NGN clinical judgment · 75 questions · Test 3

NCLEX Clinical Judgment Practice Test 3

NCLEX-style clinical judgment practice — one item at a time with tabbed case exhibits, check-answer feedback, and item rationales with option-level feedback.

This is a fixed 75-item NCLEX-style / NGN-style formative practice set — not a computerized adaptive NCLEX simulation. Scores are for learning only and do not predict NCLEX success.

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Test 3 — ten unfolding acute-care clinical judgment cases with tabbed exhibits and staged chart updates, plus fifteen standalone NGN items. Tap Check answer, then Next. Timer pauses only after a complete answer is checked.

Case chartsTabbed exhibits with staged updates

CJMM stepsRecognize through evaluate

Formative scoringComponent-level credit

SummaryCJMM & Client Needs review

Choose a mode

Study mode — immediate rationale and option feedback after each Check answer.Exam mode — responses are saved without correctness, score, or rationale until you finish each unfolding case (or each standalone item). Full teaching review unlocks then.

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Question 1 of 75Total time: 0:00

Case exhibitQuestion

Recognize cues

☰ Review chart tabs before answering. Later items in each case may add timestamped updates.

Order: 12-lead ECG within 10 minutes of arrival; notify provider of results
Order: Continuous cardiac monitoring; IV access
Order: Administer supplemental oxygen for SpO₂ below 90%, respiratory distress, shock, or other evidence of hypoxemia, according to protocol
Order: Aspirin 325 mg chewed if ordered and not contraindicated

Question 1 of 75 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Raymond Cole, 58-year-old man in the Emergency department. Review the case exhibit tabs, then answer the following. Which findings are most clinically significant for urgent management?

Select all that apply. You may choose more than one option.

A. ST elevation in inferior leadsB. Crushing chest pressure with diaphoresisC. Elevated and rising troponinD. Temperature 36.8 °C without coughE. Pain onset within the past hour

Question 2 of 75 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Raymond Cole, 58-year-old man in the Emergency department. Review the case exhibit tabs, then answer the following. Which presenting condition best explains the ECG and troponin findings together?

A. Stable angina without myocardial injuryB. Acute myocardial infarction with ongoing ischemiaC. Pericarditis as the only explanation for troponin riseD. Anxiety hyperventilation without coronary occlusion

Question 3 of 75 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Raymond Cole, 58-year-old man in the Emergency department. Review the case exhibit tabs, then answer the following. Which problem requires the most immediate intervention?

A. Chronic hypertension without acute ischemiaB. Mild musculoskeletal strain from lawn workC. Isolated nicotine withdrawal anxietyD. Acute myocardial infarction with need for emergent reperfusion

Question 4 of 75 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Raymond Cole, 58-year-old man in the Emergency department. Review the case exhibit tabs, then answer the following. Classify each nursing action for this acute chest-pain presentation.

Select one response in each row (you may choose only one column per row).

Finding / action	Indicated now	Requires follow-up	Unsafe or not indicated
Give chewed aspirin 325 mg per order if not contraindicated
Delay reperfusion evaluation until next-day cardiology clinic
Maintain continuous cardiac monitoring and IV access
Complete all admission paperwork before obtaining the ECG

Question 5 of 75 — Take action

Multiple Choice — Select the best answerTake action

The nurse is caring for Raymond Cole, 58-year-old man in the Emergency department. Review the case exhibit tabs, then answer the following. While preparing this client for possible reperfusion, which action is most appropriate?

A. Keep continuous monitoring, give ordered aspirin if not contraindicated, and notify the provider promptly for the reperfusion pathwayB. Complete a detailed smoking-cessation teaching packet before notifying cardiologyC. Obtain serial troponins over the next 6 hours before any reperfusion discussionD. Give a benzodiazepine for anxiety and reassess chest pain in 1 hour without further escalation

Question 6 of 75 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Raymond Cole, 58-year-old man in the Emergency department. Review the case exhibit tabs, then answer the following. After primary PCI: pain 2/10, ST segments resolving, SpO₂ 97% on room air, no bleeding at access site. Which indicate a positive early response?

Trend snapshot
Pain 9→2; ST elevation resolving; HR 102→78; access site dry; SpO₂ 97% RA.

Select all that apply. You may choose more than one option.

A. Marked reduction in ischemic chest painB. Resolving ST-segment elevationC. New hypotension with expanding groin hematomaD. Stable oxygenation without new dyspneaE. Recurrent ventricular fibrillation requiring shocks

Question 7 of 75 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Alicia Mendez, 32-year-old woman, G1P0 at 34 weeks in the Obstetric triage. Review the case exhibit tabs, then answer the following. Which assessment and lab findings require immediate recognition in this obstetric client?

Select all that apply. You may choose more than one option.

A. BP 168/112 mmHg with severe headacheB. Epigastric/RUQ pain with elevated liver enzymesC. Platelets 95 × 10³/µLD. Isolated ankle swelling without hypertensionE. Visual disturbances with hyperreflexia

Question 8 of 75 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Alicia Mendez, 32-year-old woman, G1P0 at 34 weeks in the Obstetric triage. Review the case exhibit tabs, then answer the following. Which presenting condition best explains the combination of hypertension, proteinuria, and RUQ pain?

A. Gastroenteritis unrelated to pregnancyB. Chronic hypertension without end-organ changeC. Preeclampsia with hepatic involvementD. Normal third-trimester discomfort only

Question 9 of 75 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Alicia Mendez, 32-year-old woman, G1P0 at 34 weeks in the Obstetric triage. Review the case exhibit tabs, then answer the following. Which problem is the highest immediate priority?

A. Mild dependent edema without neurologic signsB. Risk of eclamptic seizure and maternal end-organ injuryC. Irregular Braxton Hicks contractions without cervical changeD. Gestational diabetes with stable glucose and no hypertension

Question 10 of 75 — Generate solutions

Bow-Tie — Select actions and monitoring for the central problemGenerate solutions

The nurse is caring for Alicia Mendez, 32-year-old woman, G1P0 at 34 weeks in the Obstetric triage. Review the case exhibit tabs, then answer the following. Complete the bow-tie for preeclampsia with severe features.

Actions take place on the left and right; monitoring parameters below.

Action

Problem

Action

Monitor

Question 11 of 75 — Take action

Multiple Choice — Select the best answerTake action

The nurse is caring for Alicia Mendez, 32-year-old woman, G1P0 at 34 weeks in the Obstetric triage. Review the case exhibit tabs, then answer the following. Magnesium sulfate is infusing. The client reports feeling warm and flushed. Which action should the nurse take?

A. Stop magnesium permanently and give no further doses without assessmentB. Increase the infusion rate to clear symptoms fasterC. Continue infusion; warmth/flushing can be expected — keep monitoring RR, reflexes, and urine outputD. Reassure the client and reduce neurologic checks to every 4 hours because flushing is expected

Question 12 of 75 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Alicia Mendez, 32-year-old woman, G1P0 at 34 weeks in the Obstetric triage. Review the case exhibit tabs, then answer the following. Two hours later: BP 148/92 after labetalol, reflexes 2+ without clonus, RR 16/min, FHR category I, headache improved. Which indicate improvement?

Trend snapshot
BP 170/114→148/92; clonus resolved; headache severe→mild; RR 18→16.

Select all that apply. You may choose more than one option.

A. Blood pressure below severe-range thresholdsB. Resolution of clonus with intact reflexesC. Respiratory rate 8/min with absent reflexesD. Improved headache with reassuring fetal tracingE. Sudden unresponsiveness with tonic-clonic activity

Question 13 of 75 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Infant Maya Chen, 6-month-old girl in the Pediatric emergency department. Review the case exhibit tabs, then answer the following. Which findings indicate significant respiratory compromise in this infant?

Select all that apply. You may choose more than one option.

A. SpO₂ 88% on room airB. RR 58/min with marked retractions and nasal flaringC. Coughing and tiring after only about 1 oz during feedsD. Happy playful behavior without increased work of breathingE. Positive RSV antigen alone without respiratory distress

Question 14 of 75 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Infant Maya Chen, 6-month-old girl in the Pediatric emergency department. Review the case exhibit tabs, then answer the following. Which presenting condition best explains hypoxemia with retractions and poor feeding?

A. Isolated ear infection without respiratory involvementB. Congenital heart disease as the only possible causeC. Normal newborn periodic breathingD. Acute viral bronchiolitis with increased work of breathing and fatigue

Question 15 of 75 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Infant Maya Chen, 6-month-old girl in the Pediatric emergency department. Review the case exhibit tabs, then answer the following. Which problem is the greatest immediate threat?

A. Respiratory failure risk from fatigue and hypoxemiaB. Mild nasal congestion with SpO₂ 98% and no retractionsC. Isolated otitis media without lower-airway findingsD. Expected low-grade fever after vaccines without respiratory distress

Question 16 of 75 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Infant Maya Chen, 6-month-old girl in the Pediatric emergency department. Review the case exhibit tabs, then answer the following. Classify each nursing action for this infant.

Select one response in each row (you may choose only one column per row).

Finding / action	Indicated now	Requires follow-up	Unsafe or not indicated
Provide oxygen to meet SpO₂ goal and suction nares before feeds
Offer large bottle volumes rapidly despite coughing and fatigue
Monitor intake, output, and work of breathing closely
Give a one-time nebulized bronchodilator from stock without an order

Question 17 of 75 — Take action

Multiple Choice — Select the best answerTake action

The nurse is caring for Infant Maya Chen, 6-month-old girl in the Pediatric emergency department. Review the case exhibit tabs, then answer the following. The infant’s SpO₂ is 88% on room air with marked retractions. What should the nurse do first?

A. Begin discharge teaching on home nebulizersB. Place the infant supine flat without monitoringC. Apply oxygen per protocol and position for airway comfort; reassess SpO₂ and work of breathingD. Withhold all suctioning to avoid crying

Question 18 of 75 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Infant Maya Chen, 6-month-old girl in the Pediatric emergency department. Review the case exhibit tabs, then answer the following. After oxygen and supportive care: SpO₂ 94% on 1 L/min, RR 42/min, fewer retractions, took 2 oz with pacing. Which indicate improvement?

Trend snapshot
SpO₂ 88%→94%; RR 58→42; retractions marked→mild; intake improved.

Select all that apply. You may choose more than one option.

A. Improved oxygen saturation on low-flow oxygenB. Decreased respiratory rate and work of breathingC. New cyanosis with SpO₂ 80%D. Improved oral intake with paced feedingE. Apneic pauses lasting 20 seconds

Question 19 of 75 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Jordan Blake, 27-year-old client in the Psychiatric emergency service. Review the case exhibit tabs, then answer the following. Which findings indicate an acute psychiatric safety risk needing immediate intervention?

Select all that apply. You may choose more than one option.

A. Responding to internal stimuli with persecutory delusions of imminent harmB. Escalating agitation with pacing and refusal of oral medicationC. Antipsychotic nonadherence beginning three weeks agoD. Negative urine drug screen alone proving wellnessE. Tachycardia with high expressed fear and threats toward perceived persecutors

Question 20 of 75 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Jordan Blake, 27-year-old client in the Psychiatric emergency service. Review the case exhibit tabs, then answer the following. Which presenting condition best explains this presentation?

A. Uncomplicated grief without thought disorderB. Psychotic relapse related to medication nonadherenceC. Hypoglycemia as the sole cause of paranoiaD. Normal stress response without safety risk

Question 21 of 75 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Jordan Blake, 27-year-old client in the Psychiatric emergency service. Review the case exhibit tabs, then answer the following. Which problem is the highest priority right now?

A. Chronic negative symptoms without current agitationB. Mild insomnia without paranoia or assaultive riskC. Need for outpatient medication teaching once stabilizedD. Risk of harm related to paranoia and agitation

Question 22 of 75 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Jordan Blake, 27-year-old client in the Psychiatric emergency service. Review the case exhibit tabs, then answer the following. Classify each nursing action.

Select one response in each row (you may choose only one column per row).

Finding / action	Indicated now	Requires follow-up	Unsafe or not indicated
Maintain 1:1 observation in a low-stimulation area
Argue forcefully to prove delusions are false
Offer oral medication again using calm, clear limits
Reduce observation to every 30 minutes while the client stays in the day room

Question 23 of 75 — Take action

Multiple Choice — Select the best answerTake action

The nurse is caring for Jordan Blake, 27-year-old client in the Psychiatric emergency service. Review the case exhibit tabs, then answer the following. The client becomes more agitated and reaches toward a staff member. De-escalation has failed. What should the nurse do?

A. Ensure safety, call for assistance, and administer ordered acute medication per protocolB. Continue verbal de-escalation alone for another 30 minutes before calling for helpC. Offer the client a private room and check back in 15 minutes without additional staffD. Apply physical restraints immediately as the first intervention without attempting ordered medication

Question 24 of 75 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Jordan Blake, 27-year-old client in the Psychiatric emergency service. Review the case exhibit tabs, then answer the following. One hour after IM antipsychotic and 1:1 care: quieter, sitting, accepts water, no attempts to strike staff. Which indicate improvement?

Trend snapshot
Pacing→sitting; loud responding↓; cooperative with fluids; no assaultive moves.

Select all that apply. You may choose more than one option.

A. Decreased psychomotor agitationB. Increased cooperation with basic careC. New assault on a peerD. Ability to sit in a quieter areaE. Attempted elopement through a fire exit

Question 25 of 75 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Elena Vasquez, 54-year-old woman with cirrhosis in the Medical unit. Review the case exhibit tabs, then answer the following. Which findings support hepatic encephalopathy and identify a likely precipitating factor?

Select all that apply. You may choose more than one option.

A. New confusion and drowsinessB. Asterixis on examC. Constipation for several days preceding the changeD. Elevated ammonia level alone without any change in mentationE. History of similar confusion episodes when constipated

Question 26 of 75 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Elena Vasquez, 54-year-old woman with cirrhosis in the Medical unit. Review the case exhibit tabs, then answer the following. Which presenting problem best links constipation to this mental status change?

A. Simple dehydration without liver involvementB. Increased intestinal ammonia production/absorption precipitating encephalopathyC. Stroke as the only possible cause of asterixisD. Normal sleepiness after a large meal

Question 27 of 75 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Elena Vasquez, 54-year-old woman with cirrhosis in the Medical unit. Review the case exhibit tabs, then answer the following. Which problem is the priority?

A. Chronic compensated cirrhosis without acute mentation changeB. Mild pruritus from chronic cholestasis without mentation changeC. Stable chronic ascites without mentation changeD. Hepatic encephalopathy with fall/aspiration risk

Question 28 of 75 — Generate solutions

Cloze (Drop-Down) — Complete the clinical statementGenerate solutions

The nurse is caring for Elena Vasquez, 54-year-old woman with cirrhosis in the Medical unit. Review the case exhibit tabs, then answer the following. Select the statement that correctly guides initial nursing management.

The nurse should prioritize ____ while monitoring stool output and mentation. .

Question 29 of 75 — Take action

Ordered Response — Rank actions in priority orderTake action

The nurse is caring for Elena Vasquez, 54-year-old woman with cirrhosis in the Medical unit. Review the case exhibit tabs, then answer the following. Place the actions in the best priority sequence. Some actions may occur concurrently in clinical practice.

Assign rank 1 to the first action (one rank per row).

Ensure airway protection and fall precautions for altered mentation
Administer lactulose as ordered and assess stool response
Reorient frequently and notify provider of mentation changes
Document mentation, asterixis, and stool trends on neurologic checks

Question 30 of 75 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Elena Vasquez, 54-year-old woman with cirrhosis in the Medical unit. Review the case exhibit tabs, then answer the following. After lactulose: oriented to person/place, no asterixis, 3 soft stools, ammonia trending down. Which indicate improvement?

Trend snapshot
Confused→oriented ×2; asterixis present→absent; BM 0→3; ammonia 95→58.

Select all that apply. You may choose more than one option.

A. Improved orientationB. Resolution of asterixisC. New deep comaD. Therapeutic stool frequency on lactuloseE. Rising ammonia with worsening confusion

Question 31 of 75 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Malik Johnson, 19-year-old man with sickle cell disease in the Emergency department. Review the case exhibit tabs, then answer the following. Which findings are most concerning in this client with sickle cell disease?

Select all that apply. You may choose more than one option.

A. Severe bone/soft-tissue pain similar to prior crisesB. Tachycardia with inadequate recent fluid intakeC. Hemoglobin below the client's usual baselineD. Painless well hydration without distressE. Elevated reticulocyte count

Question 32 of 75 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Malik Johnson, 19-year-old man with sickle cell disease in the Emergency department. Review the case exhibit tabs, then answer the following. Which presenting condition best explains this presentation?

A. Acute chest syndrome as the only finding (infiltrate present)B. Uncomplicated muscle strain without sickle involvementC. Vaso-occlusion with ischemia-related pain and dehydrationD. Primary pneumonia with lobar consolidation

Question 33 of 75 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Malik Johnson, 19-year-old man with sickle cell disease in the Emergency department. Review the case exhibit tabs, then answer the following. Which problem is the priority?

A. Mild baseline fatigue between crises without acute painB. Severe vaso-occlusive pain with risk of complications if undertreatedC. Resolved pain from a crisis last month, now pain-free at restD. Chronic compensated anemia at the client's usual hemoglobin

Question 34 of 75 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Malik Johnson, 19-year-old man with sickle cell disease in the Emergency department. Review the case exhibit tabs, then answer the following. Classify each nursing action for VOC.

Select one response in each row (you may choose only one column per row).

Finding / action	Indicated now	Requires follow-up	Unsafe or not indicated
Administer IV opioid analgesia per protocol and reassess pain
Limit IV fluids out of concern for volume overload despite dehydration
Encourage incentive spirometry and monitor SpO₂
Apply ice packs directly to the painful limbs for comfort

Question 35 of 75 — Take action

Multiple Choice — Select the best answerTake action

The nurse is caring for Malik Johnson, 19-year-old man with sickle cell disease in the Emergency department. Review the case exhibit tabs, then answer the following. Pain remains 9/10 after triage. What should the nurse do first?

A. Give oral acetaminophen alone and reassess in 4 hours without opioidsB. Give meperidine as first-line for every sickle crisisC. Start ordered IV opioid and IV fluids; continue SpO₂ and respiratory monitoringD. Start oral opioids, encourage oral fluids, and reassess in the waiting area for 2 hours before IV access

Question 36 of 75 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Malik Johnson, 19-year-old man with sickle cell disease in the Emergency department. Review the case exhibit tabs, then answer the following. After opioids and fluids: pain 4/10, HR 88/min, SpO₂ 97% RA, using incentive spirometer. Which indicate improvement?

Trend snapshot
Pain 9→4; HR 118→88; SpO₂ 94→97%; spirometry improved.

Select all that apply. You may choose more than one option.

A. Reduced pain scoreB. Decreased heart rate toward baselineC. New hypoxia with chest pain and infiltrateD. Improved incentive spirometry effortE. Sudden unresponsiveness

Question 37 of 75 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Chris Nguyen, 41-year-old man after MVC in the Surgical ICU. Review the case exhibit tabs, then answer the following. Which neurologic and vital-sign findings require immediate recognition after TBI?

Select all that apply. You may choose more than one option.

A. Decreasing GCS with vomitingB. Hypertension with bradycardia (Cushing pattern emerging)C. Worsening headacheD. Playful baseline mentation without changeE. CT with mass effect/midline shift

Question 38 of 75 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Chris Nguyen, 41-year-old man after MVC in the Surgical ICU. Review the case exhibit tabs, then answer the following. Which presenting condition best explains bradycardia with rising systolic BP after TBI?

A. Primary athletic heart without injuryB. Simple dehydration tachycardia patternC. Normal sleep-related bradycardia onlyD. Cushing response to increasing ICP

Question 39 of 75 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Chris Nguyen, 41-year-old man after MVC in the Surgical ICU. Review the case exhibit tabs, then answer the following. Which problem is the greatest immediate threat?

A. Impending herniation from rising ICPB. Mild scalp abrasion without neurologic changeC. Expected post-MVC anxiety without Cushing signsD. Stable concussion without imaging mass effect

Question 40 of 75 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Chris Nguyen, 41-year-old man after MVC in the Surgical ICU. Review the case exhibit tabs, then answer the following. Classify each nursing action for rising ICP.

Select one response in each row (you may choose only one column per row).

Finding / action	Indicated now	Requires follow-up	Unsafe or not indicated
Keep HOB elevated ~30° with head midline
Cluster all noxious care back-to-back without pauses
Notify provider of GCS drop and Cushing changes
Allow free coughing/straining without bowel regimen when constipated

Question 41 of 75 — Take action

Ordered Response — Rank actions in priority orderTake action

The nurse is caring for Chris Nguyen, 41-year-old man after MVC in the Surgical ICU. Review the case exhibit tabs, then answer the following. Place the actions in the best priority sequence. Actions may overlap in clinical practice.

Assign rank 1 to the first action (one rank per row).

Ensure airway/oxygenation and call for rapid assistance
Position HOB 30° with head midline
Notify provider/neurosurgery of neurologic decline
Prepare ordered osmotic therapy and continue neuro checks

Question 42 of 75 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Chris Nguyen, 41-year-old man after MVC in the Surgical ICU. Review the case exhibit tabs, then answer the following. After osmotherapy and positioning: GCS improves to 13, pupils equal/reactive, BP 140/78, HR 72. Which indicate improvement?

Trend snapshot
GCS 11→13; HR 58→72; pulse pressure narrowing; vomiting stopped.

Select all that apply. You may choose more than one option.

Question 43 of 75 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Margaret Ellis, 72-year-old woman, POD 1 left THA in the Orthopedic unit. Review the case exhibit tabs, then answer the following. Which new postoperative findings require immediate concern on POD 1 after THA?

Select all that apply. You may choose more than one option.

A. Acute confusionB. Petechial rash on chest/upper bodyC. Sudden hypoxemia and tachycardiaD. Warm foot with intact pulses only (expected baseline)E. Respiratory distress out of proportion to a simple anxiety episode

Question 44 of 75 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Margaret Ellis, 72-year-old woman, POD 1 left THA in the Orthopedic unit. Review the case exhibit tabs, then answer the following. Which presenting condition best fits sudden hypoxemia, confusion, and petechiae on POD 1 THA?

A. Simple wound hematoma without systemic signsB. Normal postoperative sleepiness onlyC. Fat embolism syndromeD. Uncomplicated nausea from anesthesia alone

Question 45 of 75 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Margaret Ellis, 72-year-old woman, POD 1 left THA in the Orthopedic unit. Review the case exhibit tabs, then answer the following. Which problem is the priority?

A. Mild expected POD1 surgical-site tenderness without respiratory changeB. Acute hypoxemic respiratory compromise possibly from fat embolismC. Anticipated afternoon physical therapy without acute hypoxemiaD. Chronic deconditioning from osteoarthritis before surgery

Question 46 of 75 — Generate solutions

Bow-Tie — Select actions and monitoring for the central problemGenerate solutions

The nurse is caring for Margaret Ellis, 72-year-old woman, POD 1 left THA in the Orthopedic unit. Review the case exhibit tabs, then answer the following. Complete the bow-tie for suspected fat embolism after THA.

Actions take place on the left and right; monitoring parameters below.

Action

Problem

Action

Monitor

Question 47 of 75 — Take action

Multiple Choice — Select the best answerTake action

The nurse is caring for Margaret Ellis, 72-year-old woman, POD 1 left THA in the Orthopedic unit. Review the case exhibit tabs, then answer the following. While awaiting the provider, which action is most appropriate?

A. Flex the hip fully to 'stretch out' shortness of breathB. Hold VTE prophylaxis without clarifying with the providerC. Leave continuous monitoring to reduce sensory stimulationD. Maintain oxygen, keep the client calm, continue frequent vitals/neuro checks, and avoid hip positions that risk dislocation

Question 48 of 75 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Margaret Ellis, 72-year-old woman, POD 1 left THA in the Orthopedic unit. Review the case exhibit tabs, then answer the following. After oxygen and escalation: SpO₂ 96% on 2 L/min, alert, petechiae stable, no new chest pain. Which indicate early stabilization?

Trend snapshot
SpO₂ 90→96%; confusion clearing; HR 120→92.

Select all that apply. You may choose more than one option.

A. Improved oxygen saturationB. Clearing mentationC. Progressive respiratory failure requiring intubationD. Heart rate trending toward baselineE. New cold pulseless operative foot

Question 49 of 75 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Robert Hale, 63-year-old man in the Medical-surgical unit. Review the case exhibit tabs, then answer the following. Which findings require immediate recognition in this client with LLQ pain?

Select all that apply. You may choose more than one option.

A. LLQ pain with fever and leukocytosisB. CT showing localized sigmoid wall inflammationC. Nausea with localized guardingD. Painless jaundice as the primary findingE. Tachycardia with systemic inflammatory signs

Question 50 of 75 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Robert Hale, 63-year-old man in the Medical-surgical unit. Review the case exhibit tabs, then answer the following. Which presenting condition best fits this LLQ inflammatory pattern?

A. Acute colonic diverticulitisB. Uncomplicated GERDC. Migraine without abdominal findingsD. Stable hemorrhoids only

Question 51 of 75 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Robert Hale, 63-year-old man in the Medical-surgical unit. Review the case exhibit tabs, then answer the following. Which problem is the priority to prevent?

A. Mild chronic constipation without peritoneal signsB. Progression to perforation/peritonitisC. Known diverticulosis without acute CT inflammationD. Controlled GERD on home PPI without abdominal findings

Question 52 of 75 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Robert Hale, 63-year-old man in the Medical-surgical unit. Review the case exhibit tabs, then answer the following. Classify each nursing action.

Select one response in each row (you may choose only one column per row).

Finding / action	Indicated now	Requires follow-up	Unsafe or not indicated
Maintain NPO and administer IV antibiotics as ordered
Give a full oral cathartic bowel prep tonight without order
Perform serial abdominal assessments and vital signs
Advance to clear liquids and start oral antibiotics immediately without reassessment

Question 53 of 75 — Take action

Multiple Choice — Select the best answerTake action

The nurse is caring for Robert Hale, 63-year-old man in the Medical-surgical unit. Review the case exhibit tabs, then answer the following. The abdomen becomes rigid with rebound tenderness and BP falls to 88/54. What should the nurse do?

A. Increase IV fluids and reassess blood pressure in 1 hour before notifying anyoneB. Request a surgical consult for tomorrow morning after overnight observation and serial examsC. Continue current observation without notification because lactate was earlier normalD. Activate the rapid-response/emergency escalation process, notify the provider and surgical team STAT, maintain NPO status, and support airway, breathing and circulation

Question 54 of 75 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Robert Hale, 63-year-old man in the Medical-surgical unit. Review the case exhibit tabs, then answer the following. Update 48 hours after emergent surgical management: hemodynamically stable, afebrile, abdomen soft with expected postoperative tenderness; WBC 9.5 × 10³/µL; receiving IV antibiotics and postoperative monitoring. Which indicate improvement?

Trend snapshot
T 38.4→36.9; WBC 15.8→9.5; BP stabilized; abdomen soft with expected postop tenderness.

Select all that apply. You may choose more than one option.

A. Resolution of feverB. Decreasing leukocytosisC. New board-like rigidityD. Softer abdomen with expected postoperative tenderness and improving painE. Hypotension with lactate 4.5

Question 55 of 75 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Harold Quinn, 78-year-old man with HFrEF in the Telemetry unit. Review the case exhibit tabs, then answer the following. Which findings require immediate recognition in this client taking digoxin, while the digoxin level is still pending?

Select all that apply. You may choose more than one option.

A. Nausea with xanthopsia (yellow-green vision)B. Bradycardia with PVCs on ECGC. Serum potassium 2.9 mEq/LD. New fatigue with mild confusionE. Asymptomatic well-controlled rate without GI/visual symptoms

Question 56 of 75 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Harold Quinn, 78-year-old man with HFrEF in the Telemetry unit. Review the case exhibit tabs, then answer the following. Which presenting problem best links rising creatinine and hypokalemia to this presentation?

A. Reduced digoxin clearance with electrolyte-facilitated toxicityB. Simple viral syndrome without drug effectC. Iron deficiency anemia as the only cause of yellow visionD. Normal aging without medication risk

Question 57 of 75 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Harold Quinn, 78-year-old man with HFrEF in the Telemetry unit. Review the case exhibit tabs, then answer the following. Which problem is the priority?

A. Mild chronic ankle edema from HF without new arrhythmiaB. Need for routine low-sodium diet teaching without toxicity signsC. Life-threatening arrhythmia risk from digoxin toxicityD. Stable chronic HF without drug toxicity or bradycardia

Question 58 of 75 — Generate solutions

Cloze (Drop-Down) — Complete the clinical statementGenerate solutions

The nurse is caring for Harold Quinn, 78-year-old man with HFrEF in the Telemetry unit. Review the case exhibit tabs, then answer the following. Choose the correct priority action statement.

The nurse should ____. .

Question 59 of 75 — Take action

Matrix / Grid — Select one response per rowTake action

The nurse is caring for Harold Quinn, 78-year-old man with HFrEF in the Telemetry unit. Review the case exhibit tabs, then answer the following. Classify each nursing action for suspected digoxin toxicity.

Select one response in each row (you may choose only one column per row).

Finding / action	Indicated now	Requires follow-up	Unsafe or not indicated
Hold digoxin and place the client on continuous telemetry
Notify the provider of the toxic level and symptomatic bradycardia
Administer the ordered potassium replacement
Continue digoxin tonight and notify cardiology only at morning rounds
Arrange only a routine digoxin level later today without holding the dose

Question 60 of 75 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Harold Quinn, 78-year-old man with HFrEF in the Telemetry unit. Review the case exhibit tabs, then answer the following. After holding digoxin and repleting K+: HR 68, nausea resolved, vision clearing, K+ 4.1. Which indicate improvement?

Trend snapshot
HR 48→68; K+ 2.9→4.1; nausea↓; visual halos↓.

Select all that apply. You may choose more than one option.

A. Heart rate improved from symptomatic bradycardiaB. Potassium normalizedC. New complete heart block with syncopeD. Resolution of nausea and visual changesE. Digoxin level climbing further with worsening ectopy

Question 61 of 75 — Take action

Extended Multiple Response — Select all that applyTake action

The nurse is caring for Andre Willis, 61-year-old man receiving chemotherapy in the Oncology outpatient clinic. Review the case exhibit tabs, then answer the following. Which instructions should the nurse include when teaching infection precautions during neutropenia?

Select all that apply. You may choose more than one option.

A. Avoid raw or undercooked meats, eggs, and unpasteurized productsB. Wash hands frequently and before eating or touching the faceC. Report a temperature of 38 °C or higher immediatelyD. Keep fresh flowers and potted plants in the bedroomE. Avoid crowds and dusty construction or soil exposure during nadir

Question 62 of 75 — Take action

Bow-Tie — Select actions and monitoring for the central problemTake action

The nurse is caring for Denise Fowler, 57-year-old woman in the Medical-surgical unit. Review the case exhibit tabs, then answer the following. Complete the bow-tie for the client developing an acute transfusion reaction.

Actions take place on the left and right; monitoring parameters below.

Action

Problem

Action

Monitor

Question 63 of 75 — Take action

Cloze (Drop-Down) — Complete the clinical statementTake action

The nurse is caring for Harold Nguyen, 66-year-old man with atrial fibrillation in the Anticoagulation clinic. Review the case exhibit tabs, then answer the following. Complete the priority teaching statement.

When teaching a client taking warfarin, the nurse should advise the client to .

Question 64 of 75 — Take action

Multiple Choice — Select the best answerTake action

The nurse is caring for Baby Reyes, 2-hour-old term newborn in the Mother-baby unit. Review the case exhibit tabs, then answer the following. Which action should the nurse take first for this jittery newborn with a glucose of 34 mg/dL?

A. Administer oral glucose gel and begin feeding, then recheck glucoseB. Obtain a confirmatory serum glucose before beginning any treatmentC. Feed the infant immediately and reassess glucose in 30 minutes without IV dextroseD. Notify the neonatal provider immediately and initiate IV dextrose per symptomatic hypoglycemia protocol

Question 65 of 75 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Paula Grant, 44-year-old woman with bipolar disorder in the Behavioral health unit. Review the case exhibit tabs, then answer the following. Which findings are consistent with lithium toxicity?

Select all that apply. You may choose more than one option.

Question 66 of 75 — Analyze cues

Matrix / Grid — Select one response per rowAnalyze cues

The nurse is caring for Walter Boyd, 79-year-old man with limited mobility in the Skilled nursing facility. Review the case exhibit tabs, then answer the following. Classify each skin finding by pressure injury stage (select one column per row).

Select one response in each row (you may choose only one column per row).

Finding / action	Stage 1	Stage 2	Stage 3
Sacral shallow open ulcer with red-pink bed and no slough
Right heel intact skin with nonblanchable erythema
Left hip full-thickness loss exposing subcutaneous fat
Partial-thickness loss appearing as an intact serum-filled blister

Question 67 of 75 — Take action

Extended Multiple Response — Select all that applyTake action

The nurse is caring for Ruth Delgado, 74-year-old woman in the Medical unit. Review the case exhibit tabs, then answer the following. Which precautions should the nurse implement for this client?

Select all that apply. You may choose more than one option.

A. Place the client on contact precautions in a private roomB. Perform hand hygiene after glove removal; use soap and water when hands are visibly soiled or during a C. difficile outbreak, according to facility policyC. Wear a gown and gloves when entering the roomD. Clean the room with an approved sporicidal (bleach) agentE. Discontinue precautions as soon as one stool becomes formed

Question 68 of 75 — Take action

Ordered Response — Rank actions in priority orderTake action

The nurse is caring for Bianca Serrano, 30-year-old woman at 34 weeks gestation in the Labor and delivery unit. Review the case exhibit tabs, then answer the following. Place the actions in the best priority sequence for suspected magnesium sulfate toxicity. Actions may overlap in clinical practice.

Assign rank 1 to the first action (one rank per row).

Stop the magnesium sulfate infusion
Apply oxygen and support ventilation; prepare for advanced airway if needed
Notify the provider and prepare to administer calcium gluconate per order
Continue monitoring respirations, reflexes, and urine output

Question 69 of 75 — Take action

Multiple Choice — Select the best answerTake action

The nurse is caring for George Halloran, 72-year-old man with Parkinson disease in the Rehabilitation unit. Review the case exhibit tabs, then answer the following. Which nursing action is most important to reduce this client's fall risk?

A. Administer carbidopa-levodopa on time and assist with slow position changesB. Encourage rapid movements to overcome freezing episodesC. Keep the client on bed rest to avoid any ambulationD. Allow independent ambulation to the bathroom once morning medications are given

Question 70 of 75 — Analyze cues

Matrix / Grid — Select one response per rowAnalyze cues

The nurse is caring for Marcus Feld, 48-year-old man after thoracic surgery in the Surgical step-down unit. Review the case exhibit tabs, then answer the following. Classify each chest tube finding or action.

Select one response in each row (you may choose only one column per row).

Finding / action	Expected / indicated	Assess system and report	Unsafe or incorrect
Gentle tidaling in the water-seal chamber with respiration
Continuous bubbling — assess tubing/connections for air leak and report findings
Gradually decreasing serosanguineous drainage
Clamping the chest tube routinely for ambulation without an order

Question 71 of 75 — Take action

Cloze (Drop-Down) — Complete the clinical statementTake action

The nurse is caring for Sofia Marin, 39-year-old woman with type 1 diabetes in the Endocrinology clinic. Review the case exhibit tabs, then answer the following. Complete the teaching statement about insulin timing.

The nurse teaches that rapid-acting lispro insulin should be given .

Question 72 of 75 — Take action

Ordered Response — Rank actions in priority orderTake action

The nurse is caring for Nadia Okafor, 26-year-old woman in the Neurology unit. Review the case exhibit tabs, then answer the following. Place the actions in the best priority sequence for the immediate postictal period. Actions may overlap in clinical practice.

Assign rank 1 to the first action (one rank per row).

Turn the client to the side (recovery position) to protect the airway
Suction oral secretions and provide oxygen as needed
Perform a focused neurologic assessment as the client recovers
Document seizure onset, duration, characteristics, and postictal status

Question 73 of 75 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Clifford James, 68-year-old man with chronic kidney disease in the Medical unit. Review the case exhibit tabs, then answer the following. Which findings indicate fluid volume overload?

Select all that apply. You may choose more than one option.

A. Bibasilar crackles with dyspneaB. Jugular venous distentionC. Dependent pitting edemaD. Weight gain of 3 kg in 2 daysE. Dry mucous membranes and poor skin turgor

Question 74 of 75 — Take action

Multiple Choice — Select the best answerTake action

The nurse is caring for Eleanor Fritz, 70-year-old woman in the Surgical unit. Review the case exhibit tabs, then answer the following. A competent client changes her mind and no longer wants the scheduled surgery. Which action by the nurse best respects the client's autonomy?

A. Keep her NPO on the OR schedule and ask the surgeon to counsel her after morning roundsB. Notify the surgeon of the client's decision and support her right to declineC. Ask the son to help persuade her while preparing the consent for signatureD. Document the refusal and pause further teaching until the surgeon reviews the change with her

Question 75 of 75 — Take action

Bow-Tie — Select actions and monitoring for the central problemTake action

The nurse is caring for Miriam Cole, 68-year-old woman with type 2 diabetes in the Emergency department. Review the case exhibit tabs, then answer the following. Complete the bow-tie for this client presenting with a hyperglycemic crisis.

Actions take place on the left and right; monitoring parameters below.

Action

Problem

Action

Monitor

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