NSG 100- TEST 2- CLINICAL
JUDGMENT AND THE NURSING
PROCESS QUESTIONS & UPDATED
ANSWERS 100%
Nursing Process Step 4- Implementation Question- Select the correct action.
A nurse is caring for a client who is receiving continuous enteral feedings via a
nasogastric tube with an open system. Which of the following actions should the nurse
take?
NCLEX TIP: To successfully answer this item you must recall appropriate techniques for
administering continuous enteral feedings as well as risks and actions you should take
to decrease these risks.
A) Keep the head of the bed flat.
B) Add the client's medication to the enteral feeding
C) Check gastric residual every 12 hrs
D) Flush the tubing with 30 mL of water every 4 hours. - Correct Answer ✔✔ D) Flush
the tubing with 30 mL of water every 4 hours. -This action will verify placement of the
tube and help maintain patency of the tube.
Incorrect Answers and Rationals:
A) Keep the head of the bed flat. - This position is not safe for the client. This position
increases the risk of aspiration of the tube feeding.
B) Add the client's medication to the enteral feeding- This action is not safe for
administering medication when a client is receiving continuous tube feedings.
C) Check gastric residual every 12 hrs.- This action is not safe. The nurse should check
gastric residual more frequently every 4-6 hrs to monitor how well the client is tolerating
the feeding.
Nursing Process Step 4- Implementation Question- Client Education
A nurse is caring for a client who has emphysema and is experiencing severe dyspnea.
Which of the following positions should the nurse instruct the client to assume?
NCLEX TIP: To correctly answer this question you must recall nursing knowledge
regarding effects the emphysema has on the lungs and the effect different client
positions has on lung expansion.
A) Knee-chest position with pillows under head and stomach.
,B) Sitting in a straight back chair
C) Lying supine with knees flexed
D) Sitting on the side of the bed leaning on an overbed table. - Correct Answer ✔✔ D)
Sitting on the side of the bed leaning on an overbed table. - This position would be
effective in alleviating dyspnea as it places the client in a position that allows full
expansion of the lungs as well as letting her rest the upper body on the overbed table.
Incorrect Answers and Rationals:
A) Knee-chest position with pillows under head and stomach. - This position does not
alleviate dyspnea
B) Sitting in a straight back chair- This would allow expansion of the clients lung but
would cause fatigue for the lack of support.
C) Lying supine with knees flexed- This would increase dyspnea due to the pressure on
the abdominal organs on the diaphragm and the lungs.
Critical Thinking Skills Question- Clinical Judgement
A nurse is teaching a client who has a new diagnosis of type 1 diabetes mellitus. The
nurse should identify which of the following statements as an indication that the
teaching is effective?
NCLEX TIP: Critical thinking involves applying knowledge to Analyze, Evaluate, and
Create a plan of action. Refer to the Critical Thinking steps to answer this question. See
the steps below as it pertains to this question.
Step 1. Evaluate the clients statement to determine if she understands how to manage
her new diagnosis of diabetes mellitus.
Step 2. Recall information you need to solve this problem. In this case, you need to
know how to perform self blood glucose monitoring, the onset times of regular insulin,
how to treat a hypoglycemia reaction, and how to manage sick days.
Step 3: Evaluate each option.
A) "I will puncture the pad of my finger when I am testing bloo - Correct Answer ✔✔ B)
"I will give myself a shot of regular insulin 30 minutes before I eat breakfast." - The client
understands the teaching. She should administer regular insulin 30 minutes before
meals so that the onset coincides with food intake. This allows time for the absorption of
insulin and for it to work at in the appropriate time.
Incorrect answers and rationals:
A) "I will puncture the pad of my finger when I am testing blood glucose." - The client
doesn't. understand the teaching. The pads of the fingers have fewer blood vessels and
more nerve fibers, so the client should avoid this. Instead she should puncture the skin
to either side to promote blood flow and decrease pain.
, C) "I will eat a snack of 5 grams of carbohydrates if my blood glucose is low." - The
client does not understand the teaching. She should eat a snack of 10-15 grams of
carbs such as 120 mL or 4 ounces of fruit juice. This is necessary to rapidly elevate the
blood glucose level.
D) " I will decrease the amount of fluids I drink when I am sick." - Client does not
understand teaching. During acute illness the client should drink 240-360 mL or 8-12
ounces of sugar free liquids every hour while awake to prevent dehydration.
Critical Thinking Skills Question- Clinical Judgement
A hospice nurse is caring for an adolescent who has a terminal illness and his family.
The client's father tells the nurse that he cannot cope anymore and has decided to
move out of the house. Which of the following statements should the nurse make?
NCLEX TIP: To successfully answer this question use Step 1 (Identify and Analyze) the
problem and know how to use therapeutic communication, identify what is therapeutic
and non therapeutic communication, and know how to respond to help a client cope.
A) "It is important that you provide emotional support for your family at this time."
B) "You will regret making this decision after your child's death."
C) "You have to do what is best for yourself during this stressful time."
D) "Let's talk about some ways you have handled other stressors in your life." - Correct
Answer ✔✔ D) "Let's talk about some ways you have handled other stressors in your
life." - The nurse is using the therapeutic technique of offering general leads. She does
this to allow the client to express his feelings as well as helping him to focus on ways he
can cope with the current situation.
Incorrect Answers with Rationals:
A) "It is important that you provide emotional support for your family at this time." - The
nurse is not using therapeutic communication and is giving her opinion on how the client
should behave. This response can make the client feel as if he has to behave as the
nurse does.
B) "You will regret making this decision after your child's death." - The nurse is not using
therapeutic communication. She is challenging the client by telling him how he will feel if
he takes this action without regard for his feelings.
C) "You have to do what is best for yourself during this stressful time." - The nurse is not
using therapeutic communication. The nurse is agreeing with the client which implies
that the nurse is able to judge his behavior and give approval.
Nursing Process Step 3- Planning Question - Select a course of action
A nurse is planning to administer an IM medication. Which of the following actions
should the nurse plan to take?
JUDGMENT AND THE NURSING
PROCESS QUESTIONS & UPDATED
ANSWERS 100%
Nursing Process Step 4- Implementation Question- Select the correct action.
A nurse is caring for a client who is receiving continuous enteral feedings via a
nasogastric tube with an open system. Which of the following actions should the nurse
take?
NCLEX TIP: To successfully answer this item you must recall appropriate techniques for
administering continuous enteral feedings as well as risks and actions you should take
to decrease these risks.
A) Keep the head of the bed flat.
B) Add the client's medication to the enteral feeding
C) Check gastric residual every 12 hrs
D) Flush the tubing with 30 mL of water every 4 hours. - Correct Answer ✔✔ D) Flush
the tubing with 30 mL of water every 4 hours. -This action will verify placement of the
tube and help maintain patency of the tube.
Incorrect Answers and Rationals:
A) Keep the head of the bed flat. - This position is not safe for the client. This position
increases the risk of aspiration of the tube feeding.
B) Add the client's medication to the enteral feeding- This action is not safe for
administering medication when a client is receiving continuous tube feedings.
C) Check gastric residual every 12 hrs.- This action is not safe. The nurse should check
gastric residual more frequently every 4-6 hrs to monitor how well the client is tolerating
the feeding.
Nursing Process Step 4- Implementation Question- Client Education
A nurse is caring for a client who has emphysema and is experiencing severe dyspnea.
Which of the following positions should the nurse instruct the client to assume?
NCLEX TIP: To correctly answer this question you must recall nursing knowledge
regarding effects the emphysema has on the lungs and the effect different client
positions has on lung expansion.
A) Knee-chest position with pillows under head and stomach.
,B) Sitting in a straight back chair
C) Lying supine with knees flexed
D) Sitting on the side of the bed leaning on an overbed table. - Correct Answer ✔✔ D)
Sitting on the side of the bed leaning on an overbed table. - This position would be
effective in alleviating dyspnea as it places the client in a position that allows full
expansion of the lungs as well as letting her rest the upper body on the overbed table.
Incorrect Answers and Rationals:
A) Knee-chest position with pillows under head and stomach. - This position does not
alleviate dyspnea
B) Sitting in a straight back chair- This would allow expansion of the clients lung but
would cause fatigue for the lack of support.
C) Lying supine with knees flexed- This would increase dyspnea due to the pressure on
the abdominal organs on the diaphragm and the lungs.
Critical Thinking Skills Question- Clinical Judgement
A nurse is teaching a client who has a new diagnosis of type 1 diabetes mellitus. The
nurse should identify which of the following statements as an indication that the
teaching is effective?
NCLEX TIP: Critical thinking involves applying knowledge to Analyze, Evaluate, and
Create a plan of action. Refer to the Critical Thinking steps to answer this question. See
the steps below as it pertains to this question.
Step 1. Evaluate the clients statement to determine if she understands how to manage
her new diagnosis of diabetes mellitus.
Step 2. Recall information you need to solve this problem. In this case, you need to
know how to perform self blood glucose monitoring, the onset times of regular insulin,
how to treat a hypoglycemia reaction, and how to manage sick days.
Step 3: Evaluate each option.
A) "I will puncture the pad of my finger when I am testing bloo - Correct Answer ✔✔ B)
"I will give myself a shot of regular insulin 30 minutes before I eat breakfast." - The client
understands the teaching. She should administer regular insulin 30 minutes before
meals so that the onset coincides with food intake. This allows time for the absorption of
insulin and for it to work at in the appropriate time.
Incorrect answers and rationals:
A) "I will puncture the pad of my finger when I am testing blood glucose." - The client
doesn't. understand the teaching. The pads of the fingers have fewer blood vessels and
more nerve fibers, so the client should avoid this. Instead she should puncture the skin
to either side to promote blood flow and decrease pain.
, C) "I will eat a snack of 5 grams of carbohydrates if my blood glucose is low." - The
client does not understand the teaching. She should eat a snack of 10-15 grams of
carbs such as 120 mL or 4 ounces of fruit juice. This is necessary to rapidly elevate the
blood glucose level.
D) " I will decrease the amount of fluids I drink when I am sick." - Client does not
understand teaching. During acute illness the client should drink 240-360 mL or 8-12
ounces of sugar free liquids every hour while awake to prevent dehydration.
Critical Thinking Skills Question- Clinical Judgement
A hospice nurse is caring for an adolescent who has a terminal illness and his family.
The client's father tells the nurse that he cannot cope anymore and has decided to
move out of the house. Which of the following statements should the nurse make?
NCLEX TIP: To successfully answer this question use Step 1 (Identify and Analyze) the
problem and know how to use therapeutic communication, identify what is therapeutic
and non therapeutic communication, and know how to respond to help a client cope.
A) "It is important that you provide emotional support for your family at this time."
B) "You will regret making this decision after your child's death."
C) "You have to do what is best for yourself during this stressful time."
D) "Let's talk about some ways you have handled other stressors in your life." - Correct
Answer ✔✔ D) "Let's talk about some ways you have handled other stressors in your
life." - The nurse is using the therapeutic technique of offering general leads. She does
this to allow the client to express his feelings as well as helping him to focus on ways he
can cope with the current situation.
Incorrect Answers with Rationals:
A) "It is important that you provide emotional support for your family at this time." - The
nurse is not using therapeutic communication and is giving her opinion on how the client
should behave. This response can make the client feel as if he has to behave as the
nurse does.
B) "You will regret making this decision after your child's death." - The nurse is not using
therapeutic communication. She is challenging the client by telling him how he will feel if
he takes this action without regard for his feelings.
C) "You have to do what is best for yourself during this stressful time." - The nurse is not
using therapeutic communication. The nurse is agreeing with the client which implies
that the nurse is able to judge his behavior and give approval.
Nursing Process Step 3- Planning Question - Select a course of action
A nurse is planning to administer an IM medication. Which of the following actions
should the nurse plan to take?
