RN exams clinical judgment practice questions, set 76
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 76
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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 a member of an interdisciplinary teamthat uses critical pathways. According to the critical pathway, on day 2 of the hospital stay, the patient should be sitting in the chair. It is day 3, and the patient cannot sit in the chair. What should the nurse do?
A. Add this data to the problem list.
B. Focus chart using the DAR format.
C. Document the variance in the patient’s record.
D. Report a positive variance in the next interdisciplinary team meeting.
Show answer and rationale
Correct answer: C — Document the variance in the patient’s record.
The correct answer is C: Document the variance in the patient’s record. By documenting the variance in the patient's record, the nurse can provide a clear record of the deviation from the critical pathway. This documentation is essential for tracking the patient's progress accurately and identifying potential issues that may require intervention. It allows for proper communication among the interdisciplinary team and ensures that everyone is aware of the deviation.
Choice A is incorrect because adding data to the problem list may not provide a comprehensive record of the variance. Choice B is incorrect because focusing on charting using the DAR format does not address the deviation from the critical pathway. Choice D is incorrect because reporting a positive variance in the next team meeting may not accurately reflect the patient's actual progress and may lead to miscommunication within the team.
Question 2
Epinephrine is effective in helping reverse the adverse effects of anaphylaxis. It is the drug of choice because it causes bronchodilation and vasoconstriction to improve respiratory effort and improve blood pressure. What other effect does epinephrine have on the patient's body during an anaphylactic reaction?
A. It reduces the release of chemical mediators from the mast cells
B. It is effective in reducing the inflammatory response of the reaction
C. Increases the heart rate to improve peripheral perfusion
D. It causes peripheral vasoconstriction to reduce the itching associated with the reaction
Show answer and rationale
Correct answer: A — It reduces the release of chemical mediators from the mast cells
Step-by-step rationale for the correct answer (A):
1. Epinephrine acts on alpha and beta-adrenergic receptors.
2. By binding to alpha receptors, it causes vasoconstriction which helps in increasing blood pressure.
3. By binding to beta-2 receptors, it causes bronchodilation which improves respiratory effort.
4. Epinephrine also reduces the release of chemical mediators such as histamine from mast cells, which helps in counteracting the allergic response.
5. Therefore, choice A is correct as it highlights an additional beneficial effect of epinephrine in managing anaphylaxis.
Summary of why other choices are incorrect:
B: Epinephrine does not directly reduce the inflammatory response; it mainly acts on vasoconstriction and bronchodilation.
C: While epinephrine can increase heart rate, the primary purpose is not to improve peripheral perfusion, but to counteract the effects of anaphylaxis.
Question 3
The nurse has made it a goal to increase the rate at which women begin prenatal care in the first trimester. The nurse relates this decision to national goals for better maternal and infant outcomes. What guidelines will the nurse use to guide her maternal health goals?
A. WHO Maternal care guidelines
B. State Practice Acts
C. AWHONN white papers
D. Healthy People 2020
Show answer and rationale
Correct answer: D — Healthy People 2020
The correct answer is D: Healthy People 2020. The nurse will use Healthy People 2020 guidelines because they are evidence-based, nationally recognized objectives that focus on improving the health and well-being of individuals, families, and communities. These guidelines specifically address maternal and infant health outcomes, making them the most relevant choice for the nurse's goal.
Incorrect Choices:
A: WHO Maternal care guidelines - While WHO guidelines are important, they are not specific to the national goals and objectives the nurse is trying to align with.
B: State Practice Acts - State Practice Acts govern the scope of practice for nurses and do not provide specific guidelines for maternal health goals.
C: AWHONN white papers - AWHONN provides valuable resources, but they may not be as comprehensive or nationally recognized as Healthy People 2020 for setting maternal health goals.
Question 4
The nurse is providing support for the parents of a neonate born with anencephaly. The parents repeatedly state, “I don’t believe this is happening to us. We were so careful during pregnancy.†The nurse associates the parents’ comments with which stage of grief?
A. Disbelief
B. Depression
C. Denial of reality
D. Anger with each other
Show answer and rationale
Correct answer: A — Disbelief
The correct answer is A: Disbelief. In the context of the scenario, the parents' statements indicate a sense of shock and difficulty accepting the reality of their situation, which aligns with the stage of disbelief in the grief process. During this stage, individuals may struggle to comprehend the situation and may question how it could have happened despite their efforts. This initial stage typically involves denial and confusion.
Choice B: Depression, is incorrect because the parents' statements do not reflect feelings of sadness or hopelessness, which are typical of the depression stage of grief.
Choice C: Denial of reality, is incorrect as the parents' statements are more about disbelief and questioning rather than outright denial of the situation.
Choice D: Anger with each other, is incorrect as there is no mention of the parents expressing anger towards each other in the scenario.
Question 5
A pregnant woman weighs 90.9 kg. The nurse is educating the patient on complications that the patient may be at risk for during pregnancy. Which response by the patient indicates that she understands?
A. Due to my weight, there is a possibility that I may develop gestational diabetes.
B. I am not overweight, but I am still at risk for gestational diabetes.
C. My mother had preeclampsia during one of her pregnancies.
D. I will need to do a glucose tolerance test in my second trimester.
Show answer and rationale
Correct answer: A — Due to my weight, there is a possibility that I may develop gestational diabetes.
The correct answer is A because maternal obesity is a risk factor for gestational diabetes. The patient's weight of 90.9 kg puts her at an increased risk. Gestational diabetes is more likely to occur in overweight or obese pregnant women. The patient's understanding that her weight increases the possibility of developing gestational diabetes demonstrates comprehension of the risk factors.
Choice B is incorrect because weight alone is a significant risk factor for gestational diabetes, regardless of whether the patient is considered overweight or not.
Choice C is incorrect as a family history of preeclampsia is a risk factor for preeclampsia, not gestational diabetes.
Choice D is incorrect because while a glucose tolerance test may be part of prenatal care, it does not specifically address the patient's understanding of the risk factors associated with her weight and gestational diabetes.
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Question 6
The nurse is caring for a patient who suffered a head trauma following a fall. The patient’s heart rate is 112 beats/min and blood pressure is 88/50 mm Hg. The patient has poor skin turgor and dry mucous membranes. The patient is confused and restless. The following laboratory values are reported: serum sodium is 115 mEq/L; blood urea nitrogen (BUN) 50 mg/dL; and creatinine 8 mg/dL. The findings are consistent with which disorder?
A. Cerebral salt wasting
B. Diabetes insipidus
C. Syndrome of inappropriate secretion of antidiuretic hormone
D. Thyroid storm
Correct answer:
The correct answer is A: Cerebral salt wasting. This is indicated by the low serum sodium level (115 mEq/L), which can occur in patients with head trauma and lead to excessive sodium loss through the kidneys. This results in hypovolemia, leading to low blood pressure and tachycardia. The elevated BUN (50 mg/dL) and creatinine (8 mg/dL) levels suggest dehydration and renal impairment due to volume depletion. The patient's poor skin turgor, dry mucous membranes, confusion, and restlessness further support the diagnosis of cerebral salt wasting.
Summary:
B: Diabetes insipidus is characterized by excessive urination and thirst due to insufficient production of antidiuretic hormone (ADH). This patient's symptoms are not consistent with diabetes insipidus.
C: Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is characterized by excessive release of ADH, leading to water retention and
The wife of a client newly diagnosed with paranoid schizophrenia asks the nurse, 'My husband was well adjusted until a month ago, and then, after a lot of work stress, he got sick. What can I expect? Will he be this sick for the rest of his life?' What information can the nurse provide about prognosis?
A. This disorder responds well to treatment and, with follow-up, may not recur.'
B. All types of schizophrenia are chronic relapsing disorders.'
C. Outcomes are poor related to client prehospital disorganization.'
D. The usual outcome is that only partial remission is achieved.'
Correct answer:
Step 1: Paranoid schizophrenia is a subtype that tends to have a better prognosis compared to other types.
Step 2: The statement that the disorder responds well to treatment and may not recur aligns with the typical course of paranoid schizophrenia.
Step 3: With proper medication and therapy, individuals with paranoid schizophrenia can experience significant improvement and have periods of stability.
Step 4: Recurrence of symptoms is less likely compared to other types of schizophrenia.
Step 5: Therefore, choice A is correct as it provides accurate information about the prognosis of paranoid schizophrenia.
Summary: Choice B is incorrect because not all types of schizophrenia are chronic relapsing disorders. Choice C is incorrect as outcomes are not solely determined by prehospital disorganization. Choice D is incorrect as partial remission is not the usual outcome for paranoid schizophrenia.
Bacteria that have been identified as frequently responsible for nonsexually transmitted infections of the reproductive system include:
A. Escherichia coli, Gardnerella vaginalis, and Staphylococcus aureus
B. Streptococcus faecalis, Klebsiella oxytoca, and Serratia marcescens
C. Clostridium tetani, Bacillus cereus, and Staphylococcus aureus
D. Neisseria gonorrhoeae, Helicobacter pylori, and Pseudomonas aeruginosa
Correct answer:
The correct answer is A (Escherichia coli, Gardnerella vaginalis, and Staphylococcus aureus) because they are known to commonly cause nonsexually transmitted infections of the reproductive system. Escherichia coli can cause urinary tract infections that can ascend to the reproductive system. Gardnerella vaginalis is associated with bacterial vaginosis, a common infection of the vagina. Staphylococcus aureus can cause infections in the reproductive system through various means.
Choices B, C, and D are incorrect:
B: Streptococcus faecalis, Klebsiella oxytoca, and Serratia marcescens are not commonly associated with reproductive system infections.
C: Clostridium tetani and Bacillus cereus are not typically involved in reproductive system infections.
D: Neisseria gonorrhoeae causes sexually transmitted infections, Helicobacter pylori causes gastrointestinal issues, and Pseudomonas aeruginosa is more
A male client notifies the nurse that he feels short of breath and has chest pressure radiating down his left arm. A STAT 12-lead electrocardiogram (ECG) is obtained and shows ST segment elevation in leads II, III, aVF, and V4R. The nurse collects blood samples and gives a normal saline bolus. What action is most important for the nurse to implement?
A. Obtain the results for STAT serum cardiac biomarkers.
B. Assess for contraindications for thrombolytic therapy.
C. Measure ST-segment height and waveform changes.
D. Transfer for percutaneous coronary intervention (PCI).
Correct answer:
Assessing for contraindications for thrombolytic therapy is crucial as it determines whether the client is a candidate for reperfusion therapy. In this scenario, the client is presenting with symptoms and ECG changes consistent with an acute myocardial infarction (MI). Thrombolytic therapy aims at restoring blood flow to the heart muscle, reducing the size of the infarct. However, it is essential to assess for contraindications such as recent surgery, active bleeding, or a history of stroke to avoid potential complications. Obtaining serum cardiac biomarkers or measuring ST-segment changes are important steps in the diagnosis of MI but are not as time-sensitive as assessing for contraindications to thrombolytic therapy. Transfer for percutaneous coronary intervention (PCI) is a definitive treatment for MI, but assessing for thrombolytic therapy eligibility takes precedence in this acute situation.
What is the role of ovarian stimulation in fertility treatments?
A. To suppress ovulation and preserve egg quality.
B. To encourage the production of multiple eggs for retrieval.
C. To eliminate the need for embryo freezing.
D. To improve uterine lining thickness for implantation.
Correct answer:
The correct answer is B. Ovarian stimulation in fertility treatments aims to encourage the production of multiple eggs for retrieval, increasing the chances of successful fertilization and pregnancy. By stimulating the ovaries to produce multiple eggs, fertility specialists can select the healthiest eggs for fertilization. This process is crucial for individuals with infertility issues or those undergoing assisted reproductive technologies like in vitro fertilization (IVF).
Choice A is incorrect because ovarian stimulation does not aim to suppress ovulation but rather to enhance egg production. Choice C is incorrect because ovarian stimulation does not eliminate the need for embryo freezing; embryos may still need to be frozen for future use. Choice D is incorrect because ovarian stimulation does not directly target uterine lining thickness; it primarily focuses on egg production in the ovaries.
Family assessment is essential in order to meet family nee ds. Which of the following must be assessed first to assist the nurse in providing family-centered care?
A. Assessment of patient and family’s developmental stag es and needs
B. Description of the patient’s home environment
C. Identification of immediate family, extended family, a nd decision makers
D. Observation and assessment of how family members fu nction with each other
Correct answer:
The correct answer is A because assessing the patient and family's developmental stages and needs is crucial in understanding their current situation and determining the appropriate care plan. By assessing developmental stages, the nurse can tailor interventions to meet the family's specific needs. This assessment also helps in identifying potential challenges or areas requiring support.
Choice B is incorrect as it focuses solely on the physical environment and does not address the family's developmental stages and needs.
Choice C is incorrect as it emphasizes identifying family members without considering the importance of understanding their developmental stages and needs in providing family-centered care.
Choice D is incorrect as it concentrates on family dynamics without directly addressing the crucial aspect of assessing developmental stages and needs for effective family-centered care.
How would the community health nurse use summative evaluation data when evaluating the education plan for a group of homeless IV drug users?
A. Determine if the education will advance the knowledge of the population so they will make healthier choices
B. They have no hope
C. They never want to change
Correct answer:
The correct answer is A. The community health nurse would use summative evaluation data to determine if the education plan has advanced the knowledge of the homeless IV drug users, leading to healthier choices. Summative evaluation assesses the overall effectiveness of the program after its completion. By analyzing the data gathered from the evaluation, the nurse can measure the impact of the education plan on the knowledge levels of the population. This information is crucial in determining if the intended outcomes of the education plan have been achieved.
Choices B and C are incorrect because they are not related to the purpose of summative evaluation. Summative evaluation focuses on assessing the overall impact of the program, not on making assumptions about the population's hope or willingness to change. Choice D is incomplete and does not provide a valid alternative to the correct answer.
A client with hypertension receives a prescription for enalapril, an angiotensin-converting enzyme (ACE) inhibitor. Which instruction should the nurse include in the medication teaching plan?
A. Increase intake of potassium-rich foods.
B. Report increased bruising or bleeding.
C. Stop medication if a cough develops.
D. Limit intake of leafy green vegetables.
Correct answer:
The correct instruction for the nurse to include in the medication teaching plan is to 'Report increased bruising or bleeding.' ACE inhibitors can cause thrombocytopenia, which lowers platelet count and increases the risk of bruising and bleeding. Choice A is incorrect because while ACE inhibitors may cause potassium levels to increase, the instruction should not be to increase intake of potassium-rich foods without healthcare provider guidance. Choice C is incorrect because a cough is a common side effect of ACE inhibitors due to bradykinin accumulation, and stopping the medication abruptly is not recommended without consulting the healthcare provider. Choice D is incorrect because there is no need to limit intake of leafy green vegetables specifically with ACE inhibitors; however, consistent intake of vitamin K-rich foods is recommended to maintain a stable INR for clients taking anticoagulants.
During a client assessment, the client says, 'I can't walk very well.' Which action should the nurse implement first?
A. Predict the likelihood of the outcome.
B. Consider alternatives.
C. Choose the most successful approach.
D. Identify the problem.
Correct answer:
The correct answer is D: Identify the problem. This is the first action the nurse should take in the nursing process as it helps in understanding the client's issue. By identifying the problem, the nurse can gather more information through further assessment to determine the underlying cause of the client's difficulty in walking. This step is crucial for developing an effective care plan and interventions.
A: Predict the likelihood of the outcome - This choice is not appropriate as predicting the outcome should come after identifying the problem and implementing interventions.
B: Consider alternatives - While considering alternatives is important in the decision-making process, it is not the immediate action needed in this scenario.
C: Choose the most successful approach - This choice is premature as the nurse needs to first identify the problem before determining the most successful approach.
A 6-year-old child is alert but quiet when brought to the emergency center with periorbital ecchymosis and ecchymosis behind the ears. The nurse suspects potential child abuse and continues to assess the child for additional manifestations of a basilar skull fracture. What assessment finding would be consistent with a basilar skull fracture?
A. Hematemesis and abdominal distention.
B. Asymmetry of the face and eye movements.
C. Rhinorrhoea or otorrhoea with Halo sign.
D. Abnormal position and movement of the arm.
Correct answer:
The correct answer is C: Rhinorrhoea or otorrhoea with Halo sign. This finding is consistent with a basilar skull fracture because it indicates a cerebrospinal fluid (CSF) leak from the skull base. The Halo sign refers to a ring of CSF surrounded by blood, which can be seen on a white absorbent pad. This specific sign is a classic indicator of a basilar skull fracture, as the CSF leakage from the ears or nose can be tinged with blood due to the fracture disrupting nearby blood vessels.
For the other choices:
A: Hematemesis and abdominal distention are not typical manifestations of a basilar skull fracture. They are more indicative of gastrointestinal issues or internal bleeding.
B: Asymmetry of the face and eye movements can be seen with facial nerve or orbital injuries, but it is not specific to a basilar skull fracture.
D: Abnormal position and movement of the arm are not directly related to a
RN exams clinical judgment practice questions, set 76 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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