RN exams clinical judgment practice questions, set 90
RN exams · clinical judgment
RN exams clinical judgment practice questionsset 90
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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 patient on mechanical ventilation experiences a sudden drop in oxygen saturation. What should the nurse check first?
A. Check the ventilator tubing for disconnection.
B. Increase the patient's oxygen flow.
C. Perform a full physical assessment.
D. Reassess the patient's oxygen levels after 5 minutes.
Show answer and rationale
Correct answer: A — Check the ventilator tubing for disconnection.
The correct answer is to check the ventilator tubing for disconnection first when a patient on mechanical ventilation experiences a sudden drop in oxygen saturation. This is crucial because equipment malfunction, such as tubing disconnection, can lead to decreased oxygen delivery, resulting in a drop in oxygen saturation. Checking the tubing ensures that the ventilation system is functioning properly and that the patient is receiving the necessary oxygen. Option B is incorrect because increasing oxygen flow without checking for equipment issues may not address the root cause of the drop in saturation. Option C is not the priority in this situation as the immediate focus should be on assessing and ensuring the functioning of the ventilation equipment. Option D delays addressing the potential equipment malfunction, which could worsen the patient's condition if not promptly resolved.
Question 2
What should the healthcare provider consider when providing support to a family whose infant has just been diagnosed with biliary atresia?
A. The prognosis for full recovery is excellent.
B. Death usually occurs by 6 months of age.
C. Liver transplantation may be needed eventually.
D. Children with surgical correction live normal lives.
Show answer and rationale
Correct answer: C — Liver transplantation may be needed eventually.
When supporting a family whose infant has been diagnosed with biliary atresia, it is important to consider that liver transplantation may be needed eventually. Biliary atresia is a serious condition where bile flow from the liver to the gallbladder is blocked or absent. While surgical interventions like the Kasai procedure can temporarily improve bile flow and delay the need for transplantation, the long-term survival often depends on liver transplantation as the child grows older. Choices A, B, and D are incorrect because the prognosis for full recovery is not excellent as biliary atresia is a chronic condition that often requires ongoing medical management, death usually does not occur by 6 months of age but the condition does require intervention, and not all children with surgical correction can live normal lives without the need for further interventions like transplantation.
Question 3
Prior to obtaining a trapeze bar for a client with limited mobility, which client assessment is most important for the nurse to obtain?
A. Balance and coordination
B. Cognitive status
C. Level of pain
D. Upper body muscle strength
Show answer and rationale
Correct answer: D — Upper body muscle strength
The correct answer is D: Upper body muscle strength. The ability to use a trapeze bar requires adequate upper body strength to support the weight and facilitate repositioning. While assessing pain, coordination, and cognitive status are important, the priority is determining if the client can physically manage the trapeze bar safely. Without sufficient upper body muscle strength, the client may not be able to use the trapeze bar effectively and safely. Assessing balance and coordination is also important but secondary to ensuring the client has the required upper body strength. Cognitive status is crucial for understanding instructions related to using the trapeze bar, but it is not the most critical assessment in this scenario. Pain assessment is essential for overall care but does not directly impact the client's ability to use a trapeze bar like upper body muscle strength does.
Question 4
A patient with HIV is admitted to the hospital because of chronic severe diarrhea. The nurse caring for this patient should expect the physician to order what drug for the management of the patients diarrhea?
A. Zithromax
B. Sandostatin
C. Levaquin
D. Biaxin
Show answer and rationale
Correct answer: B — Sandostatin
The correct answer is B: Sandostatin. This drug is a somatostatin analog that can help manage HIV-related chronic severe diarrhea by reducing gastrointestinal secretions. Sandostatin works by inhibiting the release of various hormones and neurotransmitters in the gut, which can help control diarrhea in HIV patients.
Rationale:
A: Zithromax is an antibiotic that is not typically used to manage chronic severe diarrhea in HIV patients.
C: Levaquin is also an antibiotic and not indicated for managing diarrhea in HIV patients.
D: Biaxin is another antibiotic and not the appropriate choice for managing chronic severe diarrhea in HIV patients.
In summary, Sandostatin is the correct choice as it specifically targets the underlying cause of diarrhea in HIV patients by reducing gastrointestinal secretions, whereas the other options are antibiotics that are not indicated for this purpose.
Question 5
Cyrill with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty-six hours later, the client's urine output suddenly rises above 200 ml/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse's suspicion of diabetes insipidus?
A. Above-normal urine and serum osmolality levels
B. Below-normal urine and serum osmolality levels
C. Above-normal urine osmolality level, below-normal serum osmolality level
D. Below-normal urine osmolality level, above-normal serum osmolality level
The correct answer is D. Diabetes insipidus results from inadequate production or action of antidiuretic hormone, leading to excessive urine output and dilute urine. In this case, the sudden rise in urine output above 200 ml/hour indicates a large volume of dilute urine being excreted. Therefore, the urine osmolality will be low (below normal) due to its diluteness. On the other hand, the serum osmolality will be high (above normal) because the body is unable to retain water properly, leading to dehydration and concentration of solutes in the blood. This imbalance in osmolality levels between urine and serum supports the nurse's suspicion of diabetes insipidus.
Incorrect choices:
A: Above-normal urine and serum osmolality levels - This is incorrect because in diabetes insipidus, urine osmolality is low (dilute) and serum osmolality is high.
B: Below-normal urine and serum os
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Question 6
The nurse obtains a health history from an older adult with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse helps identify a risk factor for IE?
A. “Do you have a history of a heart attack?â€
B. “Is there a family history of endocarditis?â€
C. “Have you had any recent immunizations?â€
D. “Have you had dental work done recently?â€
Correct answer:
The correct answer is D: "Have you had dental work done recently?" This question helps identify a risk factor for infective endocarditis (IE) as dental procedures can introduce bacteria into the bloodstream, potentially leading to IE in individuals with prosthetic heart valves. Dental work is a known risk factor for IE due to the transient bacteremia that can occur during dental procedures, especially in those with prosthetic heart valves. Choices A, B, and C are incorrect as they do not directly relate to the risk factors for IE in this specific scenario. Asking about a history of heart attack (A) is not directly related to IE risk factors. Family history of endocarditis (B) may have some relevance, but it is not as directly linked to the current situation as dental work. Recent immunizations (C) are important for overall health but not a specific risk factor for IE in this case.
A nurse who is conducting a staff in-service on the phases of a disaster continuum teaches participants that, during the impact/response stage, activities focus on:
A. community awareness in anticipation of a terrorist attack or natural disaster.
B. determining the effectiveness of the disaster medical assistance team (DMAT).
C. the use of an all-hazards approach.
D. initiating response activities.
Correct answer:
The correct answer is D because during the impact/response stage of a disaster, the main focus is on initiating immediate response activities to address the immediate needs of individuals affected by the disaster. This includes activities such as search and rescue, providing medical care, and establishing emergency shelters.
Choice A is incorrect because community awareness and anticipation of disasters typically occur during the preparedness phase, not the impact/response stage.
Choice B is incorrect because determining the effectiveness of DMAT is more relevant to the recovery phase of a disaster, not the immediate response phase.
Choice C is incorrect because the all-hazards approach refers to a comprehensive strategy for addressing various types of disasters, but it does not specifically relate to the activities carried out during the impact/response stage of a disaster.
Which of the following drugs most likely interacted with metoclopramide, thus triggering the adverse effects reported by the patient?
A. Amitriptyline
B. Lithium
C. Zolpidem
D. Paroxetine
Correct answer:
The correct answer is A: Amitriptyline. Metoclopramide interacts with amitriptyline by inhibiting its metabolism, leading to increased levels of amitriptyline in the body. This can result in adverse effects such as sedation, confusion, and potential serotonin syndrome.
Explanation:
1. Metoclopramide is known to inhibit CYP2D6 enzyme, which is responsible for metabolizing amitriptyline.
2. Increased amitriptyline levels can lead to enhanced sedative effects and central nervous system depression.
3. The combination can also increase the risk of serotonin syndrome due to the additive serotonergic effects of both drugs.
Summary:
B: Lithium - Lithium does not have a significant metabolic interaction with metoclopramide.
C: Zolpidem - Zolpidem is primarily metabolized by different enzymes and does not interact significantly with metoclopramide.
D: Paroxetine - Although both
A nurse is caring for a patient with a history of hypertension. The nurse should educate the patient to avoid which of the following?
A. Increasing potassium intake.
B. Consuming more fruits and vegetables.
C. Limiting sodium intake.
D. Increasing caffeine consumption.
Correct answer:
The correct answer is D: Increasing caffeine consumption. Caffeine can potentially raise blood pressure in individuals with hypertension. The rationale is that caffeine is a stimulant that can lead to temporary spikes in blood pressure. This can be harmful for patients with a history of hypertension as it can exacerbate their condition.
A: Increasing potassium intake is generally recommended for individuals with hypertension as it can help lower blood pressure.
B: Consuming more fruits and vegetables is also beneficial for hypertension due to their high fiber and nutrient content.
C: Limiting sodium intake is crucial for managing hypertension as high sodium levels can lead to increased blood pressure.
In summary, increasing caffeine consumption is the correct answer to avoid for patients with hypertension, as it can potentially worsen their condition by raising blood pressure.
The physician prescribes haloperidol (Haldol), a first-generation antipsychotic drug, for a patient with schizophrenia who displays delusions, hallucinations, apathy, and social isolation. Which symptoms should most be monitored to evaluate the expected improvement from this medication?
A. Talking to himself, belief that others will harm him
B. Flat affect, avoidance of social activities, poor hygiene
C. Loss of interest in recreational activities, alogia
D. Impaired eye contact, needs help to complete tasks
Correct answer:
The correct answer is A because the symptoms of delusions and hallucinations are key indicators of improvement in schizophrenia with antipsychotic treatment. These symptoms directly relate to the patient's perception of reality and are core features of the disorder. Monitoring these symptoms provides objective evidence of the medication's effectiveness in addressing the patient's psychotic symptoms.
Choices B, C, and D are incorrect because they mainly indicate negative symptoms of schizophrenia, such as flat affect, social withdrawal, and cognitive deficits. While monitoring these symptoms is important for assessing overall functioning and quality of life, they are not the primary target of improvement with antipsychotic medications. Symptoms like delusions and hallucinations are considered primary targets for evaluating the efficacy of antipsychotic treatment in schizophrenia.
The nurse obtains a health history from an older adult with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse helps identify a risk factor for IE?
A. “Do you have a history of a heart attack?”
B. “Is there a family history of endocarditis?”
C. “Have you had any recent immunizations?”
D. “Have you had dental work done recently?”
Correct answer:
The correct answer is D: "Have you had dental work done recently?" This question helps identify a risk factor for infective endocarditis (IE) as dental procedures can introduce bacteria into the bloodstream, potentially leading to IE in individuals with prosthetic heart valves. Dental work is a known risk factor for IE due to the transient bacteremia that can occur during dental procedures, especially in those with prosthetic heart valves. Choices A, B, and C are incorrect as they do not directly relate to the risk factors for IE in this specific scenario. Asking about a history of heart attack (A) is not directly related to IE risk factors. Family history of endocarditis (B) may have some relevance, but it is not as directly linked to the current situation as dental work. Recent immunizations (C) are important for overall health but not a specific risk factor for IE in this case.
The nurse is caring for a patient with a diagnosis of vulvar cancer who has returned from the PACU after undergoing a wide excision of the vulva. How should this patients analgesic regimen be best managed?
A. Analgesia should be withheld unless the patients pain becomes unbearable.
B. Scheduled analgesia should be administered around-the-clock to prevent pain.
C. All analgesics should be given on a PRN, rather than scheduled, basis.
D. Opioid analgesics should be avoided and NSAIDs exclusively provided.
Correct answer:
The correct answer is B: Scheduled analgesia should be administered around-the-clock to prevent pain. After undergoing a wide excision of the vulva, the patient is likely to experience significant pain. Scheduled analgesia ensures that the patient receives pain relief consistently, preventing pain from becoming severe. This approach helps to maintain a therapeutic level of pain control and improves patient comfort and satisfaction.
Choice A is incorrect because withholding analgesia until the pain becomes unbearable can lead to unnecessary suffering and poor pain management. Choice C is incorrect as PRN dosing may result in inadequate pain relief and fluctuations in pain control. Choice D is incorrect as opioids are often necessary for postoperative pain management, and NSAIDs alone may not provide sufficient relief for the level of pain associated with a wide excision surgery.
The human body regulates homeostasis by communicating at the cellular level through the nervous and endocrine systems. Which of the following is responsible for serving as the command and control center for linking the systems together?
A. Hypothalamus
B. Adrenal gland
C. Thyroid gland
D. Pituitary gland
Correct answer:
The correct answer is A: Hypothalamus. The hypothalamus serves as the command and control center for linking the nervous and endocrine systems. It regulates body temperature, thirst, hunger, and other vital functions.
Rationale:
1. The hypothalamus is located in the brain and plays a crucial role in maintaining homeostasis by regulating hormone secretion from the pituitary gland.
2. It receives input from the nervous system and sends signals to the pituitary gland to release hormones that control various bodily functions.
3. The hypothalamus also controls the autonomic nervous system, which regulates involuntary processes such as heart rate and digestion.
4. The adrenal gland (B), thyroid gland (C), and pituitary gland (D) are important components of the endocrine system, but they do not serve as the central command center for linking the nervous and endocrine systems together.
A baby is born with a penis, a scrotum with no testes, no vagina, and XX chromosomes. This condition is referred to as hermaphroditism. Which of the following could cause this abnormality?
A. Abnormally high levels of human chorionic gonadotropin production by the trophoblast cells
B. Abnormally low rates of estrogen production by the placenta
C. Abnormally high levels of luteinizing hormone in the maternal blood
D. Abnormally high levels of testosterone in the maternal blood
Correct answer:
The correct answer is D: Abnormally high levels of testosterone in the maternal blood. This can cause virilization of the female fetus, leading to the development of male external genitalia. Testosterone exposure during fetal development can result in the formation of a penis and scrotum without testes in a genetic female (XX).
Rationale:
1. Testosterone is responsible for the development of male external genitalia.
2. XX chromosomes indicate a genetic female.
3. Lack of testes indicates incomplete masculinization.
4. High levels of testosterone can override the default female development pattern.
Other choices are incorrect because:
A: Human chorionic gonadotropin does not directly affect fetal genital development.
B: Estrogen is not responsible for male genital development.
C: Luteinizing hormone does not directly influence the development of external genitalia in the fetus.
A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?
A. Complete the questions in chronological order.
B. Focus on the patient’s presenting situation.
C. Make accurate interpretations of the data.
D. Conduct an observational overview.
Correct answer:
The correct answer is B: Focus on the patient's presenting situation. In the problem-oriented approach, the nurse starts by gathering data related to the patient's current health issue or concern. This step is crucial as it helps identify the primary problem and sets the direction for further data collection and analysis. By focusing on the patient's presenting situation, the nurse can prioritize information gathering and make informed decisions about the next steps in care.
Incorrect choices:
A: Completing questions in chronological order may not be relevant to the patient's current issue and could lead to missing important details.
C: Making accurate interpretations of the data comes after data collection, so it is not the first step.
D: Conducting an observational overview is important but typically follows focusing on the presenting situation to gather specific information.
RN exams clinical judgment practice questions, set 90 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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