Clinical Judgment and the NCLEX-RN® Examination

Box 1-1

Level of Cognitive Ability: Applying

The nurse notes blanching, coolness, and edema at the peripheral intravenous (IV) site. On the basis of these findings, the nurse would implement which action?

1. 1. Remove the IV.
2. 2. Apply a warm compress.
3. 3. Check for a blood return.
4. 4. Measure the area of infiltration.

Box 1-6

Integrated Processes

A client is scheduled for angioplasty. The client says to the nurse, “I’m so afraid that it will hurt and will make me worse off than I am.” Which response by the nurse is therapeutic?

1. 1. “Can you tell me what you understand about the procedure?”
2. 2. “Your fears are a sign that you really should have this procedure.”
3. 3. “Those are very normal fears, but please be assured that everything will be okay.”
4. 4. “Try not to worry. This is a well-known and easy procedure for the cardiologist.”

Box 1-7

Fill-in-the-Blank Question

A prescription reads: acetaminophen liquid, 650 mg orally every 4 hours PRN for pain. The medication label reads: 500 mg/15 mL. The nurse prepares how many milliliters to administer one dose? Fill in the blank. Record your answer using one decimal place.

Box 1-8

Multiple-Response Question

The emergency department nurse is caring for a child suspected of acute epiglottitis. Which interventions apply in the care of the child? Select all that apply.

1.   1. Obtain a throat culture.
2.   2. Auscultate lung sounds.
3.   3. Prepare the child for a chest x-ray.
4.   4. Maintain the child in a supine position.
5.   5. Obtain a pediatric-size tracheostomy tray.
6.   6. Place the child on an oxygen saturation monitor.

In a multiple-response question, you will be asked to select or check all of the options, such as interventions, that relate to the information in the question. Focus on the subject, interventions for the child with suspected acute epiglottitis. To answer this question, recall that acute epiglottitis is a serious obstructive inflammatory process that requires immediate intervention and that airway patency is a priority. Auscultating lung sounds allows the nurse to obtain information about airway patency without causing further airway compromise by examining the throat. Examination of the throat with a tongue depressor or attempting to obtain a throat culture is contraindicated because the examination can precipitate further obstruction. A lateral neck and chest x-ray is obtained to determine the degree of obstruction, if present. To reduce respiratory distress, the child should sit upright. The child is placed on an oxygen saturation monitor to monitor oxygenation status. Tracheostomy and intubation may be necessary if respiratory distress is severe. Remember to follow the specific directions given on the computer screen.

Box 1-9

Figure Question

A client who experienced a myocardial infarction is being monitored via cardiac telemetry. The nurse notes the sudden onset of this cardiac rhythm on the monitor (refer to figure) and immediately takes which action?

1. 1. Takes the client’s blood pressure
2. 2. Initiates cardiopulmonary resuscitation (CPR)
3. 3. Places a nitroglycerin tablet under the client’s tongue
4. 4. Continues to monitor the client and then contacts the cardiologist

Box 1-10

Chart/Exhibit Question

The nurse reviews the history and physical examination documented in the medical record of a client requesting a prescription for oral contraceptives. The nurse determines that oral contraceptives are contraindicated because of which documented items? Refer to chart. Select all that apply.

Box 1-11

Graphic Item Option Question

The nurse would place the client in which position to administer an enema? (Refer to the figures in 1 to 4.)

1. 1. 

   

2. 2. 

   

3. 3. 

   

4. 4. 

   

Box 1-12

NGN Items: Case Study With Extended Multiple Response and CLOZE Item

Victoria Machane, 76 years old, is brought to the emergency department by her son, Michael. Michael tells the nurse that Victoria has not been able to tolerate any physical activity and that when she tries to do something she tires very easily. Victoria began to experience shortness of breath and a cough that started this morning, and Michael states that his mother’s skin looked pale and gray. On assessment, the nurse notes that Victoria exhibits shortness of breath on exertion; she is coughing and expectorating frothy white mucus. Her pulse rate is 102 beats/min, and her blood pressure is 164/98 mm Hg. The nurse auscultates Victoria’s lung sounds and notes the presence of bilateral crackles in the lower lobes. Victoria is hospitalized. Her current home medications include betaxolol hydrochloride for glaucoma and glimepiride for type 2 diabetes mellitus. She also takes over-the-counter hydroxyaluminum sodium carbonate to help prevent acid indigestion. Heart failure is diagnosed. In addition to the medication that Victoria takes at home, the following medications are prescribed: captopril, furosemide, metoprolol, and digoxin.

Item Type: CLOZE

Cognitive Skill: Analyze Cues

Which medication would be of most concern and require clarification prior to administration? Complete the following sentences by choosing from the dropdown lists.

• The nurse should not administer the (Select one)

Because (Select one)

Captopril is an angiotensin-converting enzyme (ACE) inhibitor. The main side/adverse effects of this medication are cough, hypotension, hyperkalemia, and tachycardia. Other side effects associated with ACE inhibitors include headache, dizziness, fatigue, insomnia, and weight loss. Victoria’s BP is low at 98/64 mm Hg. Digoxin is a cardiac glycoside and would require clarification about administration if the pulse were below 60 beats per minute or if she were showing signs of toxicity. Victoria’s pulse rate is 62 beats per minute. Glimepiride is used to manage blood glucose levels and would require clarification about administration if the blood glucose was low. Victoria’s blood glucose is normal (normal level is 70 - 99 mg/dL [3.9 - 5.5 mmol/L]). Furosemide is a diuretic. Although the nurse would monitor for a drop in BP in the client receiving furosemide, the primary concern is hypokalemia. Victoria’s potassium level is normal (normal level is 3.5-5.0 mEq/L [3.5-5.0 mmol/L]).

Box 1-13

NGN Item: Extended Drag and Drop; Cognitive Skill: Generate Solutions

The nurse is preparing assignments for the day for the eight clients below and needs to assign clients to a registered nurse (RN), a licensed practical nurse (LPN), and an assistive personnel (AP). Drag each client to the most appropriate health care provider.

Box 1-14

NGN Item: Enhanced Hot Spot (Highlighting); Cognitive Skill: Recognize Cues

The nurse is assessing a male client admitted 1 day ago for newly diagnosed type 2 diabetes mellitus. Clinical findings are noted below.

Which of the current findings requires immediate follow-up?

Click on the current findings that require immediate follow-up to highlight it. Highlight only findings that require follow-up. To deselect, click the finding again.

Box 1-15

NGN Item: Matrix Item; Cognitive Skill: Take Action

The nurse notes that there has been an increase in the number of central-line–associated blood stream infections (CLABSIs) that developed in the clients being cared for on the nursing unit. How would the nurse proceed to implement a quality improvement program? For each action below, click or mark with an X to specify whether the action would be:

Indicated: An action that the nurse would take to resolve the problem

Nonessential: An action that the nurse could take without harming the client, but the action would not be likely to address the problem

Contraindicated: An action that could harm the client and would not be taken

Quality improvement, also known as performance improvement, focuses on processes or systems that significantly contribute to client safety and effective client care outcomes; criteria are used to monitor outcomes of care and to determine the need for change to improve the quality of care. If the nurse notes a particular problem, such as an increase in the CLABSIs, the nurse should collect data about the problem. This should include information such as the primary and secondary diagnoses of the clients developing the infection, the type and location of IV catheters being used, the site of the catheter, IV site dressings being used, frequency of assessment and methods of care to the IV site, and length of time that the IV catheter was inserted. Once these data are collected and analyzed, the nurse should examine evidence-based practice protocols to identify the best practices for care to IV sites to prevent infection. These practices can then be implemented and followed by evaluation of results based on the evidence-based practice protocols used. Collecting identifying client information is contraindicated because of client confidentiality and is unnecessary in this quality improvement effort. Noting the mental status of the client can be done but is not likely to address the problem. Noting the types of medications being infused can also be done but will not address the problem of IV site infection. Although it is helpful to know the expected duration of the IV site, this information does not change infection control practices in managing the IV site and is therefore considered a nonessential action.