RN exams clinical judgment practice questions, set 55
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 55
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
An older adult client with chronic emphysema is admitted with acute onset of weakness, palpitation, and vomiting. Which information is most important for the nurse to obtain during the initial interview?
A. Medication compliance over the past few weeks.
B. Recent sleep patterns and rest.
C. Recent history of smoking.
D. Activity level prior to symptom onset.
Show answer and rationale
Correct answer: A — Medication compliance over the past few weeks.
The correct answer is A: Medication compliance over the past few weeks. In a client with chronic emphysema experiencing acute symptoms, it is crucial to assess medication compliance as it directly impacts symptom control and disease management. Ensuring the client has been adherent to their prescribed medications can provide insights into potential exacerbating factors or the need for adjustments in the treatment plan. Choices B, C, and D are less critical during the initial assessment compared to medication compliance. Recent sleep patterns and rest (choice B) may be relevant but are secondary to ensuring proper medication management. While smoking history (choice C) is important in chronic lung conditions, the immediate focus should be on the current status of medication use. Activity level prior to symptom onset (choice D) is also pertinent but not as crucial as confirming medication compliance to address the acute symptoms.
Question 2
Guidelines for serving meal trays include
A. Serving the residents who need the most help with eating first
B. Doing as much as possible for residents to make mealtimes more efficient
C. Discouraging conversation during meals
D. Saying positive things about the food being served
Show answer and rationale
Correct answer: D — Saying positive things about the food being served
The correct answer is D because saying positive things about the food being served helps create a positive dining experience for the residents, leading to improved appetite and enjoyment of the meal. By providing positive feedback, it encourages residents to try new foods and promotes a healthy eating environment. This approach also respects individual preferences and promotes dignity.
A: Serving the residents who need the most help with eating first - While important for efficient meal service, it may not be the best approach for promoting a positive dining experience for all residents.
B: Doing as much as possible for residents to make mealtimes more efficient - Efficiency is crucial, but it shouldn't compromise the quality of the dining experience or individual preferences.
C: Discouraging conversation during meals - Conversation can enhance the dining experience, promote social interaction, and improve overall well-being.
Question 3
On auscultation of a patient's lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding?
A. Inspiratory crackles at the bases.
B. Expiratory wheezes in both lungs.
C. Abnormal lung sounds in the apices of both lungs.
D. Pleural friction rub in the right and left lower lobes.
Show answer and rationale
Correct answer: A — Inspiratory crackles at the bases.
The correct answer is A: Inspiratory crackles at the bases. This finding indicates the presence of crackles, which are discontinuous, non-musical sounds heard during inspiration. Crackles in the lower third of both lungs suggest the presence of fluid or mucus in the alveoli or small airways. The term "bases" refers to the lower portions of the lungs. Crackles are typically associated with conditions such as pneumonia, heart failure, or pulmonary edema.
Explanation of other choices:
B: Expiratory wheezes in both lungs - Wheezes are continuous, high-pitched musical sounds heard during expiration and are typically associated with asthma or bronchitis. This does not match the description provided in the question.
C: Abnormal lung sounds in the apices of both lungs - The apices refer to the upper portions of the lungs. The description in the question does not match this location.
D: Pleural friction rub in the right and left lower
Question 4
Which of the following would be included in a total health database for a well person?
A. Nursing goals for the patient
B. Anticipated growth and development patterns
C. A patient's perception of his or her health status
D. The nurse's perception of disease as related to this patient
Show answer and rationale
Correct answer: C — A patient's perception of his or her health status
The correct answer is C: A patient's perception of his or her health status. In a total health database for a well person, it is important to include the patient's own perception of their health status as it provides valuable insights into their overall well-being and can help detect any potential health issues early on. This information is crucial for preventive care and promoting a patient-centered approach to healthcare.
A: Nursing goals for the patient - This information would be relevant for a patient with specific health goals or conditions but not necessarily for a well person.
B: Anticipated growth and development patterns - This information is more relevant for pediatric or adolescent populations rather than for a well adult.
D: The nurse's perception of disease as related to this patient - The nurse's perception is subjective and not as valuable as the patient's own perception in understanding their health status.
Question 5
Which is a nursing intervention for a patient taking carbidopa-levodopa for Parkinson disease?
A. Encourage the patient to adhere to a high-protein high sodium diet.
B. Inform the patient that perspiration may be dark and may stain clothing.
C. Advise the patient that glucose levels should be checked with urine testing.
D. Warn the patient that it may take 4 to 5 days before symptoms are controlled.
Show answer and rationale
Correct answer: B — Inform the patient that perspiration may be dark and may stain clothing.
The correct answer is B: Inform the patient that perspiration may be dark and may stain clothing. This is because carbidopa-levodopa can cause dark sweat due to its effect on dopamine levels. This information is crucial for patient education to prevent unnecessary concerns or distress.
Choice A is incorrect because high-protein intake can interfere with the absorption of levodopa, leading to reduced effectiveness of the medication.
Choice C is incorrect because checking glucose levels with urine testing is not relevant for monitoring the effects of carbidopa-levodopa in Parkinson's disease. Blood glucose monitoring would be more appropriate for diabetes management.
Choice D is incorrect because the onset of action for carbidopa-levodopa is typically faster, within hours to days, rather than 4 to 5 days. It is important for the patient to be aware of the potential side effects and expected timeline for symptom improvement.
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Question 6
Otherwise she has had no health problems. Her father has high blood pressure. Her mother had unilateral breast cancer in her 70s. The patient denies tobacco, alcohol, or drug use. She is a family law attorney and is married. Her examination is essentially unremarkable. Which risk factor of her personal and family history most puts her in danger of getting breast cancer?
A. First-degree relative with premenopausal breast cancer
B. Age at menarche of less than 12
C. First live birth between the ages of 25 and 29
D. First-degree relative with postmenopausal breast cancer
Correct answer:
The most significant risk factor for breast cancer in the patient's personal and family history is having a first-degree relative with premenopausal breast cancer. This is because the age at which a family member was diagnosed with breast cancer can be indicative of potential genetic predispositions that may increase the patient's own risk of developing the disease. Women with a first-degree relative who was diagnosed with breast cancer before menopause (premenopausal) are at a higher risk themselves compared to those with a family history of postmenopausal breast cancer. In this case, the patient's mother had unilateral breast cancer in her 70s, which suggests a higher risk compared to postmenopausal breast cancer. Other factors such as early age at menarche or age at first live birth are also important in assessing breast cancer risk, but having a first-degree relative with premenopausal breast cancer is the most significant
The nurse enters the room of a patient who just gave birth 2 days ago to a healthy newborn. The nurse asks her what her newborn's name is and she shrugs and says, 'I haven't thought about a name yet.' What priority is the nurse most concerned about with this patient?
A. The patient has not transitioned from the fourth stage of labor.
B. Parent-to-newborn attachment may be a concern.
C. The mother may be contemplating suicide.
D. Different cultural practices.
Correct answer:
The correct answer is B: Parent-to-newborn attachment may be a concern. The nurse is most concerned about the lack of bonding or attachment between the mother and her newborn, as indicated by the mother not having thought about a name yet. This lack of interest or engagement with the newborn could potentially impact the mother's ability to form a healthy attachment, which is crucial for the newborn's well-being. The nurse should prioritize assessing and supporting the mother in developing a bond with her baby.
Choices A, C, and D are incorrect:
A: The patient not naming the newborn does not indicate she has not transitioned from the fourth stage of labor.
C: There is no evidence to suggest that the mother may be contemplating suicide based solely on her not naming the newborn.
D: Different cultural practices do not seem to be the primary concern in this scenario compared to the potential lack of parent-to-newborn attachment.
A pregnant patient at 34 weeks gestation reports sudden swelling of the hands, feet, and face. What is the nurse's priority action?
A. Monitor the patient's blood pressure and check for signs of preeclampsia.
B. Encourage the patient to elevate the legs to reduce swelling.
C. Administer diuretics as prescribed to reduce fluid retention.
D. Instruct the patient to drink more water and reduce sodium intake.
Correct answer:
The correct answer is A: Monitor the patient's blood pressure and check for signs of preeclampsia.
Rationale:
1. Sudden swelling of the hands, feet, and face in a pregnant patient at 34 weeks gestation can be a sign of preeclampsia.
2. Preeclampsia is a serious condition characterized by high blood pressure and protein in the urine, which can lead to complications for both the mother and the baby.
3. Monitoring the patient's blood pressure and checking for signs of preeclampsia is crucial for early detection and management of the condition.
4. Prompt intervention is necessary to prevent potential severe outcomes such as seizures, stroke, or organ damage.
Summary of Incorrect Choices:
B: Elevating the legs may provide temporary relief but does not address the underlying cause of the sudden swelling, which could be preeclampsia.
C: Administering diuretics without assessing the patient's blood pressure and ruling out
Which of the following symptoms did the patient most likely experience upon recovery from sedation?
A. Nausea and vomiting
B. Increased respiratory rate
C. Anterograde amnesia
D. Limb muscle spasms
Correct answer:
The correct answer is C: Anterograde amnesia. Upon recovery from sedation, the patient most likely experienced anterograde amnesia, which is the inability to form new memories after sedation. This occurs due to the effects of sedative medications on the brain's ability to encode and store new information temporarily. This symptom is commonly associated with sedative medications and is a typical outcome of sedation procedures.
A: Nausea and vomiting are common side effects of sedation but are more likely to occur during or shortly after sedation, rather than upon recovery.
B: Increased respiratory rate may occur during sedation due to the effects of sedative medications on the respiratory system, but it is not a typical symptom upon recovery.
D: Limb muscle spasms are not typically associated with recovery from sedation and are more likely to be a sign of a different medical condition or side effect of a different medication.
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
Correct answer:
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.
A nurse preceptor is assigned to help several graduate nurses assess their ability to convey warmth to patients. Which activity, if selected by the nurse preceptor, is best?
A. Set up sessions for the graduate nurses to practice various nonverbal gestures.
B. Ask the graduate nurses to record the behaviors of experienced nurses on the unit.
C. Provide the graduate nurses with a list of nonverbal behaviors that convey warmth.
D. Have the graduate nurses evaluate each other during simulated patient interviews.
Correct answer:
The correct answer is A because setting up sessions for the graduate nurses to practice various nonverbal gestures allows for hands-on learning and skill development. This approach gives the nurses the opportunity to actively engage in practicing conveying warmth through nonverbal cues, such as smiling, eye contact, and body language. This experiential learning method is effective in helping the nurses understand and internalize the importance of nonverbal communication in conveying warmth to patients.
Option B is incorrect because simply observing experienced nurses may not actively involve the graduate nurses in practicing and developing their own skills. Option C is less effective as just providing a list may not translate into practical application and skill development. Option D is not as effective as having the nurses evaluate each other may not provide the structured guidance and feedback needed for skill improvement.
A 66-year-old woman is retiring and will no longer have health insurance through her place of employment. Which agency should the client be referred to by the employee health nurse for health insurance needs?
A. Woman, Infants, and Children program
B. Medicaid
C. Medicare
D. Consolidated Omnibus Budget Reconciliation Act provision
Correct answer:
The correct answer is C: Medicare. Title XVII of the Social Security Act of 1965 created the Medicare Program to provide medical insurance for individuals who are 65 years or older, disabled, or have permanent kidney failure. Medicare is the appropriate agency to refer a 66-year-old woman who is retiring and losing her employment-based health insurance. Choice A, the Woman, Infants, and Children program, is not suitable for this scenario as it provides assistance for low-income pregnant women, breastfeeding women, and young children. Choice B, Medicaid, is a program that helps individuals with low income and resources cover medical costs, which may not be applicable to this woman's situation. Choice D, the Consolidated Omnibus Budget Reconciliation Act provision, known as COBRA, allows employees to continue their group health insurance coverage after leaving their job but may not be the best option for this woman in this case.
A client states, "You won't believe what my husband said to me during visiting hours. He has no right treating me that way." Which nursing response would best assess the situation that occurred?
A. "Does your husband treat you like this very often?"
B. "What do you think is your role in this relationship?"
C. "Why do you think he behaved like that?"
D. "Describe what happened during your time with your husband."
Correct answer:
The correct answer is D because it encourages the client to provide specific details about the situation, leading to a clearer understanding of what happened. By asking the client to describe the events during visiting hours, the nurse can gather essential information to assess the situation accurately. This open-ended question allows the client to express their thoughts and feelings freely, enabling the nurse to identify any potential issues or concerns.
Choices A, B, and C are incorrect because they do not focus on gathering specific information about the situation that occurred. Option A assumes the behavior is recurring without knowing the details. Option B shifts the focus to the client's role rather than the husband's behavior. Option C asks for speculation on the husband's behavior without allowing the client to provide actual details. These options may lead to assumptions and incomplete assessment of the situation.
Which of the following statements is accurate in explaining why gram-negative bacteria are generally more resistant to penicillin than gram-positive bacteria
A. gram-negative bacteria produce smaller quantities of transpeptidase enzyme
B. gram-negative bacteria can concentrate β-lactamase enzymes in the periplasmic space
C. gram-negative bacteria have an outer membrane that acts as an extra barrier
D. gram-negative bacteria have a thicker cell wall
Correct answer:
The correct answer is C: gram-negative bacteria have an outer membrane that acts as an extra barrier. This outer membrane in gram-negative bacteria contains lipopolysaccharides and porins, which restrict the entry of antibiotics like penicillin. The outer membrane acts as an additional layer of protection, making it harder for penicillin to penetrate and reach its target, the peptidoglycan layer. Choices A, B, and D do not directly address the specific mechanism of resistance seen in gram-negative bacteria. Choice A focuses on transpeptidase enzyme quantity, which is not the primary reason for penicillin resistance. Choice B refers to β-lactamase enzymes in the periplasmic space, which are actually enzymes that degrade penicillin and contribute to resistance, but this is not unique to gram-negative bacteria. Choice D mentions a thicker cell wall, which is a characteristic of gram-positive bacteria, not gram-negative bacteria.
The nurse is reviewing a patient’s database for significant changes and discovers that the patient has not voided in over 8 hours. The patient’s kidney function lab results are abnormal, and the patient’s oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review?
A. Diagnosis
B. Planning NursingStoreRN
C. Implementation
D. Evaluation
Correct answer:
The correct answer is A: Diagnosis. After reviewing the patient's database and identifying concerning signs such as not voiding for over 8 hours, abnormal kidney function, and decreased oral intake, the nurse must move to the diagnosis step. In this step, the nurse will analyze the data collected to identify the patient's actual and potential health problems. This will help the nurse formulate appropriate nursing diagnoses and develop a plan of care to address the identified issues.
Choice B (Planning) comes after the diagnosis step, where specific goals and interventions are established; Choice C (Implementation) follows planning and involves executing the planned interventions; Choice D (Evaluation) is the final step where the nurse assesses the effectiveness of the interventions. In this scenario, the nurse must first determine the patient's health problems before proceeding to planning, implementing, and evaluating care.
RN exams clinical judgment practice questions, set 55 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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