NCLEX Clinical Judgment Practice Test 5

Question 1 of 75 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Robert Kane, 64-year-old man in the Emergency department. Review the case exhibit tabs, then answer the following. Which findings are priority cues of significant upper gastrointestinal blood loss and impaired perfusion?

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

A. Coffee-ground emesis and melenaB. Hemoglobin 7.4 g/dLC. BUN 42 mg/dL with creatinine 1.1 mg/dLD. BP 88/54 mm Hg with HR 118/minE. Mild chronic knee painF. Cool pale skin and capillary refill of 4 seconds

Question 2 of 75 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Robert Kane, 64-year-old man in the Emergency department. Review the case exhibit tabs, then answer the following. Which interpretation best explains the client’s presentation?

A. Uncomplicated gastritis without clinically important blood lossB. Upper GI hemorrhage, likely NSAID-associated, with hypovolemic shock physiologyC. Acute pancreatitis causing third-spacing without bleedingD. Chronic anemia with stable hemodynamics

Question 3 of 75 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Robert Kane, 64-year-old man in the Emergency department. Review the case exhibit tabs, then answer the following. Which problem requires the most immediate nursing priority?

A. Deficient knowledge about long-term NSAID useB. Acute pain related to gastric mucosal irritationC. Anxiety related to emergency admissionD. Ineffective tissue perfusion from ongoing blood loss

Question 4 of 75 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Robert Kane, 64-year-old man in the Emergency department. Review the case exhibit tabs, then answer the following. For each 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
Maintain two large-bore IV lines and prepare ordered packed red blood cells
Administer the prescribed IV proton-pump inhibitor
Offer oral fluids to improve blood pressure before endoscopy
Keep NPO and prepare for urgent endoscopic evaluation
Give additional ibuprofen for epigastric discomfort

Question 5 of 75 — Take action

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

The nurse is caring for Robert Kane, 64-year-old man in the Emergency department. Review the case exhibit tabs, then answer the following. Complete the bow-tie to identify the 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 Robert Kane, 64-year-old man in the Emergency department. Review the case exhibit tabs, then answer the following. Which findings indicate that the interventions are effective?

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

A. BP 108/66 mm Hg and HR 88/minB. Urine output 42 mL/hrC. No further hematemesisD. Increasing restlessness and capillary refill of 5 secondsE. Improved skin color and orientationF. New bright-red blood in the stool with dizziness

Question 7 of 75 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Sofia Alvarez, 31-year-old woman, G2P1 at 34 weeks in the Labor and delivery triage. Review the case exhibit tabs, then answer the following. Which findings are most consistent with the client’s high-risk obstetric condition?

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

A. Painless bright-red vaginal bleedingB. Placenta covering the internal cervical opening on ultrasoundC. Soft, nontender uterusD. Recurrent painful contractions with a rigid abdomenE. Prior cesarean birthF. Moderate fetal variability with accelerations

Question 8 of 75 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Sofia Alvarez, 31-year-old woman, G2P1 at 34 weeks in the Labor and delivery triage. Review the case exhibit tabs, then answer the following. Which interpretation best explains the assessment findings?

A. Placenta previa with active bleeding and current maternal-fetal stabilityB. Placental abruption with concealed hemorrhageC. Normal cervical change associated with term laborD. Uterine rupture with fetal compromise

Question 9 of 75 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Sofia Alvarez, 31-year-old woman, G2P1 at 34 weeks in the Labor and delivery triage. Review the case exhibit tabs, then answer the following. Which action must the nurse prevent because it could cause catastrophic hemorrhage?

A. Applying continuous fetal monitoringB. Establishing large-bore IV accessC. Performing a digital vaginal examinationD. Quantifying vaginal blood loss

Question 10 of 75 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Sofia Alvarez, 31-year-old woman, G2P1 at 34 weeks in the Labor and delivery triage. Review the case exhibit tabs, then answer the following. For each proposed intervention, indicate whether it is appropriate for the current change in status.

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

Finding / action	Appropriate now	Not appropriate now
Notify the obstetric team of increased bleeding and changing maternal vital signs
Maintain continuous fetal monitoring and prepare neonatal support
Encourage the client to walk to determine whether bleeding increases
Verify type and crossmatch and ensure blood products are rapidly available
Delay escalation because the initial fetal tracing was reassuring

Question 11 of 75 — Take action

Ordered Response — Rank actions in priority orderTake action

The nurse is caring for Sofia Alvarez, 31-year-old woman, G2P1 at 34 weeks in the Labor and delivery triage. Review the case exhibit tabs, then answer the following. Place the actions in the best priority sequence after brisk bleeding, maternal hypotension, and recurrent late decelerations develop. Actions may overlap in clinical practice.

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

Activate the obstetric hemorrhage and emergency-delivery response
Position the client laterally, apply oxygen if indicated, and support airway and circulation
Increase/maintain large-bore IV access and begin ordered crystalloid and blood-product resuscitation
Prepare the client for emergency cesarean delivery and complete rapid preoperative safety checks

Question 12 of 75 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Sofia Alvarez, 31-year-old woman, G2P1 at 34 weeks in the Labor and delivery triage. Review the case exhibit tabs, then answer the following. Which findings support effective maternal and neonatal management after delivery?

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

A. BP 112/70 mm Hg and HR 90/minB. Firm uterine tone with minimal ongoing vaginal blood lossC. Increasing pallor, confusion, and urine output of 10 mL/hrD. Newborn receiving routine transitional assessment without escalating respiratory supportE. Continued brisk vaginal bleeding with falling blood pressureF. Blood products reconciled and postpartum hemorrhage monitoring continued

Question 13 of 75 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Ethan Brooks, 8-year-old boy in the Pediatric emergency department. Review the case exhibit tabs, then answer the following. Which findings indicate a severe asthma exacerbation requiring urgent treatment?

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

A. SpO2 89% on room airB. Speaking in two- to three-word phrasesC. Peak expiratory flow 35% of personal bestD. Suprasternal and intercostal retractionsE. Temperature 37.2 CF. Reduced air movement at the lung bases

Question 14 of 75 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Ethan Brooks, 8-year-old boy in the Pediatric emergency department. Review the case exhibit tabs, then answer the following. Which interpretation best explains the child’s persistent findings after initial bronchodilator therapy?

A. Mild asthma symptoms that can be managed with discharge teaching aloneB. Severe exacerbation with incomplete response and risk for respiratory failureC. Bacterial pneumonia as the primary cause of hypoxemiaD. Anxiety-related hyperventilation without lower-airway obstruction

Question 15 of 75 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Ethan Brooks, 8-year-old boy in the Pediatric emergency department. Review the case exhibit tabs, then answer the following. Which change is most concerning for impending respiratory failure?

A. Heart rate 138/min after beta2-agonist therapyB. Anxiety while sitting uprightC. Decreasing wheeze accompanied by markedly reduced air movement and drowsinessD. Mild hand tremor after albuterol

Question 16 of 75 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Ethan Brooks, 8-year-old boy in the Pediatric emergency department. Review the case exhibit tabs, then answer the following. For each intervention, indicate whether it is appropriate for this severe exacerbation.

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

Finding / action	Appropriate	Not appropriate
Repeated or continuous inhaled short-acting beta2-agonist therapy as prescribed
Inhaled ipratropium during initial severe-exacerbation treatment
Prompt systemic corticosteroid therapy
Routine sedative administration to reduce anxiety and respiratory effort
Delay escalation until wheezing becomes louder

Question 17 of 75 — Take action

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

The nurse is caring for Ethan Brooks, 8-year-old boy in the Pediatric emergency department. Review the case exhibit tabs, then answer the following. Complete the bow-tie for the child’s new deterioration.

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

Action

Problem

Action

Monitor

Question 18 of 75 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Ethan Brooks, 8-year-old boy in the Pediatric emergency department. Review the case exhibit tabs, then answer the following. Which findings and teaching points support safe recovery and reduced future risk?

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

A. Speaks in full sentences with minimal retractionsB. SpO2 96% on low-flow oxygen with improved air movementC. Uses the rescue inhaler several times every day without contacting the clinicianD. Demonstrates correct spacer technique with the controller inhalerE. Family identifies worsening symptoms and the written asthma-action-plan stepsF. Stops the inhaled corticosteroid whenever symptoms improve for one day

Question 19 of 75 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Margaret Quinn, 71-year-old woman in the Medical-surgical unit. Review the case exhibit tabs, then answer the following. Which findings require immediate follow-up because they indicate life-threatening hyperkalemia and acute kidney injury?

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

A. Potassium 6.9 mEq/LB. Peaked T waves and widening QRS complexC. Urine output 12 mL during the previous hourD. Creatinine increased from 1.5 to 3.2 mg/dLE. Glucose 108 mg/dLF. Muscle weakness and irregular bradycardia

Question 20 of 75 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Margaret Quinn, 71-year-old woman in the Medical-surgical unit. Review the case exhibit tabs, then answer the following. Which factor most likely contributed to the current potassium elevation and kidney injury?

A. Use of a short-acting beta2-agonistB. A normal glucose concentrationC. Clear lung soundsD. Combined lisinopril, spironolactone, dehydration, and recent NSAID use

Question 21 of 75 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Margaret Quinn, 71-year-old woman in the Medical-surgical unit. Review the case exhibit tabs, then answer the following. Which problem is the highest priority?

A. Risk for a lethal dysrhythmia from severe hyperkalemiaB. Long-term dietary knowledge deficitC. Chronic activity intoleranceD. Mild nausea related to uremia

Question 22 of 75 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Margaret Quinn, 71-year-old woman in the Medical-surgical unit. Review the case exhibit tabs, then answer the following. For each intervention, indicate its primary purpose in acute hyperkalemia.

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

Finding / action	Stabilizes myocardium	Shifts potassium into cells	Removes potassium from the body	Not appropriate
IV calcium gluconate
Regular insulin with dextrose
Nebulized albuterol
Urgent hemodialysis
Potassium-containing IV fluid bolus

Question 23 of 75 — Take action

Ordered Response — Rank actions in priority orderTake action

The nurse is caring for Margaret Quinn, 71-year-old woman in the Medical-surgical unit. Review the case exhibit tabs, then answer the following. Place the actions in the best priority sequence for severe hyperkalemia with ECG changes. Actions may overlap in clinical practice.

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

Maintain continuous ECG monitoring and activate emergency treatment resources
Administer ordered IV calcium to stabilize the myocardium
Administer ordered insulin with dextrose and inhaled beta2-agonist therapy
Reassess potassium, ECG, and glucose and proceed with urgent dialysis for persistent severe hyperkalemia

Question 24 of 75 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Margaret Quinn, 71-year-old woman in the Medical-surgical unit. Review the case exhibit tabs, then answer the following. Which findings indicate effective treatment and reduced immediate risk?

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

A. Potassium 4.8 mEq/LB. Normal QRS duration and regular HR 76/minC. Improved muscle strengthD. New recurrent peaked T wavesE. Glucose remains within the prescribed monitoring range after insulinF. Increasing potassium with worsening oliguria

Question 25 of 75 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Daniel Okonkwo, 48-year-old man in the Medical unit. Review the case exhibit tabs, then answer the following. Which findings are priority cues of lithium toxicity rather than a recurrence of uncomplicated mania?

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

A. Coarse tremorB. Ataxic gait and dysarthriaC. Lithium level 2.1 mEq/LD. Vomiting, diarrhea, and poor intakeE. Decreased need for sleep with expansive moodF. Acute creatinine elevation

Question 26 of 75 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Daniel Okonkwo, 48-year-old man in the Medical unit. Review the case exhibit tabs, then answer the following. Which combination most likely caused the lithium level to rise?

A. Increased dietary sodium and high fluid intakeB. A missed lithium dose followed by normal hydrationC. Dehydration, sodium loss, acute kidney injury, lisinopril, and NSAID exposureD. Use of an inhaled beta2-agonist

Question 27 of 75 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Daniel Okonkwo, 48-year-old man in the Medical unit. Review the case exhibit tabs, then answer the following. Which problem is the highest priority?

A. Long-term concern about relapse preventionB. Risk for neurologic deterioration and injury from severe lithium toxicityC. Disturbed body imageD. Knowledge deficit about sleep hygiene

Question 28 of 75 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Daniel Okonkwo, 48-year-old man in the Medical unit. Review the case exhibit tabs, then answer the following. For each proposed intervention, indicate whether it is appropriate now.

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

Finding / action	Appropriate now	Not appropriate now
Hold lithium and notify the prescribing and toxicology teams
Begin prescribed isotonic IV hydration and monitor urine output
Institute fall, aspiration, and seizure precautions as clinically indicated
Administer the next lithium dose to prevent mood destabilization
Prepare for nephrology-directed dialysis when severe neurologic toxicity and impaired clearance persist

Question 29 of 75 — Take action

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

The nurse is caring for Daniel Okonkwo, 48-year-old man in the Medical unit. Review the case exhibit tabs, then answer the following. Complete the bow-tie for the client’s worsening condition.

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

Action

Problem

Action

Monitor

Question 30 of 75 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Daniel Okonkwo, 48-year-old man in the Medical unit. Review the case exhibit tabs, then answer the following. Which findings and statements indicate recovery and safer future self-management?

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

A. Lithium 0.8 mEq/L with clear speech and restored orientationB. Creatinine and urine output are improvingC. “If I develop vomiting or diarrhea, I will contact my prescriber before continuing routine lithium doses.”D. “I can take NSAIDs regularly without discussing them because they are over the counter.”E. “I will maintain consistent fluid and sodium intake unless my clinician gives different instructions.”F. Persistent ataxia and new confusion

Question 31 of 75 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Linh Nguyen, 56-year-old woman in the Medical unit / isolation. Review the case exhibit tabs, then answer the following. Which findings are priority cues for potentially infectious pulmonary tuberculosis?

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

A. Cough lasting six weeksB. Night sweats and unintentional weight lossC. Upper-lobe cavitary opacityD. Occasional blood-streaked sputumE. Negative HIV screening testF. Residence in a congregate shelter

Question 32 of 75 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Linh Nguyen, 56-year-old woman in the Medical unit / isolation. Review the case exhibit tabs, then answer the following. Which interpretation best explains the infection-control risk created in the waiting area?

A. A contact-only exposure adequately managed by cleaning the chairB. A foodborne exposure affecting only clients who ate nearbyC. No exposure because the diagnosis was not yet laboratory confirmedD. A possible airborne exposure requiring prompt risk assessment and follow-up

Question 33 of 75 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Linh Nguyen, 56-year-old woman in the Medical unit / isolation. Review the case exhibit tabs, then answer the following. Which nursing action is the immediate priority?

A. Place the client in an airborne infection isolation room and use a fit-tested respiratorB. Obtain a complete dietary historyC. Schedule routine outpatient follow-up before implementing precautionsD. Begin contact precautions only

Question 34 of 75 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Linh Nguyen, 56-year-old woman in the Medical unit / isolation. Review the case exhibit tabs, then answer the following. For each action, indicate whether it is appropriate for coordinated care.

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

Finding / action	Appropriate	Not appropriate
Notify infection prevention and follow legally required public-health reporting procedures
Identify potentially exposed staff and clients according to the facility exposure plan
Tell household members to start the client’s medications without evaluation
Coordinate sputum collection without removing airborne precautions
Post the diagnosis publicly so coworkers can identify the client

Question 35 of 75 — Take action

Ordered Response — Rank actions in priority orderTake action

The nurse is caring for Linh Nguyen, 56-year-old woman in the Medical unit / isolation. Review the case exhibit tabs, then answer the following. Place the actions in the best sequence when the client must leave the isolation room for an essential procedure. Actions may overlap in clinical practice.

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

Confirm that transport is essential and notify the receiving department before departure
Place a surgical mask on the client and reinforce cough etiquette
Keep the client out of public waiting areas and use the most direct route
Return the client promptly to the airborne infection isolation room and perform hand hygiene/equipment cleaning according to policy

Question 36 of 75 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Linh Nguyen, 56-year-old woman in the Medical unit / isolation. Review the case exhibit tabs, then answer the following. Which client statements indicate effective teaching for treatment and transmission prevention?

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

A. “I will take every medication for the full prescribed course, even when I feel better.”B. “I will report yellowing skin, severe nausea, vision changes, or numbness and tingling.”C. “My household contacts should be evaluated through the public-health plan.”D. “I can stop isolation precautions as soon as my cough improves.”E. “I will follow directly observed therapy or the adherence plan arranged for me.”F. “Alcohol use is harmless while I take these medications.”

Question 37 of 75 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for James Porter, 29-year-old man in the Rehabilitation / neuroscience unit. Review the case exhibit tabs, then answer the following. Which findings are priority cues of autonomic dysreflexia?

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

A. Systolic BP more than 100 mm Hg above the client’s baselineB. Pounding headache and blurred visionC. Flushing and sweating above the injury levelD. BradycardiaE. Temperature 36.8 CF. Distended bladder with obstructed catheter drainage

Question 38 of 75 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for James Porter, 29-year-old man in the Rehabilitation / neuroscience unit. Review the case exhibit tabs, then answer the following. Which trigger is most likely causing this episode?

A. Mild anxiety about rehabilitationB. Bladder distention from kinked catheter tubingC. Normal bowel program completed yesterdayD. Room temperature of 22 C

Question 39 of 75 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for James Porter, 29-year-old man in the Rehabilitation / neuroscience unit. Review the case exhibit tabs, then answer the following. Which nursing action should occur first?

A. Place the client flat with legs elevatedB. Begin the scheduled bowel program before assessing the urinary catheterC. Provide a dark quiet room and reassess in one hourD. Sit the client upright and loosen constrictive items while rechecking BP frequently

Question 40 of 75 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for James Porter, 29-year-old man in the Rehabilitation / neuroscience unit. Review the case exhibit tabs, then answer the following. For each intervention, indicate whether it is appropriate during trigger assessment and prevention.

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

Finding / action	Appropriate	Not appropriate
Inspect urinary tubing for kinks and ensure unobstructed drainage
Loosen abdominal binders, support stockings, and tight clothing
Check for bowel impaction only after bladder causes have been addressed and use prescribed local anesthetic technique if rectal examination is required
Massage a distended bladder vigorously
Inspect skin, bedding, shoes, and positioning devices for pressure or injury

Question 41 of 75 — Take action

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

The nurse is caring for James Porter, 29-year-old man in the Rehabilitation / neuroscience unit. Review the case exhibit tabs, then answer the following. Complete the bow-tie for persistent hypertension after bladder drainage.

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 James Porter, 29-year-old man in the Rehabilitation / neuroscience unit. Review the case exhibit tabs, then answer the following. Which findings and statements indicate resolution and effective prevention teaching?

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

A. BP 112/68 mm Hg near the client’s baselineB. Headache, flushing, and sweating have resolvedC. “I will check my catheter tubing and bladder first if symptoms occur.”D. “I should lie flat whenever my blood pressure rises.”E. “I will carry information about autonomic dysreflexia and my usual blood pressure.”F. Recurrent severe headache with BP 190/100 mm Hg

Question 43 of 75 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Baby girl Rivera, 60-hour-old newborn born at 38 weeks' gestation in the Newborn nursery. Review the case exhibit tabs, then answer the following. Which findings increase concern for significant hyperbilirubinemia and inadequate intake?

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

A. Total serum bilirubin 18.9 mg/dL at 60 hoursB. Positive direct antiglobulin test with elevated reticulocytesC. Weight loss 9% with ineffective feedingD. Fewer wet diapers than expectedE. Direct bilirubin 0.4 mg/dLF. Jaundice extending to the calves and feet

Question 44 of 75 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Baby girl Rivera, 60-hour-old newborn born at 38 weeks' gestation in the Newborn nursery. Review the case exhibit tabs, then answer the following. Which interpretation best explains the bilirubin pattern?

A. Predominantly unconjugated hyperbilirubinemia with isoimmune hemolysis and suboptimal intakeB. Normal physiologic jaundice requiring no follow-upC. Predominantly conjugated hyperbilirubinemia from biliary obstructionD. Sepsis as the only possible cause

Question 45 of 75 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Baby girl Rivera, 60-hour-old newborn born at 38 weeks' gestation in the Newborn nursery. Review the case exhibit tabs, then answer the following. Which problem is the highest priority?

A. Parent anxiety about temporary supplementationB. Need for routine newborn photographyC. Risk for bilirubin neurotoxicity from rapidly progressive hyperbilirubinemiaD. Delayed first bath

Question 46 of 75 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Baby girl Rivera, 60-hour-old newborn born at 38 weeks' gestation in the Newborn nursery. Review the case exhibit tabs, then answer the following. For each nursing intervention during intensive phototherapy, indicate whether it is appropriate.

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

Finding / action	Appropriate	Not appropriate
Maximize exposed skin while maintaining prescribed eye protection and thermoregulation
Interrupt phototherapy for prolonged periods so the newborn can sleep undisturbed
Support frequent effective feeding and monitor daily weight, urine, and stool output
Reposition according to equipment protocol and assess skin and temperature
Apply oily lotions to prevent skin dryness under the lights

Question 47 of 75 — Take action

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

The nurse is caring for Baby girl Rivera, 60-hour-old newborn born at 38 weeks' gestation in the Newborn nursery. Review the case exhibit tabs, then answer the following. Complete the sentence using one option from each list.

Select one response for each blank. Each blank is scored separately.

Because bilirubin is approaching the exchange-transfusion threshold and neurologic signs are emerging, the nurse should and prepare for .

Question 48 of 75 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Baby girl Rivera, 60-hour-old newborn born at 38 weeks' gestation in the Newborn nursery. Review the case exhibit tabs, then answer the following. Which findings and parent statements indicate improvement and safe follow-up planning?

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

A. Bilirubin is falling on appropriately delivered therapyB. Newborn awakens for feeds and demonstrates sustained effective suckingC. Wet-diaper frequency and weight trend are improvingD. “I will wait for the scheduled visit even if my baby becomes difficult to wake.”E. “I understand when the bilirubin must be rechecked after treatment and whom to call.”F. New high-pitched cry and increasing arching

Question 49 of 75 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Carmen Delgado, 45-year-old woman in the Emergency department. Review the case exhibit tabs, then answer the following. Which findings are priority cues of acute pancreatitis with intravascular volume depletion?

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

A. Severe epigastric pain radiating to the backB. Lipase 1,240 U/LC. Tachycardia and BP 98/62 mm HgD. BUN 32 mg/dL, hematocrit 48%, and oliguriaE. Clear lung sounds at baselineF. Repeated vomiting and dry mucous membranes

Question 50 of 75 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Carmen Delgado, 45-year-old woman in the Emergency department. Review the case exhibit tabs, then answer the following. Which interpretation best explains the current condition?

A. Acute cholecystitis with biliary obstruction and cholangitisB. Acute pancreatitis, likely alcohol-associated, with early hypovolemiaC. Perforated peptic ulcer with generalized peritonitisD. Uncomplicated viral gastroenteritis

Question 51 of 75 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Carmen Delgado, 45-year-old woman in the Emergency department. Review the case exhibit tabs, then answer the following. Which problem is the highest priority during the first hours of care?

A. Need for long-term alcohol-use counselingB. Disturbed sleep patternC. Ineffective circulating volume with risk for organ hypoperfusionD. Knowledge deficit about low-fat meals

Question 52 of 75 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Carmen Delgado, 45-year-old woman in the Emergency department. Review the case exhibit tabs, then answer the following. For each 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
Continue reassessed lactated Ringer’s hydration while monitoring for fluid overload
Administer prescribed analgesic and antiemetic therapy
Begin prophylactic broad-spectrum antibiotics despite no evidence of infection
Monitor BUN, hematocrit, urine output, oxygenation, and lung sounds
Keep the client NPO for a full week regardless of symptom improvement

Question 53 of 75 — Take action

Ordered Response — Rank actions in priority orderTake action

The nurse is caring for Carmen Delgado, 45-year-old woman in the Emergency department. Review the case exhibit tabs, then answer the following. Place the actions in the best priority sequence for persistent pain, vomiting, and hypovolemia. Actions may overlap in clinical practice.

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

Reassess airway, breathing, circulation, vital signs, urine output, and fluid tolerance
Continue/titrate prescribed lactated Ringer’s therapy based on reassessment
Administer prescribed analgesic and antiemetic therapy and position for comfort
Reassess pain, perfusion, respiratory findings, and readiness for early oral or enteral nutrition

Question 54 of 75 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Carmen Delgado, 45-year-old woman in the Emergency department. 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. HR 86/min and stable blood pressureB. Urine output 45 mL/hrC. BUN decreases from 34 to 22 mg/dLD. Pain improves to 3/10 and the client tolerates a low-fat mealE. New crackles, increasing oxygen need, and worsening dyspneaF. Rising hematocrit with persistent oliguria

Question 55 of 75 — Recognize cues

Extended Multiple Response — Select all that applyRecognize cues

The nurse is caring for Thomas Greer, 58-year-old man in the Surgical / ostomy education unit. Review the case exhibit tabs, then answer the following. Which findings require follow-up for dehydration or impaired ostomy management?

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

A. Ileostomy output 1,450 mL of watery effluent in 24 hoursB. Orthostatic hypotension and tachycardiaC. Dark concentrated urine with output 25 mL/hrD. Sodium 131 mEq/L and creatinine above baselineE. Red, moist, protruding stomaF. Leakage-related peristomal irritation

Question 56 of 75 — Analyze cues

Multiple Choice — Select the best answerAnalyze cues

The nurse is caring for Thomas Greer, 58-year-old man in the Surgical / ostomy education unit. Review the case exhibit tabs, then answer the following. Which interpretation best explains the dizziness, laboratory changes, and reduced urine output?

A. Normal postoperative adaptation requiring no interventionB. Fluid overload from excessive oral intakeC. Acute urinary obstruction as the only problemD. Dehydration and sodium loss related to high ileostomy output

Question 57 of 75 — Prioritize hypotheses

Multiple Choice — Select the best answerPrioritize hypotheses

The nurse is caring for Thomas Greer, 58-year-old man in the Surgical / ostomy education unit. Review the case exhibit tabs, then answer the following. Which problem should the nurse address first?

A. Intravascular volume depletion with risk for worsening kidney injuryB. Fear about partner acceptanceC. Need for long-term travel planningD. Knowledge deficit about support groups

Question 58 of 75 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

The nurse is caring for Thomas Greer, 58-year-old man in the Surgical / ostomy education unit. Review the case exhibit tabs, then answer the following. For each intervention, indicate whether it is appropriate for coordinated discharge preparation.

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

Finding / action	Appropriate	Not appropriate
Arrange wound-ostomy nurse follow-up and verify access to supplies
Invite the partner to teaching only with the client’s permission
Teach the client to measure output and recognize dehydration and blockage warning signs
Advise the client to change the appliance only after leakage has damaged the skin
Coordinate medication review because some extended-release products may not be fully absorbed

Question 59 of 75 — Take action

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

The nurse is caring for Thomas Greer, 58-year-old man in the Surgical / ostomy education unit. Review the case exhibit tabs, then answer the following. Complete the bow-tie for the client’s current priority condition.

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

Action

Problem

Action

Monitor

Question 60 of 75 — Evaluate outcomes

Extended Multiple Response — Select all that applyEvaluate outcomes

The nurse is caring for Thomas Greer, 58-year-old man in the Surgical / ostomy education unit. Review the case exhibit tabs, then answer the following. Which findings and statements indicate effective physical and psychosocial adaptation?

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

A. Ileostomy output decreases to 850 mL/24 hr and urine becomes lighterB. Creatinine returns toward baseline and orthostatic symptoms resolveC. Peristomal skin remains intact with a secure sealD. Client independently empties and changes the pouch with minimal promptingE. “I will avoid all activities and intimacy permanently.”F. “I know whom to contact for high output, no output with cramping, skin problems, or questions about intimacy.”

Question 61 of 75 — Take action

Multiple Choice — Select the best answerTake action

Which task is most appropriate for the registered nurse to delegate to an experienced unlicensed assistive personnel (UAP)?

A. Perform the initial assessment of a client reporting new chest pressureB. Teach a client how to self-administer enoxaparinC. Ambulate a stable postoperative client who has already walked twice with staffD. Evaluate whether IV morphine relieved a client’s pain

Question 62 of 75 — Generate solutions

Extended Multiple Response — Select all that applyGenerate solutions

Which nursing actions reduce the risk of a central-line–associated bloodstream infection?

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

A. Perform hand hygiene before manipulating the lineB. Scrub the needleless connector for the required time and allow it to dryC. Assess daily whether the central line is still necessaryD. Replace an intact transparent dressing every shiftE. Maintain a clean, dry, occlusive dressing and change it using aseptic technique according to policyF. Use the line for routine blood sampling whenever convenient, regardless of necessity

Question 63 of 75 — Take action

Multiple Choice — Select the best answerTake action

A client with anorexia nervosa says, “Everyone keeps trying to control me. I am not eating lunch.” Which response by the nurse is best?

A. “You must eat because your weight is dangerously low.”B. “Tell me what feels most out of your control right now. We can review the meal plan and choices that remain yours.”C. “If you refuse lunch, you will lose all privileges.”D. “You look healthy, so there is no reason to worry about gaining weight.”

Question 64 of 75 — Generate solutions

Matrix / Grid — Select one response per rowGenerate solutions

For each nursing action involving insulin, indicate whether it is safe or unsafe.

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

Finding / action	Safe	Unsafe
Verify the insulin type, concentration, dose, timing, and current glucose before administration
Coordinate rapid-acting insulin with meal availability
Use an insulin syringe to measure U-100 insulin
Administer rapid-acting insulin and then discover the meal will be delayed for two hours
Independently change a basal-insulin dose because the client ate less breakfast

Question 65 of 75 — Take action

Multiple Choice — Select the best answerTake action

A client has signed consent for surgery but tells the nurse, “I still do not understand the main risks.” What should the nurse do?

A. Explain the surgical risks in detail and ask the client to sign againB. Reassure the client that serious complications are rare and continue preparationC. Ask a family member to explain the procedureD. Notify the surgeon or qualified procedural clinician that further explanation is required before the procedure

Question 66 of 75 — Generate solutions

Extended Multiple Response — Select all that applyGenerate solutions

Which interventions are appropriate for a hospitalized client with profound neutropenia?

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

A. Perform meticulous hand hygiene before careB. Screen visitors for infectious symptoms and restrict sick visitorsC. Avoid rectal temperatures, suppositories, and unnecessary mucosal traumaD. Use routine fresh flowers and standing water in the roomE. Monitor temperature and report fever immediately according to the neutropenic-fever protocolF. Automatically place every neutropenic client in airborne isolation

Question 67 of 75 — Take action

Multiple Choice — Select the best answerTake action

A medically evaluated client is having a panic attack, hyperventilating, and saying, “I am going to die.” Which nursing response is best?

A. Stay with the client, use short calm statements, reduce stimulation, and coach slow breathingB. “There is nothing wrong, so you need to calm down.”C. Ask the client to explain the childhood cause of the panic immediatelyD. Leave the room to encourage independence

Question 68 of 75 — Generate solutions

Extended Multiple Response — Select all that applyGenerate solutions

Which interventions reduce pressure-injury risk in an immobile incontinent client?

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

A. Reposition on an individualized schedule and offload the heelsB. Manage moisture promptly with gentle cleansing and barrier protectionC. Use pressure-redistributing support surfaces as indicatedD. Massage persistently reddened bony prominencesE. Assess nutrition and hydration and refer for support when neededF. Place a donut-shaped device beneath the sacrum

Question 69 of 75 — Take action

Ordered Response — Rank actions in priority orderTake action

A client taking warfarin develops sudden severe headache, vomiting, and unilateral weakness. 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).

Activate the emergency stroke/rapid-response process and assess airway, breathing, circulation, and neurologic status
Hold warfarin and obtain urgent coagulation studies and brain imaging as ordered
Prepare to administer prescribed rapid reversal therapy, such as four-factor prothrombin complex concentrate with IV vitamin K
Continue frequent neurologic and hemodynamic monitoring and prepare for specialty intervention

Question 70 of 75 — Generate solutions

Extended Multiple Response — Select all that applyGenerate solutions

Which actions are appropriate when measles is suspected in a health care setting?

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

A. Place the client in an airborne infection isolation roomB. Have susceptible personnel avoid entering when immune staff are availableC. Use a fit-tested N95 or higher-level respirator according to policyD. Place a surgical mask on the client during essential transportE. Use standard precautions only because the rash is already presentF. Schedule the client in a crowded waiting area to expedite assessment

Question 71 of 75 — Take action

Multiple Choice — Select the best answerTake action

An unconscious client has a valid advance directive refusing intubation. A family member demands, “Do everything.” What should the nurse do?

A. Ignore the directive because the family is presentB. Follow the documented directive and notify the provider and appropriate team of the conflictC. Ask the family member to sign a new consent overriding the client’s wishesD. Delay all care until a court order is obtained

Question 72 of 75 — Take action

Multiple Choice — Select the best answerTake action

A parent whose child died unexpectedly says, “I should have noticed something was wrong.” Which response by the nurse is best?

A. “You should not blame yourself.”B. “Everything happens for a reason.”C. “You need to be strong for your family.”D. “Tell me more about what you are thinking happened.”

Question 73 of 75 — Take action

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

Complete the sentence using one option from each list.

Select one response for each blank. Each blank is scored separately.

A postoperative client who received IV hydromorphone is difficult to arouse, has a respiratory rate of 6/min, and SpO2 82%. The nurse should first and then .

Question 74 of 75 — Take action

Multiple Choice — Select the best answerTake action

While preparing a sterile field, the nurse notices that the sterile-gloved hand passed below waist level. What should the nurse do?

A. Consider the glove contaminated and replace it using sterile techniqueB. Continue because the glove did not touch another objectC. Wipe the glove with antiseptic and continueD. Ask an assistant to decide whether contamination occurred

Question 75 of 75 — Prioritize hypotheses

Cloze (Drop-Down) — Complete the clinical statementPrioritize hypotheses

Complete the sentence using one option from each list.

Select one response for each blank. Each blank is scored separately.

Shortly after subclavian central-line placement, a client develops sudden dyspnea, hypotension, unilateral absent breath sounds, and tracheal deviation. The nurse should suspect and immediately .

NCLEX Clinical Judgment Practice Test 5

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