreased placental perfusion and fetal distress.
Summary:
- Choice A (Give the patient a bolus of intravenous fluid): While IV fluids may be needed, the priority is to address the underlying cause of hypotension first.
- Choice C (Call the obstetrician or nurse midwife): While it is important to involve the healthcare provider, immediate action to address the hypotension is crucial.
- Choice D (Give the patient an antiemetic medication for
Question 5
A patient who is 40 weeks pregnant and is in labor suddenly complains of a severe headache and blurry vision. What should the nurse assess for?
A. Preeclampsia
B. Fetal distress
C. Uterine rupture
D. Placenta previa
Show answer and rationale
Correct answer: A — Preeclampsia
The correct answer is A: Preeclampsia. In this scenario, the sudden onset of severe headache and blurry vision in a pregnant woman in labor are indicative of preeclampsia, a serious pregnancy complication characterized by high blood pressure and signs of organ damage. The nurse should assess for other symptoms of preeclampsia such as hypertension, proteinuria, edema, and epigastric pain. Preeclampsia can lead to eclampsia, seizures, and life-threatening complications for both the mother and the baby if not promptly managed.
Summary:
B: Fetal distress - Not the priority assessment when the mother is experiencing symptoms indicative of a serious maternal condition like preeclampsia.
C: Uterine rupture - Symptoms are not suggestive of uterine rupture, which typically presents with severe abdominal pain, vaginal bleeding, and signs of shock.
D: Placenta previa - Symptoms are not consistent with placenta previa, which typically
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
A nurse teaches clients about the difference between urge incontinence and stress incontinence. Which statements should the nurse include in this education? (Select all that apply.)
A. Urge incontinence involves a post-void residual volume less than 50 mL.
B. Stress incontinence occurs due to weak pelvic floor muscles.
C. Stress incontinence usually occurs in people with dementia.
D. Urge incontinence can be managed by increasing fluid intake.
Correct answer:
The correct statement to include in the education about urge incontinence and stress incontinence is choice B. Stress incontinence occurs due to weak pelvic floor muscles or urethral sphincter, leading to the inability to tighten the urethra sufficiently to overcome increased detrusor pressure. This condition is common after childbirth when pelvic muscles are stretched and weakened. Urge incontinence, on the other hand, is characterized by the inability to suppress the contraction signal from the detrusor muscle. It is often associated with abnormal detrusor contractions, which can be due to neurological abnormalities rather than post-void residual volume. Choice A is incorrect because urge incontinence is not defined by post-void residual volume. Choice C is incorrect as stress incontinence is not usually linked to dementia. Choice D is incorrect because increasing fluid intake is not a management strategy for urge incontinence.
A 22 year old male presents in your clinic, c/o pain in his testicle and penis. The pain began last night and has steadily become worse. He hurts when he urinates. He has not attempted intercourse since the pain began. He has tried Tylenol and Ibuprofen without improvement. Denies fever or night sweats. He has had 4 previous sexual partners and has had a new partner for the last month. She is using oral contraceptives and they do not use a condom. On exam, you see a young man lying on his side, mildly ill. His temp is 100.2. There are no visible lesions on the penis, or discharge from the meatus. The scrotum appears normal. Palpation of the testes reveals severe tenderness at the superior pole of the normal-sized left testicle. He also has tenderness when you palpate the structures superior to the testicle through the scrotal wall. The right testicle is unremarkable. An examining finger is placed through each inguinal ring without bulges noted with bearing down. Urine analysis shows WBCs and bacteria. What diagnosis of the male genitalia is most likely?
A. Acute orchitis
B. Acute epididymitis
C. Torsion of the spermatic cord
D. Prostatitis
Correct answer:
The correct answer is B: Acute epididymitis. The patient's symptoms of pain in the testicle and penis, worsened pain with urination, and presence of WBCs and bacteria in the urine analysis are indicative of an infection. The severe tenderness at the superior pole of the left testicle and tenderness on palpation of structures superior to the testicle through the scrotal wall suggest involvement of the epididymis. The risk factors of multiple sexual partners and recent unprotected intercourse also support the diagnosis of epididymitis, which is commonly caused by sexually transmitted infections. Acute orchitis (choice A) typically presents with swelling and tenderness of the entire testicle, not just the epididymis. Torsion of the spermatic cord (choice C) presents with sudden onset severe testicular pain and may have a high-riding testicle. Prostatitis (choice D) presents with symptoms related to the prostate gland, such as pelvic
The lower shelf of a bedside stand is generally used for storage of these items:
A. Water pitcher and cup
B. Linen and towel
C. Bedpan and urinal
D. Emesis basin and toothbrush
Correct answer:
The correct answer is C, bedpan and urinal, because the lower shelf of a bedside stand in a healthcare setting is typically used for storing items that are essential for patient care and comfort. Bedpans and urinals are commonly needed for patients who have difficulty getting out of bed to use the bathroom. These items are easily accessible when stored on the lower shelf, allowing healthcare providers to quickly assist patients.
A: Water pitcher and cup are usually placed on the top surface of the bedside stand for easy access by the patient.
B: Linen and towel are typically stored in a separate linen closet or cart in the patient's room.
D: Emesis basin and toothbrush are usually kept on the bedside table or in a designated area for personal hygiene needs.
In summary, choice C is correct as it aligns with the practicality and convenience of storing essential items for patient care on the lower shelf of a bedside stand.
A patient drifts off to sleep when there is no stimulation. The nurse can arouse her easily by calling her name, but she remains drowsy during the conversation. The best description of this patient's level of consciousness would be:
A. Lethargic.
B. Obtunded.
C. Stuporous.
D. Semialert.
Correct answer:
The correct answer is A: Lethargic. Lethargic is defined as a state of drowsiness or diminished alertness where the patient can be easily aroused by simple stimuli like calling their name, but they remain drowsy and may drift back to sleep. This patient's ability to be aroused by verbal stimuli and their drowsiness during conversation fits the description of lethargic.
Explanation for other choices:
B: Obtunded - Obtunded refers to a more severe level of decreased consciousness where the patient is difficult to fully arouse and may have limited interactions with the nurse.
C: Stuporous - Stuporous indicates an even deeper state of unconsciousness where the patient requires significant stimulation to be aroused and has minimal responsiveness.
D: Semialert - Semialert would describe a patient who is more responsive than lethargic, showing better awareness of their surroundings and able to maintain a conversation more effectively.
The nurse is caring for a patient who is in labor with her first child. The patient's mother is present for support and notes that things have changed in the delivery room since she last gave birth in the early 1980s. Which current trend or intervention may the patient's mother find most different?
A. Fetal monitoring throughout labor
B. Postpartum stay of 10 days
C. Expectant partner and family in operating room for cesarean birth
D. Hospital support for breastfeeding
Correct answer:
Step 1: The correct answer is D because hospital support for breastfeeding is a current trend that has significantly changed since the early 1980s. Back then, breastfeeding support in hospitals was minimal or nonexistent.
Step 2: Hospitals now provide extensive support for breastfeeding, including lactation consultants, education, and resources to help new mothers succeed in breastfeeding.
Step 3: This change in practice is a significant departure from the past and reflects the growing awareness of the importance of breastfeeding for both the mother and the baby's health.
Step 4: In contrast, choices A, B, and C are not as significant changes or trends compared to the evolution of hospital support for breastfeeding. Fetal monitoring, postpartum stay duration, and family presence during cesarean births have been around for a while and have seen some modifications, but they are not as dramatic as the shift in breastfeeding support.
What is the most appropriate nursing diagnosis for a client expressing sadness about losing her breast?
A. Ineffective Individual Coping.
B. Anticipatory Grieving.
C. Knowledge Deficit.
D. Fear.
Correct answer:
The correct answer is B: Anticipatory Grieving. This nursing diagnosis is appropriate because the client is expressing sadness about a potential loss (her breast). Anticipatory Grieving involves experiencing the feelings and behaviors associated with the normal process of grieving before an actual loss occurs. In this case, the client is already grieving the potential loss of her breast, which aligns with the definition of anticipatory grieving.
Incorrect options:
A: Ineffective Individual Coping - This diagnosis is more about the client's ability to cope with stressors or life events, rather than specifically related to grief.
C: Knowledge Deficit - This diagnosis is about a lack of understanding or information, which is not the primary issue in this scenario.
D: Fear - While fear may be a component of the client's emotional response, it does not fully capture the anticipatory grieving process that the client is going through.
Mr. Novello is an 81-year old male patient who presents with crampy abdominal pain in the hypogastrum and a vague history as to his last normal bowel movement. Physical examination reveals distention and high-pitched bowel sounds. The patient says he has never has this kind of problem before and denies any history of abdominal surgery. Abdominal radiographs reveal a frame pattern of colonic distention. The AGACNP considers
A. A stimulant laxative to relieve bowel contents
B. Carcinoma of the bowel as a leading diagnosis
C. Decompression of the colon with rectal tube
D. Angiography to rule out mesenteric ischemia
Correct answer:
The correct answer is C: Decompression of the colon with rectal tube. This is the most appropriate intervention for a patient with acute colonic pseudo-obstruction (ACPO), also known as Ogilvie's syndrome. In this condition, there is colonic distention without an actual mechanical obstruction, leading to symptoms like abdominal pain, distention, and high-pitched bowel sounds. Decompression with a rectal tube can help relieve the distention and prevent complications like perforation.
Choice A (stimulant laxative) is incorrect because ACPO is not due to simple constipation, so laxatives would not be effective. Choice B (carcinoma of the bowel) is unlikely given the acute onset and lack of risk factors. Choice D (angiography for mesenteric ischemia) is not indicated in this case as there are no signs of acute ischemia.
In summary, the correct choice is C because it directly addresses the underlying issue of colonic distention in
A 22 year old male presents in your clinic, c/o pain in his testicle and penis. The pain began last night and has steadily become worse. He hurts when he urinates. He has not attempted intercourse since the pain began. He has tried Tylenol and Ibuprofen without improvement. Denies fever or night sweats. He has had 4 previous sexual partners and has had a new partner for the last month. She is using oral contraceptives and they do not use a condom. On exam, you see a young man lying on his side, mildly ill. His temp is 100.2. There are no visible lesions on the penis, or discharge from the meatus. The scrotum appears normal. Palpation of the testes reveals severe tenderness at the superior pole of the normal-sized left testicle. He also has tenderness when you palpate the structures superior to the testicle through the scrotal wall. The right testicle is unremarkable. An examining finger is placed through each inguinal ring without bulges noted with bearing down. Urine analysis shows WBCs and bacteria. What diagnosis of the male genitalia is most likely?
A. Acute orchitis
B. Acute epididymitis
C. Torsion of the spermatic cord
D. Prostatitis
Correct answer:
The correct answer is B: Acute epididymitis. The patient's symptoms of pain in the testicle and penis, worsened pain with urination, and presence of WBCs and bacteria in the urine analysis are indicative of an infection. The severe tenderness at the superior pole of the left testicle and tenderness on palpation of structures superior to the testicle through the scrotal wall suggest involvement of the epididymis. The risk factors of multiple sexual partners and recent unprotected intercourse also support the diagnosis of epididymitis, which is commonly caused by sexually transmitted infections. Acute orchitis (choice A) typically presents with swelling and tenderness of the entire testicle, not just the epididymis. Torsion of the spermatic cord (choice C) presents with sudden onset severe testicular pain and may have a high-riding testicle. Prostatitis (choice D) presents with symptoms related to the prostate gland, such as pelvic
Which nursing statement explains how methylphenidate works when teaching parents about this medication?
A. "Methylphenidate's sedation side effect assists children by decreasing their energy level."
B. "How methylphenidate works is unknown. Although it is a stimulant, it does combat the symptoms of ADHD."
C. "Methylphenidate helps the child focus by decreasing the amount of dopamine in the basal ganglia and neuron synapses."
D. "Methylphenidate decreases hyperactivity by increasing serotonin levels."
Correct answer:
The correct answer is B. Methylphenidate is a stimulant that works by increasing the levels of certain neurotransmitters in the brain, specifically dopamine and norepinephrine. It helps improve focus, attention, and impulse control in individuals with ADHD. While the exact mechanism of how it works is not fully understood, research suggests that it enhances the activity of these neurotransmitters in the brain.
Choice A is incorrect because methylphenidate is not a sedative and does not decrease energy levels.
Choice C is incorrect because methylphenidate works by increasing, not decreasing, the levels of dopamine in the brain.
Choice D is incorrect because methylphenidate primarily affects dopamine and norepinephrine levels, not serotonin levels.
In summary, choice B is the correct answer as it accurately describes the general understanding of how methylphenidate works as a stimulant to alleviate symptoms of ADHD.
A nurse is asked to "float" to another area where the patients require total care. The nurse smiles, picks up her stethoscope, and says, "I'll come back and eat lunch with everyone here." When she enters the elevator she hits the wall and mutters, "Always me. Don't I have any rights"? The nurse is demonstrating which communication style?
A. Assertive
B. Aggressive
C. Passive
D. Passive-aggressive
Correct answer:
The correct answer is D, passive-aggressive. The nurse is indirectly expressing her displeasure and resistance to floating by smiling and agreeing to come back for lunch, but then displaying negative body language and muttering under her breath. This behavior is passive on the surface but aggressive in the underlying tone. The nurse is not openly confronting the issue but is still showing resistance and frustration.
A: Assertive communication involves expressing one's needs and feelings in a direct and respectful manner. The nurse is not openly communicating her feelings or needs in this scenario.
B: Aggressive communication involves expressing needs and feelings in a forceful and hostile manner. The nurse's behavior is not openly hostile towards others.
C: Passive communication involves avoiding conflict and not expressing one's needs or feelings. The nurse is indirectly expressing her displeasure, so it's not purely passive.
RN exams clinical judgment practice questions, set 53 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.
