NCLEX Clinical Judgment Practice Test 4

Question 1 of 75 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Eleanor Hayes, 72-year-old woman in the Emergency department. Review the case exhibit tabs, then answer the following. Which findings are priority cues supporting a urinary infection with associated organ dysfunction and hypoperfusion?

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

A. New disorientation to place and dateB. Lactate 4.6 mmol/LC. Urine output 15 mL during the previous hourD. History of hypertension treated with lisinoprilE. BP 88/52 mm Hg with capillary refill of 4 secondsF. Positive nitrites with costovertebral-angle tenderness

Question 2 of 75 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Eleanor Hayes, 72-year-old woman in the Emergency department. Review the case exhibit tabs, then answer the following. Which interpretation best explains the combined assessment and laboratory findings?

A. Uncomplicated cystitis without systemic involvementB. Sepsis from a urinary source with acute hypoperfusion and kidney injuryC. Medication-related orthostatic hypotension as the sole problemD. Hyperglycemic crisis without infection

Question 3 of 75 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Eleanor Hayes, 72-year-old woman in the Emergency department. Review the case exhibit tabs, then answer the following. Which problem is the highest priority at this time?

A. Risk for constipation related to reduced mobilityB. Knowledge deficit about urinary-tract infection preventionC. Chronic blood-pressure managementD. Impaired tissue perfusion related to septic shock physiology

Question 4 of 75 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Eleanor Hayes, 72-year-old woman in the Emergency department. Review the case exhibit tabs, then answer the following. For each proposed intervention, indicate whether it is appropriate for the current phase of care.

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

Finding / action	Appropriate now	Not appropriate now
Obtain ordered cultures promptly, then administer broad-spectrum IV antimicrobial therapy without avoidable delay
Administer and reassess isotonic crystalloid for hypoperfusion
Wait for final culture susceptibilities before giving any antimicrobial therapy
Trend lactate, urine output, mental status, lung sounds, and perfusion response
Administer routine sodium bicarbonate solely because lactate is elevated

Question 5 of 75 — Take action

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

The nurse is caring for Eleanor Hayes, 72-year-old woman in the Emergency department. Review the case exhibit tabs, then answer the following. Complete the bow-tie to identify the client condition, two priority actions, and two parameters to monitor.

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

Action

Problem

Action

Monitor

Question 6 of 75 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Eleanor Hayes, 72-year-old woman in the Emergency department. Review the case exhibit tabs, then answer the following. Which findings indicate that the current interprofessional treatment plan is improving perfusion?

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

A. MAP increased to 69 mm HgB. Urine output increased to 38 mL/hrC. Lactate decreased from 4.8 to 2.7 mmol/LD. Orientation and capillary refill are improvingE. WBC remains elevated during the first several hours of treatment

Question 7 of 75 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Maya Ortiz, 28-year-old woman, G2P2 in the Labor and delivery / postpartum unit. Review the case exhibit tabs, then answer the following. Which findings are priority cues of postpartum hemorrhage with developing hypovolemia?

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

A. Cumulative blood loss of 1,100 mL and increasingB. Boggy uterus displaced to the rightC. Dizziness, pallor, and cool skinD. Heart rate 118/min with BP 94/58 mm HgE. Platelet count 178 x 10^3/mcLF. A complete-appearing placenta

Question 8 of 75 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Maya Ortiz, 28-year-old woman, G2P2 in the Labor and delivery / postpartum unit. Review the case exhibit tabs, then answer the following. Which cause most likely explains the current bleeding pattern?

A. Uterine atony worsened by bladder distentionB. Disseminated intravascular coagulation as the only causeC. Retained placenta despite documented complete placental inspectionD. Normal lochia during the immediate postpartum period

Question 9 of 75 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Maya Ortiz, 28-year-old woman, G2P2 in the Labor and delivery / postpartum unit. Review the case exhibit tabs, then answer the following. Which hypothesis is the immediate priority?

A. Postpartum fatigue related to prolonged laborB. Risk for ineffective breastfeedingC. Acute blood-loss shock from ongoing postpartum hemorrhageD. Urinary retention without circulatory effects

Question 10 of 75 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Maya Ortiz, 28-year-old woman, G2P2 in the Labor and delivery / postpartum unit. Review the case exhibit tabs, then answer the following. Classify each medication or intervention for this client based on the current history and hemorrhage findings.

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

Finding / action	Appropriate	Avoid or contraindicated
Oxytocin infusion per postpartum-hemorrhage protocol
Tranexamic acid promptly when ordered and within the recommended treatment window
Methylergonovine in a client with gestational hypertension
Carboprost in a client with asthma
Misoprostol as an additional uterotonic when ordered

Question 11 of 75 — Take action

Ordered Response — Rank actions in priority orderTake action

The nurse is caring for Maya Ortiz, 28-year-old woman, G2P2 in the Labor and delivery / postpartum unit. Review the case exhibit tabs, then answer the following. Place the actions in the best priority sequence. Several actions may overlap during an actual hemorrhage response.

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

Activate the obstetric-hemorrhage response, remain with the client, call for help, and continue firm uterine/bimanual massage as directed.
Ensure rapid access through large-bore IV lines, begin ordered isotonic fluid resuscitation, and provide oxygen if clinically indicated.
Administer appropriate uterotonics and tranexamic acid according to orders and contraindications.
Initiate ordered blood-product support and prepare for balloon tamponade, interventional radiology, or surgery if bleeding persists.

Question 12 of 75 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Maya Ortiz, 28-year-old woman, G2P2 in the Labor and delivery / postpartum unit. Review the case exhibit tabs, then answer the following. Which findings show that the coordinated hemorrhage plan is effective?

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

A. Fundus firm and midlineB. Bleeding decreased to scant lochiaC. BP 106/66 mm Hg and HR 92/minD. Urine output 45 mL/hr with clear mentationE. New restlessness with a heart rate of 138/min

Question 13 of 75 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Jordan Lee, 15-year-old adolescent in the Pediatric emergency department. Review the case exhibit tabs, then answer the following. Which findings are priority cues of diabetic ketoacidosis and dehydration?

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

A. Glucose 520 mg/dL with large urine ketonesB. Venous pH 7.12 and bicarbonate 8 mEq/LC. Deep Kussmaul respirations and fruity breathD. Dry mucous membranes and delayed capillary refillE. Temperature 37.2 C without focal infectionF. Vomiting with drowsiness

Question 14 of 75 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Jordan Lee, 15-year-old adolescent in the Pediatric emergency department. Review the case exhibit tabs, then answer the following. Which interpretation best explains the potassium value of 5.6 mEq/L?

A. The child has excess total-body potassium and will not need monitoringB. Acidosis and insulin deficiency shifted potassium extracellularly despite total-body potassium depletionC. The elevated value proves kidney failure is the primary diagnosisD. Potassium replacement is permanently contraindicated

Question 15 of 75 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Jordan Lee, 15-year-old adolescent in the Pediatric emergency department. Review the case exhibit tabs, then answer the following. Which problem is the highest priority during the initial phase of treatment?

A. Long-term carbohydrate-counting knowledge deficitB. Body-image concerns related to insulin-pump useC. Severe dehydration and metabolic acidosis with risk of circulatory and neurologic deteriorationD. Risk for constipation from reduced intake

Question 16 of 75 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Jordan Lee, 15-year-old adolescent in the Pediatric emergency department. Review the case exhibit tabs, then answer the following. For each intervention, indicate whether it is appropriate for pediatric DKA management.

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

Finding / action	Appropriate	Not appropriate
Begin carefully calculated isotonic fluid replacement and reassess perfusion
Start a continuous insulin infusion after initial fluids and potassium assessment
Give an IV insulin bolus to normalize glucose as rapidly as possible
Perform frequent neurologic, glucose, and electrolyte assessments
Correct sodium and osmolality as rapidly as possible with large unmonitored fluid boluses

Question 17 of 75 — Take action

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

The nurse is caring for Jordan Lee, 15-year-old adolescent in the Pediatric emergency department. Review the case exhibit tabs, then answer the following. Complete the sentence by selecting the best response for each blank.

Because the potassium is now 3.2 mEq/L, the nurse should first ____ while continuing close cardiac and laboratory monitoring. .

Question 18 of 75 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Jordan Lee, 15-year-old adolescent in the Pediatric emergency department. Review the case exhibit tabs, then answer the following. Which findings indicate that ketoacidosis has resolved sufficiently for transition planning according to the protocol?

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

A. Venous pH 7.31 and bicarbonate 18 mEq/LB. Beta-hydroxybutyrate 0.5 mmol/LC. Normal mentation and improved hydrationD. Potassium stabilized at 3.8 mEq/LE. Glucose 185 mg/dL as the only evidence of resolution

Question 19 of 75 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Harold Kim, 67-year-old man in the Emergency department. Review the case exhibit tabs, then answer the following. Which findings are most important when determining eligibility for time-sensitive reperfusion treatment?

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

A. Exact last-known-well time of 08:05B. Disabling aphasia and unilateral weaknessC. Noncontrast CT showing no intracranial hemorrhageD. Glucose 108 mg/dLE. History of hyperlipidemiaF. No anticoagulant use or recent major surgery

Question 20 of 75 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Harold Kim, 67-year-old man in the Emergency department. Review the case exhibit tabs, then answer the following. Why must the blood pressure be lowered before IV thrombolytic therapy is administered?

A. To reduce the risk of intracranial bleeding while preserving cerebral perfusionB. To eliminate all risk of recurrent strokeC. To reach a normal outpatient blood pressure before any treatmentD. Because hypertension proves the event is hemorrhagic

Question 21 of 75 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Harold Kim, 67-year-old man in the Emergency department. Review the case exhibit tabs, then answer the following. Which hypothesis should the nurse prioritize?

A. Hypoglycemia causing transient weaknessB. Bell palsy affecting only the facial nerveC. Acute ischemic stroke causing a disabling deficit and requiring immediate reperfusion evaluationD. Chronic neuropathy causing stable unilateral weakness

Question 22 of 75 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Harold Kim, 67-year-old man in the Emergency department. Review the case exhibit tabs, then answer the following. Classify each proposed action for this client.

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

Finding / action	Indicated	Not indicated
Coordinate controlled BP reduction to the IV-thrombolysis threshold
Maintain NPO status until a validated swallow screen is completed
Administer aspirin before thrombolytic therapy to improve efficacy
Prepare for frequent neurologic and BP checks after reperfusion
Lower systolic BP rapidly to 120 mm Hg before treatment

Question 23 of 75 — Take action

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

The nurse is caring for Harold Kim, 67-year-old man in the Emergency department. Review the case exhibit tabs, then answer the following. Complete the bow-tie using the updated findings.

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

Action

Problem

Action

Monitor

Question 24 of 75 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Harold Kim, 67-year-old man in the Emergency department. Review the case exhibit tabs, then answer the following. Which findings support an effective early response without evidence of a major treatment complication?

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

A. NIHSS decreased from 14 to 8B. BP 168/92 mm HgC. No severe headache, vomiting, or acute neurologic declineD. No external bleedingE. New sudden decrease in level of consciousness

Question 25 of 75 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Marcus Webb, 42-year-old man in the Medical-surgical unit. Review the case exhibit tabs, then answer the following. Which findings indicate high acute suicide risk?

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

A. Specific overdose plan for tonightB. Access to a saved supply of opioid tabletsC. Goodbye messages and giving away a valued possessionD. Prior suicide attemptE. Supportive sibling present in the emergency departmentF. Hopelessness, insomnia, and increasing alcohol use

Question 26 of 75 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Marcus Webb, 42-year-old man in the Medical-surgical unit. Review the case exhibit tabs, then answer the following. Which conclusion is best supported by the assessment?

A. Low risk because the client came voluntarily with a siblingB. High acute risk requiring continuous safety measures and an urgent comprehensive assessmentC. No risk because toxicology results show no overdose occurredD. Moderate stress that can be managed with routine discharge instructions alone

Question 27 of 75 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Marcus Webb, 42-year-old man in the Medical-surgical unit. Review the case exhibit tabs, then answer the following. Which hypothesis is the immediate priority?

A. Chronic low self-esteem requiring long-term therapyB. Readiness for enhanced family copingC. Disturbed sleep pattern without safety implicationsD. Risk for suicide with imminent access to a planned method

Question 28 of 75 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Marcus Webb, 42-year-old man in the Medical-surgical unit. Review the case exhibit tabs, then answer the following. Classify each intervention for a high-risk suicidal client in a non-ligature-resistant emergency setting.

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

Finding / action	Indicated	Not indicated
Maintain constant 1:1 observation by a trained staff member able to intervene immediately
Ask directly about plan, intent, prior behavior, access to means, and protective factors
Remove avoidable hazards and inspect belongings according to policy
Accept a promise or "no-suicide contract" as a substitute for observation
Agree to keep suicidal thoughts secret to preserve trust

Question 29 of 75 — Take action

Multiple Choice — Select the best answerTake action

The nurse is caring for Marcus Webb, 42-year-old man in the Medical-surgical unit. Review the case exhibit tabs, then answer the following. Which action should the nurse take when the client requests privacy in the bathroom and the sibling brings a backpack into the room?

A. Maintain continuous observation, arrange safe toileting with privacy consistent with line-of-sight policy, and have another staff member secure and inventory the backpackB. Allow the client to lock the bathroom door because the client has been cooperativeC. Ask the sibling to watch the client while the nurse documents elsewhereD. Place the backpack under the bed and inspect it after the psychiatric interview

Question 30 of 75 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Marcus Webb, 42-year-old man in the Medical-surgical unit. Review the case exhibit tabs, then answer the following. Which findings demonstrate meaningful improvement in the safety plan?

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

A. The client participates in a collaborative written safety planB. The client agrees to the recommended level of careC. The client identifies supports and crisis-contact stepsD. The sibling confirms lethal means have been removed or securedE. The client simply states, "I promise I will not do it," without further assessment

Question 31 of 75 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Dorothy Chen, 78-year-old woman in the Orthopedic surgical unit. Review the case exhibit tabs, then answer the following. Which findings are relevant priority cues for recognizing acute delirium and preventable postoperative complications?

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

A. Fluctuating attention and new disorientationB. Attempting to pull equipmentC. Pain 7/10 and oxygen saturation 92% on supplemental oxygenD. Blanchable heel redness and poor intakeE. Baseline independent living before the fallF. Age 78 years by itself

Question 32 of 75 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Dorothy Chen, 78-year-old woman in the Orthopedic surgical unit. Review the case exhibit tabs, then answer the following. Which combination most likely contributed to the client’s acute confusion?

A. A stable sodium level and negative urinalysisB. Pain, hypoxia, sensory deprivation, sleep disruption, urinary retention, and deliriogenic medication exposureC. Normal aging aloneD. Hip surgery proving permanent dementia

Question 33 of 75 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Dorothy Chen, 78-year-old woman in the Orthopedic surgical unit. Review the case exhibit tabs, then answer the following. Which problem should the nurse prioritize first?

A. Need for long-term memory-care placementB. Disturbed body image from the surgical incisionC. Knowledge deficit about osteoporosis medicationD. Immediate risk for fall or device injury while reversible causes of delirium are assessed

Question 34 of 75 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Dorothy Chen, 78-year-old woman in the Orthopedic surgical unit. Review the case exhibit tabs, then answer the following. Classify each intervention for this client.

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

Finding / action	Indicated	Not indicated
Provide glasses, hearing aids, clocks, calendars, and frequent calm reorientation
Coordinate pain control, oxygenation, mobility, hydration, sleep, and medication review
Use scheduled benzodiazepines to keep the client asleep at night
Off-load heels and individualize repositioning and nutrition support
Apply restraints routinely because the client pulled at equipment

Question 35 of 75 — Take action

Ordered Response — Rank actions in priority orderTake action

The nurse is caring for Dorothy Chen, 78-year-old woman in the Orthopedic surgical unit. Review the case exhibit tabs, then answer the following. Place the nursing actions in the best priority sequence. Actions may overlap in practice.

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

Stay with the client, prevent unassisted standing, and call for the required transfer assistance.
Address the urgent toileting need using a safe transfer method while maintaining hip precautions.
Manage urinary retention according to the assessment, protocol, and provider orders.
Reassess pain, oxygenation, cognition, skin, and the fall-prevention plan after the immediate need is met.

Question 36 of 75 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Dorothy Chen, 78-year-old woman in the Orthopedic surgical unit. Review the case exhibit tabs, then answer the following. Which findings indicate that the care plan is effective?

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

A. Improved attention and use of the call lightB. Safe transfers with the prescribed level of assistanceC. Longer nighttime sleep periods without daytime oversedationD. Heel redness resolves with off-loadingE. New need for physical restraints

Question 37 of 75 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Antonio Ruiz, 58-year-old man in the Medical unit. Review the case exhibit tabs, then answer the following. Which findings are priority cues supporting a severe COPD exacerbation with acute-on-chronic ventilatory failure?

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

A. SpO2 82% on room airB. pH 7.28 with PaCO2 68 mm HgC. Drowsiness and brief responsesD. Accessory-muscle use and RR 30/minE. Chronic home oxygen use during sleepF. Purulent sputum with increased volume

Question 38 of 75 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Antonio Ruiz, 58-year-old man in the Medical unit. Review the case exhibit tabs, then answer the following. Why is the oxygen target set at 88% to 92% rather than attempting immediate saturation of 100%?

A. Controlled oxygen treats hypoxemia while reducing the risk of worsening hypercapnia from excessive oxygenB. Clients with COPD should never receive supplemental oxygenC. A saturation of 82% is acceptable in all clients with chronic lung diseaseD. The target prevents bronchodilators from causing tachycardia

Question 39 of 75 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Antonio Ruiz, 58-year-old man in the Medical unit. Review the case exhibit tabs, then answer the following. Which hypothesis is the priority?

A. Stable chronic bronchitis without acute changeB. Isolated anxiety causing all respiratory findingsC. Acute hypercapnic respiratory failure during a COPD exacerbationD. Pulmonary embolism proven by the sputum color alone

Question 40 of 75 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Antonio Ruiz, 58-year-old man in the Medical unit. Review the case exhibit tabs, then answer the following. Classify each proposed intervention.

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

Finding / action	Indicated	Not indicated
Titrate oxygen to the prescribed 88% to 92% range
Administer short-acting bronchodilators and systemic corticosteroids
Administer antimicrobial therapy for increased purulent sputum when ordered
Give a sedative to suppress the sensation of dyspnea before correcting ventilation
Prepare for noninvasive ventilation if acidosis and work of breathing persist

Question 41 of 75 — Take action

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

The nurse is caring for Antonio Ruiz, 58-year-old man in the Medical unit. Review the case exhibit tabs, then answer the following. Complete the bow-tie using the updated findings.

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

Action

Problem

Action

Monitor

Question 42 of 75 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Antonio Ruiz, 58-year-old man in the Medical unit. Review the case exhibit tabs, then answer the following. Which findings indicate that the acute plan is effective and support later self-management teaching?

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

A. pH increased to 7.31 and PaCO2 decreased to 62 mm HgB. Respiratory rate decreased to 24/min with less accessory-muscle useC. Client is alert and speaks in longer sentencesD. SpO2 remains 90% within the prescribed target rangeE. Client states that smoking reduction alone is enough and complete cessation is unnecessary

Question 43 of 75 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Patricia Nolan, 54-year-old woman in the Postoperative surgical unit. Review the case exhibit tabs, then answer the following. Which findings raise concern for immune-mediated heparin-induced thrombocytopenia?

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

A. Platelet fall from 228 to 96 x 10^3/mcLB. Platelet decline beginning on day 5 to 6 of heparin exposureC. New unilateral calf swelling and painD. Stable hemoglobin without active bleedingE. Clean surgical incisionF. Use of heparin flushes in addition to prophylactic heparin

Question 44 of 75 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Patricia Nolan, 54-year-old woman in the Postoperative surgical unit. Review the case exhibit tabs, then answer the following. Which interpretation best explains the findings?

A. Expected postoperative thrombocytopenia with no thrombotic significanceB. Probable immune-mediated HIT with associated venous thrombosisC. Disseminated intravascular coagulation proven by the clean incisionD. Warfarin toxicity before warfarin has been administered

Question 45 of 75 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Patricia Nolan, 54-year-old woman in the Postoperative surgical unit. Review the case exhibit tabs, then answer the following. Which complication is the priority threat?

A. Minor bruising at the injection site onlyB. Delayed surgical wound healingC. Progression of HIT-associated thrombosis or pulmonary embolismD. Constipation from reduced mobility

Question 46 of 75 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Patricia Nolan, 54-year-old woman in the Postoperative surgical unit. Review the case exhibit tabs, then answer the following. Classify each action for a client with high-probability HIT.

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

Finding / action	Indicated	Not indicated
Stop prophylactic heparin and all heparin flushes
Notify the provider and document heparin as a serious adverse drug reaction
Initiate the prescribed non-heparin anticoagulant
Give additional heparin until the confirmatory test returns
Start warfarin alone immediately while platelets are 96 x 10^3/mcL

Question 47 of 75 — Take action

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

The nurse is caring for Patricia Nolan, 54-year-old woman in the Postoperative surgical unit. Review the case exhibit tabs, then answer the following. Complete the bow-tie after the DVT is confirmed.

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

Action

Problem

Action

Monitor

Question 48 of 75 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Patricia Nolan, 54-year-old woman in the Postoperative surgical unit. Review the case exhibit tabs, then answer the following. Which findings indicate that treatment is effective?

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

A. Platelet count rises to 148 x 10^3/mcLB. Calf pain and swelling decreaseC. No new thrombosis or symptoms of pulmonary embolismD. No clinically significant bleedingE. Heparin flushes are restarted because the platelet count improved

Question 49 of 75 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Aisha Brooks, 22-year-old woman in the Medical unit. Review the case exhibit tabs, then answer the following. Which findings support immediate concern for a highly contagious airborne infection?

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

A. Fever with cough, coryza, and conjunctivitisB. Rash beginning at the hairline and spreading downwardC. Buccal white lesionsD. No documented MMR immunityE. Recent international travelF. Oxygen saturation 97% on room air

Question 50 of 75 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Aisha Brooks, 22-year-old woman in the Medical unit. Review the case exhibit tabs, then answer the following. Which transmission route is most important for immediate planning?

A. Contact transmission requiring gloves onlyB. Bloodborne transmission requiring a sharps container onlyC. Foodborne transmission requiring dietary isolationD. Airborne transmission requiring an AIIR and respiratory protection

Question 51 of 75 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Aisha Brooks, 22-year-old woman in the Medical unit. Review the case exhibit tabs, then answer the following. Which problem has the highest priority while the client remains in the general waiting area?

A. Risk of exposing multiple susceptible patients and staff to a highly contagious airborne illnessB. Need for routine discharge teaching about hydrationC. Possible boredom while waiting for laboratory resultsD. Long-term vaccination planning for future travel

Question 52 of 75 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Aisha Brooks, 22-year-old woman in the Medical unit. Review the case exhibit tabs, then answer the following. For each task, identify whether the RN must perform it or may delegate it to a trained unlicensed assistive person after precautions and directions are established.

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

Finding / action	RN responsibility	May delegate to trained UAP
Perform the initial respiratory and rash assessment
Teach the client why Airborne Precautions and transport restrictions are required
Obtain a routine temperature and report the value while using required PPE
Deliver a meal tray using required PPE after the plan is established
Determine whether the client can safely leave isolation for transport

Question 53 of 75 — Take action

Ordered Response — Rank actions in priority orderTake action

The nurse is caring for Aisha Brooks, 22-year-old woman in the Medical unit. Review the case exhibit tabs, then answer the following. Place the actions in the best priority sequence when measles is suspected in the waiting area.

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

Place a procedure mask on the client when tolerated and move the client away from the shared waiting area immediately.
Transfer the client to a verified airborne infection isolation room; staff entering use fit-tested N95 or higher respiratory protection.
Notify infection prevention and public health and begin identifying exposed persons.
Limit movement; for essential transport, keep the client masked and communicate isolation requirements to the receiving department.

Question 54 of 75 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Aisha Brooks, 22-year-old woman in the Medical unit. Review the case exhibit tabs, then answer the following. Which findings indicate that the infection-control response is effective?

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

A. Negative pressure is verified in the isolation roomB. No unprotected staff entry occurs after precautions beginC. Exposed patients and staff are identified for immunity review and follow-upD. Essential transport occurs with the client masked and the receiving department notifiedE. The client returns to the public waiting area after the x-ray

Question 55 of 75 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Walter Price, 75-year-old man in the Telemetry / step-down unit. Review the case exhibit tabs, then answer the following. Which findings increase this client’s risk for readmission and require transition-of-care planning?

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

A. Stops the diuretic when edema improvesB. Uses ibuprofen most daysC. Frequently eats canned soupD. Does not own a scaleE. Missed follow-up because of transportation problemsF. Current oxygen saturation 96% on room air

Question 56 of 75 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Walter Price, 75-year-old man in the Telemetry / step-down unit. Review the case exhibit tabs, then answer the following. Why is routine ibuprofen use a concern in this client?

A. It permanently increases ejection fractionB. It replaces the need for guideline-directed heart-failure medicationC. It can promote sodium and fluid retention and worsen kidney function or diuretic effectivenessD. It prevents all potassium abnormalities

Question 57 of 75 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Walter Price, 75-year-old man in the Telemetry / step-down unit. Review the case exhibit tabs, then answer the following. Which problem should the team prioritize before discharge?

A. Persistent acute pulmonary edema despite clear lungs and stable oxygenationB. High risk for ineffective self-management because of knowledge, literacy, equipment, medication, and transportation barriersC. Need for unrestricted sodium intake to prevent weaknessD. Readiness to manage the regimen independently without further assessment

Question 58 of 75 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Walter Price, 75-year-old man in the Telemetry / step-down unit. Review the case exhibit tabs, then answer the following. Classify each discharge intervention.

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

Finding / action	Supports safe self-management	Does not support safe self-management
Use plain-language teach-back with a simplified medication schedule
Provide a scale and teach daily weights at the same time under similar conditions
Arrange transportation and early follow-up
Give a long technical handout and ask the client to sign that it was received
Tell the client to stop medications whenever symptoms improve

Question 59 of 75 — Take action

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

The nurse is caring for Walter Price, 75-year-old man in the Telemetry / step-down unit. Review the case exhibit tabs, then answer the following. Complete the teaching statement by selecting the best option for each blank.

The nurse should teach the client to ____ and to ____, while avoiding routine NSAID use unless specifically approved by the prescriber. .

Question 60 of 75 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Walter Price, 75-year-old man in the Telemetry / step-down unit. Review the case exhibit tabs, then answer the following. Which findings demonstrate discharge readiness?

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

A. Client demonstrates correct daily weighingB. Client identifies canned soup and restaurant meals as common high-sodium sourcesC. Client explains when and whom to call for rapid weight gain or worsening symptomsD. Client describes the medication schedule and why routine NSAIDs are avoidedE. Transportation and follow-up are confirmedF. Client repeats, "I will stop furosemide when my ankles improve"

Question 61 of 75 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The charge nurse receives four reports. Which client should the nurse assess first?

A. A client 3 hours after thyroidectomy who reports neck tightness and is swallowing repeatedlyB. A client with COPD whose SpO2 is 90% within the prescribed 88% to 92% targetC. A client 1 day after abdominal surgery requesting the next prescribed analgesic for pain rated 7/10D. A client with a new colostomy who is anxious about learning pouch care

Question 62 of 75 — Generate solutions

Extended Multiple Response — Select all that applyGenerate solutions

A competent adult is preparing to sign consent for a surgical procedure. Which actions are appropriate for the nurse?

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

A. Verify that the client is signing voluntarily and appears to have decision-making capacityB. Witness the signature according to facility policyC. Notify the surgeon or qualified provider if the client has unanswered questions about risks or alternativesD. Provide the surgeon’s detailed risk-benefit explanation in place of the surgeonE. Confirm that the correct procedure and site are reflected on the consent formF. Ask a sedated client to sign quickly before transport

Question 63 of 75 — Take action

Multiple Choice — Select the best answerTake action

A client with decision-making capacity has a valid documented do-not-resuscitate order. The client becomes pulseless, and a family member shouts, "Do everything." Which action should the nurse take?

A. Begin CPR because the family member is presentB. Follow the valid order and facility policy while providing support to the familyC. Ignore the documented order until the ethics committee meetsD. Ask the family member to sign a new consent while the client is pulseless

Question 64 of 75 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

For each task, identify the most appropriate team member on a medical-surgical unit. Assume state law and facility policy allow the described assignments.

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

Finding / action	RN	LPN/VN	UAP
Initial assessment of a newly admitted client with chest pain
Reinforce previously taught ostomy care for a stable client
Obtain and record routine vital signs for a stable postoperative client
Evaluate a client’s response to a newly administered IV antihypertensive
Assist a stable client with bathing and ambulation using an established plan

Question 65 of 75 — Take action

Ordered Response — Rank actions in priority orderTake action

A central venous catheter dressing is damp and lifting at the edge. Place the dressing-change actions in the best sequence.

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

Perform hand hygiene, explain the procedure, position the client, and apply a mask to the client and nurse according to policy.
Don clean gloves, remove the old dressing carefully, assess the site, remove gloves, and perform hand hygiene.
Open the sterile kit, don sterile gloves, and cleanse the site with the recommended chlorhexidine-alcohol preparation using friction.
Allow the antiseptic to air dry completely, then apply a sterile dressing and label it according to policy.
Document the site assessment and dressing change and report signs of infection or catheter migration.

Question 66 of 75 — Generate solutions

Extended Multiple Response — Select all that applyGenerate solutions

Which interventions are appropriate for a hospitalized client with suspected Clostridioides difficile diarrhea?

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

A. Initiate Contact Precautions and place the client in a single room when availableB. Wear gown and gloves for room entry and client/environment contactC. Use dedicated or appropriately disinfected equipmentD. Ensure environmental cleaning uses an agent and process effective against C. difficile spores according to policyE. Perform hand hygiene after glove removal; use soap and water when hands are visibly soiled or during an outbreak according to facility guidanceF. Rely on gloves without hand hygiene because the gloves were intact

Question 67 of 75 — Take action

Multiple Choice — Select the best answerTake action

A client begins a generalized tonic-clonic seizure while in bed. Which action should the nurse take?

A. Insert a padded tongue blade to prevent tongue injuryB. Restrain the client’s arms and legs firmlyC. Offer water as soon as the jerking beginsD. Stay with the client, protect the head, turn to the side when possible, clear nearby hazards, and time the seizure

Question 68 of 75 — Generate solutions

Extended Multiple Response — Select all that applyGenerate solutions

A pregnant client at 30 weeks asks which vaccines are recommended or avoided. Which teaching points are appropriate?

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

A. Tdap is recommended during each pregnancy, preferably during 27 through 36 weeksB. Inactivated influenza vaccine is recommended during influenza seasonC. MMR should be avoided during pregnancy and given postpartum if indicatedD. Varicella vaccine should be avoided during pregnancy and given postpartum if indicatedE. All vaccines are contraindicated during pregnancyF. Vaccination decisions should follow current CDC guidance and the client’s clinical history

Question 69 of 75 — Generate solutions

Multiple Choice — Select the best answerGenerate solutions

Which sleep arrangement should the nurse recommend for a healthy newborn?

A. Supine on a firm, flat, separate sleep surface with a fitted sheet and no loose objectsB. Side-lying in a positioner to prevent aspirationC. Prone on a soft mattress after feedingD. In an adult bed between two caregivers

Question 70 of 75 — Take action

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

Complete the sick-day teaching for an adolescent with type 1 diabetes.

During illness, the adolescent should generally ____, while following the individualized sick-day plan and seeking urgent help for persistent vomiting, breathing difficulty, or altered mental status. .

Question 71 of 75 — Generate solutions

Multiple Choice — Select the best answerGenerate solutions

A client whose partner died two weeks ago says, "I keep reaching for the phone to call them, and then I remember." Which response is most therapeutic?

A. "You need to stay busy so you do not think about it."B. "Tell me what those moments have been like for you."C. "At least your partner is no longer suffering."D. "You should be feeling better after two weeks."

Question 72 of 75 — Take action

Ordered Response — Rank actions in priority orderTake action

Place the actions for administering an intermittent enteral feeding in the best sequence. Follow the prescribed tube-verification and medication policies.

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

Verify the prescription, identify the client, assess the abdomen and tolerance, and confirm tube position according to policy.
Elevate the head of bed to at least 30 to 45 degrees unless contraindicated.
Flush the tube with the prescribed water amount and administer the feeding at the ordered rate.
Flush the tube after the feeding and keep the head of bed elevated for the prescribed period.
Document intake, tolerance, abdominal findings, and any signs of aspiration or feeding intolerance.

Question 73 of 75 — Generate solutions

Extended Multiple Response — Select all that applyGenerate solutions

Which statements should the nurse include when teaching a client who is starting warfarin?

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

A. Keep vitamin K intake reasonably consistent rather than eliminating all leafy greensB. Attend scheduled INR testing and dose-adjustment appointmentsC. Report unusual bleeding, black stools, severe headache, or a significant fallD. Check with the prescriber or pharmacist before starting NSAIDs, antibiotics, or herbal productsE. Double the next dose whenever one dose is missedF. Use a soft toothbrush and take precautions to reduce injury

Question 74 of 75 — Take action

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

A hospitalized client with diabetes is unconscious, diaphoretic, and NPO. Point-of-care glucose is 34 mg/dL, and a patent IV is present. Complete the bow-tie.

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

Action

Problem

Action

Monitor

Question 75 of 75 — Take action

Multiple Choice — Select the best answerTake action

During administration of a vesicant chemotherapy drug through a peripheral IV, the client reports burning and the site becomes swollen. Which action should the nurse take first?

A. Flush the line rapidly with normal saline to clear the drug from the tissueB. Remove the catheter immediately before attempting aspirationC. Stop the infusion immediately, leave the catheter in place, and follow the drug-specific extravasation protocol for aspiration and antidote managementD. Apply pressure and continue the infusion at a slower rate

NCLEX Clinical Judgment Practice Test 4

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