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Clinical Judgment Practice Exam-with 100% verified solutions -personalized success
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Clinical Judgment Practice Exam-with 100% verified solutions -personalized success
If the client has an elevated blood
1. When is it most important for the
pressure.
nurse to assess a pregnant client's
deep tendon reflexes (DTRs)? Rationale:
A. Within the first trimester of preg-
A systolic greater than 140 mm Hg or
nancy.
a diastolic greater than 90 mm Hg is
B. If the client has an elevated
a sign of preeclampsia. Deep tendon
blood pressure.
reflexes (DTRs) greater than 2+ are
C. When the client has ankle ede-
also a sign of preeclampsia as is pro-
ma.
teinuria greater than or equal to 1+ on
D. During admission to labor and
dipstick measurement. Preeclampsia
delivery.
usually occurs after the 20th week of
pregnancy.
She is a gravida 6, para 5.
2. When assessing a recently deliv-
ered, multigravida client, the nurse
Rationale:
finds that her vaginal bleeding is
Repeated gravid experiences cause
more than expected. Which factor
the uterus to lose muscle tone (uter-
in this client's history is related to
ine atony) which is the most common
this finding?
cause of excessive bleeding following
A. She received butorphanol 2 mg
childbirth.
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.
Begin manual ventilation immediately.
3. An unconscious client is admit-
ted to the intensive care unit and
Rationale:
is placed on a ventilator. The ven-
Ventilators provide mechanical respi-
tilator alarms continuously and
rations. A constant alarm and low oxy-
the client's oxygen saturation lev-
gen saturation indicates a malfunction
el is 62%. Which action should the
or problem with the respirations being
nurse take first?
provided. The first action that must be
A. Call respiratory therapy.
taken is to begin manual ventilation
B. Begin manual ventilation imme-
until the problem has been resolved.
diately.
C. Monitor oxygen saturation levels
every 5 minutes.
, Clinical Judgment Practice Exam-with 100% verified solutions -
personalized success
D. Silence the alarm and call the
technician.
4. The nurse has completed the diet A tuna fish sandwich with chips and
teaching of a client who is being ice cream.
discharged following treatment of
a leg wound. A high protein diet Rationale:
is encouraged to promote wound In a high protein diet, a lunch with fish
healing. Which lunch choice by the and dairy contains the highest amount
client indicates that the teaching of protein. For instance, four ounces
was effective? of tuna contains 11 grams of protein,
A. A peanut butter sandwich with and ice cream 5 grams of protein per
soda and cookies. cup.
B. A tuna fish sandwich with chips
and ice cream.
C. A salad with three kinds of let-
tuce and fruit.
D. Vegetable soup, crackers, and
milk.
5. The nurse plans to collect a Urinate at a specified time, discard
24-hour urine specimen for a creati- this urine, and collect all subsequent
nine clearance test. Which instruc- urine during the next 24 hours.
tion should the nurse provide to the
adult male client? Rationale:
A. Cleanse around the meatus, dis- Voiding, discarding the sample, and
card first portion of voiding, and beginning the collection are the cor-
collect the rest in a sterile bottle. rect steps for collecting a 24-hour
B. Urinate at a specified time, dis- urine specimen. Discarding even one
card this urine, and collect all sub- voided specimen during the collection
sequent urine during the next 24 invalidates the test.
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 speci-
, Clinical Judgment Practice Exam-with 100% verified solutions -
personalized success
men every 6 hours, for the next 24
hours.
6. An adolescent who was diagnosed Had a cold and ear infection for the
with diabetes mellitus Type 1 at the past two days.
age of 9, is admitted to the hospital
in diabetic ketoacidosis. Which oc- Rationale:
currence is the most likely cause of Acute infections increase the body's
the ketoacidosis? need for insulin to control hyper-
A. Incorrectly administered too glycemia and put the client at risk for
much insulin. diabetic ketoacidosis (DKA).
B. Skipped eating lunch.
C. Ate an extra peanut butter sand-
wich before gym class.
D. Had a cold and ear infection for
the past two days.
7. At 40-weeks gestation, a client who Place a wedge under the client's right
is in active labor is lying in a supine hip.
position and tells the nurse that
she has finally found a comfort- Rationale:
able position. What action should Hypotension from pressure on the
the nurse take? vena cava due to the weight of the
A. Encourage the client to turn on fetus is a risk for the full-term client.
her left side. Placing a wedge under the right hip
B. Place pillows under the client's will displace the fetus and relieve pres-
head and knees. sure on the vena cava.
C. Explain to the client that her po-
sition is not safe.
D. Place a wedge under the client's
right hip.
8. The nurse is assessing a client with Decerebrate posturing during position
a closed head injury sustained in a changes.
motor vehicle collision. Which find-
ing indicates the lowest level of Rationale:
neurologic functioning? The lowest level of neurological func-
A. Withdrawal from painful stimuli. tioning is characterized by decer-
B. Decerebrate posturing during ebrate posturing (abnormal exten-
, Clinical Judgment Practice Exam-with 100% verified solutions -
personalized success
position changes. sion). Posturing (decorticate or decer-
C. Localization of a tactile stimulus. ebrate) is not considered a purpose-
D. Decorticate posturing during tra- ful response to pain. As neurological
cheal suctioning. functioning deteriorates, the client will
progress from localization of a tac-
tile stimulus to withdrawal from painful
stimuli, followed by decorticate pos-
turing in response to the stimuli, be-
fore finally exhibiting decerebrate pos-
turing.
9. A client with delusions tells the "You seem quite frightened right now."
nurse, "You aren't doing your job.
Go get those people over there and Rationale:
shoot them before they get me." A client with delusions firmly holds
Which statement is the nurse's false beliefs to be true, and it is best
best response? to acknowledge feelings related to
A. "There is no one who will hurt the delusion. Reassuring statements
you." such as, "You will be alright" are not
B. "You are in a safe place. No one effective for such clients.
can get to you here."
C. "You seem quite frightened right
now."
D. "What would you like to see me
do to protect you?"
10. The wife of a newly-diagnosed Explain that there are no known con-
client with Parkinson's disease ventional, alternative, or complimen-
asks the nurse if alternative or com- tary therapies that cure Parkinson's
plimentary medical therapies might disease.
cure the disease. Which response
should the nurse provide? Rationale:
A. Explain that there are no The client's wife should be given truth-
known conventional, alternative, or ful information that there is no known
complimentary therapies that cure cure for Parkinson's disease available
Parkinson's disease. today.
B. Tell the wife that her hus-
band's neurologist would know
more about alternative treatments
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