NCLEX-PN Clinical Judgment & Patient Care Management (2026/2027
Update) |SBON
1. A Licensed Practical Nurse (LPN) is assigned to care for four clients. Which
client should the nurse see first?
A. A client with deep vein thrombosis (DVT) complaining of sudden shortness of breath.
B. A client who had an abdominal cholecystectomy 4 hours ago and has not voided.
C. A client with chronic obstructive pulmonary disease (COPD) with an oxygen saturation of 90%.
D. A client scheduled for discharge who needs instructions on wound care.
Answer: A
Rationale: Sudden shortness of breath in a client with DVT suggests a pulmonary
embolism, which is a life-threatening emergency (ABC priority).
2. According to the NCSBN Clinical Judgment Measurement Model, which action
represents the step of ‘Recognizing Cues’?
A. Identifying that a client’s heart rate has increased from 80 to 115 bpm.
B. Deciding to administer a PRN dose of acetaminophen for a fever.
C. Predicting that a client is at risk for falls due to age.
D. Checking if the client’s pain level decreased after medication.
Answer: A
Rationale: Recognizing cues involves identifying relevant information from different
sources (data collection/assessment).
,3. An LPN is delegating tasks to an Unlicensed Assistive Personnel (UAP). Which
task is appropriate for the nurse to delegate?
A. Feeding a client who is being evaluated for dysphagia.
B. Teaching a client how to use an incentive spirometer.
C. Performing the initial head-to-toe assessment on a new admission.
D. Assisting a stable client with a total hip replacement to ambulate.
Answer: D
Rationale: UAPs can perform routine tasks for stable clients, such as ambulation.
Assessment and teaching are nursing responsibilities.
4. A client is receiving a continuous intravenous infusion. The LPN notes the site
is cool, pale, and swollen. What is the priority action?
A. Apply a warm compress to the site.
B. Stop the infusion and remove the catheter.
C. Slow the infusion rate to a KVO (Keep Vein Open) rate.
D. Notify the healthcare provider immediately.
Answer: B
Rationale: These signs indicate infiltration. The priority is to stop the infusion and remove
the IV to prevent further tissue damage.
5. Which lab value should the LPN report immediately for a client taking
Warfarin?
A. PTT of 35 seconds.
B. INR of 5.2.
C. Hgb of 14 g/dL.
D. INR of 2.5.
Answer: B
Rationale: An INR of 5.2 is significantly above the therapeutic range (usually 2-3) and
places the client at high risk for bleeding.
, 6. An LPN is caring for a client with a C. difficile infection. Which infection
control measure is most important?
A. Washing hands with soap and water.
B. Using alcohol-based hand sanitizer after care.
C. Wearing an N95 respirator mask.
D. Placing the client in a room with negative pressure.
Answer: A
Rationale: C. diff spores are resistant to alcohol; soap and water are required for
mechanical removal.
7. A client is prescribed Digoxin 0.125 mg daily. Which symptom should the LPN
recognize as an early sign of toxicity?
A. Increased appetite.
B. Sudden hypertension.
C. Anorexia and nausea.
D. Dry hacking cough.
Answer: C
Rationale: Gastrointestinal symptoms like anorexia, nausea, and vomiting are often the
earliest signs of Digoxin toxicity.
8. When using the SBAR tool, in which section does the nurse describe the
client’s current mental status and skin color?
A. Situation
B. Background
C. Assessment
D. Recommendation
Answer: C
Rationale: The ‘Assessment’ portion of SBAR includes clinical findings and the nurse’s
analysis of the current situation.
Update) |SBON
1. A Licensed Practical Nurse (LPN) is assigned to care for four clients. Which
client should the nurse see first?
A. A client with deep vein thrombosis (DVT) complaining of sudden shortness of breath.
B. A client who had an abdominal cholecystectomy 4 hours ago and has not voided.
C. A client with chronic obstructive pulmonary disease (COPD) with an oxygen saturation of 90%.
D. A client scheduled for discharge who needs instructions on wound care.
Answer: A
Rationale: Sudden shortness of breath in a client with DVT suggests a pulmonary
embolism, which is a life-threatening emergency (ABC priority).
2. According to the NCSBN Clinical Judgment Measurement Model, which action
represents the step of ‘Recognizing Cues’?
A. Identifying that a client’s heart rate has increased from 80 to 115 bpm.
B. Deciding to administer a PRN dose of acetaminophen for a fever.
C. Predicting that a client is at risk for falls due to age.
D. Checking if the client’s pain level decreased after medication.
Answer: A
Rationale: Recognizing cues involves identifying relevant information from different
sources (data collection/assessment).
,3. An LPN is delegating tasks to an Unlicensed Assistive Personnel (UAP). Which
task is appropriate for the nurse to delegate?
A. Feeding a client who is being evaluated for dysphagia.
B. Teaching a client how to use an incentive spirometer.
C. Performing the initial head-to-toe assessment on a new admission.
D. Assisting a stable client with a total hip replacement to ambulate.
Answer: D
Rationale: UAPs can perform routine tasks for stable clients, such as ambulation.
Assessment and teaching are nursing responsibilities.
4. A client is receiving a continuous intravenous infusion. The LPN notes the site
is cool, pale, and swollen. What is the priority action?
A. Apply a warm compress to the site.
B. Stop the infusion and remove the catheter.
C. Slow the infusion rate to a KVO (Keep Vein Open) rate.
D. Notify the healthcare provider immediately.
Answer: B
Rationale: These signs indicate infiltration. The priority is to stop the infusion and remove
the IV to prevent further tissue damage.
5. Which lab value should the LPN report immediately for a client taking
Warfarin?
A. PTT of 35 seconds.
B. INR of 5.2.
C. Hgb of 14 g/dL.
D. INR of 2.5.
Answer: B
Rationale: An INR of 5.2 is significantly above the therapeutic range (usually 2-3) and
places the client at high risk for bleeding.
, 6. An LPN is caring for a client with a C. difficile infection. Which infection
control measure is most important?
A. Washing hands with soap and water.
B. Using alcohol-based hand sanitizer after care.
C. Wearing an N95 respirator mask.
D. Placing the client in a room with negative pressure.
Answer: A
Rationale: C. diff spores are resistant to alcohol; soap and water are required for
mechanical removal.
7. A client is prescribed Digoxin 0.125 mg daily. Which symptom should the LPN
recognize as an early sign of toxicity?
A. Increased appetite.
B. Sudden hypertension.
C. Anorexia and nausea.
D. Dry hacking cough.
Answer: C
Rationale: Gastrointestinal symptoms like anorexia, nausea, and vomiting are often the
earliest signs of Digoxin toxicity.
8. When using the SBAR tool, in which section does the nurse describe the
client’s current mental status and skin color?
A. Situation
B. Background
C. Assessment
D. Recommendation
Answer: C
Rationale: The ‘Assessment’ portion of SBAR includes clinical findings and the nurse’s
analysis of the current situation.
