Clinical Judgment Practice Exam (138 Questions & Answers) with Rationale.
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Philosophy
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Philosophy
Clinical Judgment Practice Exam (138 Questions & Answers) with Rationale.Clinical Judgment Practice Exam (138 Questions & Answers) with Rationale.Clinical Judgment Practice Exam (138 Questions & Answers) with Rationale.
Clinical Judgment Practice Exam (138 Questions & Answers)
with Rationale
1. When is it most important for the nurse to assess a pregnant client's deep tendon reflexes
(DTRs)?
A. Within the first trimester of pregnancy.
B. If the client has an elevated blood pressure.
C. When the client has ankle edema.
D. During admission to labor and delivery. - Correct answer If the client has an
elevated blood pressure.
2. Rationale:
3. A systolic greater than 140 mm Hg or a diastolic greater than 90 mm Hg is a sign of
preeclampsia. Deep tendon reflexes (DTRs) greater than 2+ are also a sign of preeclampsia
as is proteinuria greater than or equal to 1+ on dipstick measurement. Preeclampsia
usually occurs after the 20th week of pregnancy.
4. When assessing a recently delivered, multigravida client, the nurse finds that her vaginal
bleeding is more than expected. Which factor in this client's history is related to this
finding?
A. She received butorphanol 2 mg IVP during labor.
B. The second stage of labor lasted 10 minutes.
C. She is a gravida 6, para 5.
D. She is over 35 years of age. - Correct answer She is a gravida 6, para 5.
5. Rationale:
6. Repeated gravid experiences cause the uterus to lose muscle tone (uterine atony) which is
the most common cause of excessive bleeding following childbirth.
7. An unconscious client is admitted to the intensive care unit and is placed on a ventilator.
The ventilator alarms continuously and the client's oxygen saturation level is 62%. Which
action should the nurse take first?
A. Call respiratory therapy.
B. Begin manual ventilation immediately.
C. Monitor oxygen saturation levels every 5 minutes.
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, D. Silence the alarm and call the technician. - Correct answer Begin manual
ventilation immediately.
8. Rationale:
9. Ventilators provide mechanical respirations. A constant alarm and low oxygen saturation
indicates a malfunction or problem with the respirations being provided. The first action
that must be taken is to begin manual ventilation until the problem has been resolved.
10. The nurse has completed the diet teaching of a client who is being discharged following
treatment of a leg wound. A high protein diet is encouraged to promote wound healing.
Which lunch choice by the client indicates that the teaching was effective?
A. A peanut butter sandwich with soda and cookies.
B. A tuna fish sandwich with chips and ice cream.
C. A salad with three kinds of lettuce and fruit.
D. Vegetable soup, crackers, and milk. - Correct answer A tuna fish sandwich with
chips and ice cream.
11. Rationale:
12. In a high protein diet, a lunch with fish and dairy contains the highest amount of protein.
For instance, four ounces of tuna contains 11 grams of protein, and ice cream 5 grams of
protein per cup.
13. The nurse plans to collect a 24-hour urine specimen for a creatinine clearance test. Which
instruction should the nurse provide to the adult male client?
A. Cleanse around the meatus, discard first portion of voiding, and collect the rest in
a sterile bottle.
B. Urinate at a specified time, discard this urine, and collect all subsequent urine
during the next 24 hours.
C. For the next 24 hours, notify nurse when the bladder is full, and the nurse will
collect catheterized specimens.
D. Urinate immediately into a urinal, and the lab will collect the specimen every 6
hours, for the next 24 hours. - Correct answer Urinate at a specified time, discard
this urine, and collect all subsequent urine during the next 24 hours.
14. Rationale:
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,15. Voiding, discarding the sample, and beginning the collection are the correct steps for
collecting a 24-hour urine specimen. Discarding even one voided specimen during the
collection invalidates the test.
16. An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9, is
admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely
cause of the ketoacidosis?
A. Incorrectly administered too much insulin.
B. Skipped eating lunch.
C. Ate an extra peanut butter sandwich before gym class.
D. Had a cold and ear infection for the past two days. - Correct answer Had a cold and
ear infection for the past two days.
17. Rationale:
18. Acute infections increase the body's need for insulin to control hyperglycemia and put the
client at risk for diabetic ketoacidosis (DKA).
19. At 40-weeks gestation, a client who is in active labor is lying in a supine position and tells
the nurse that she has finally found a comfortable position. What action should the nurse
take?
A. Encourage the client to turn on her left side.
B. Place pillows under the client's head and knees.
C. Explain to the client that her position is not safe.
D. Place a wedge under the client's right hip. - Correct answer Place a wedge under
the client's right hip.
20. Rationale:
21. Hypotension from pressure on the vena cava due to the weight of the fetus is a risk for the
full-term client. Placing a wedge under the right hip will displace the fetus and relieve
pressure on the vena cava.
22. The nurse is assessing a client with a closed head injury sustained in a motor vehicle
collision. Which finding indicates the lowest level of neurologic functioning?
A. Withdrawal from painful stimuli.
B. Decerebrate posturing during position changes.
C. Localization of a tactile stimulus.
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, D. Decorticate posturing during tracheal suctioning. - Correct answer Decerebrate
posturing during position changes.
23. Rationale:
24. The lowest level of neurological functioning is characterized by decerebrate posturing
(abnormal extension). Posturing (decorticate or decerebrate) is not considered a
purposeful response to pain. As neurological functioning deteriorates, the client will
progress from localization of a tactile stimulus to withdrawal from painful stimuli, followed
by decorticate posturing in response to the stimuli, before finally exhibiting decerebrate
posturing.
25. A client with delusions tells the nurse, "You aren't doing your job. Go get those people
over there and shoot them before they get me." Which statement is the nurse's best
response?
A. "There is no one who will hurt you."
B. "You are in a safe place. No one can get to you here."
C. "You seem quite frightened right now."
D. "What would you like to see me do to protect you?" - Correct answer "You seem
quite frightened right now."
26. Rationale:
27. A client with delusions firmly holds false beliefs to be true, and it is best to acknowledge
feelings related to the delusion. Reassuring statements such as, "You will be alright" are
not effective for such clients.
28. The wife of a newly-diagnosed client with Parkinson's disease asks the nurse if alternative
or complimentary medical therapies might cure the disease. Which response should the
nurse provide?
A. Explain that there are no known conventional, alternative, or complimentary
therapies that cure Parkinson's disease.
B. Tell the wife that her husband's neurologist would know more about alternative
treatments to cure Parkinsonism.
C. Encourage the wife to ventilate her feelings about having a husband with
Parkinson's disease.
D. Compile a list of alternative medications that are effective in curing Parkinson's
disease. - Correct answer Explain that there are no known conventional,
alternative, or complimentary therapies that cure Parkinson's disease.
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