KAPLAN NGN CLINICAL JUDGMENT
TEST EXAM Complete Practice
Examination with Correct Answers &
Detailed Rationales | 2026/2027 Edition
Question 1:
A nurse is caring for a client who reports sudden, sharp chest pain that increases with
inspiration. The client is restless and has an SpO₂ of 89% on room air. Which action
should the nurse take first?
A) Administer oxygen at 2 L/min via nasal cannula
B) Position the client in high-Fowler's position
C) Assess lung sounds
D) Notify the provider immediately
Correct Answer: B) Position the client in high-Fowler's position
Rationale: The client is experiencing respiratory distress. High-Fowler's position
maximizes lung expansion and oxygenation. Positioning is a non-invasive, immediate
action that can improve breathing; while oxygen administration is necessary, it's not the
very first action. Airway and breathing are the priority .
Question 2:
A client with a history of seizures begins to have a generalized tonic-clonic seizure. What
is the nurse's priority action?
A) Restrain the client's limbs to prevent injury
B) Insert a padded tongue blade
C) Lower the client to the floor and protect the head
D) Administer IV lorazepam immediately
Correct Answer: C) Lower the client to the floor and protect the head
,Rationale: The priority during a seizure is to prevent injury. The nurse should ease the
client to the floor, clear the area, and protect the head. Never restrain a client or insert
anything into their mouth .
Question 3:
A nurse on a medical-surgical unit is assigned to four clients. Which client should the
nurse assess first?
A) Client with a scheduled wound dressing change
B) Client with new-onset chest pain radiating to the jaw
C) Client requesting discharge teaching
D) Client requesting pain medication
Correct Answer: B) Client with new-onset chest pain radiating to the jaw
Rationale: This is a classic sign of acute coronary syndrome (MI). This is life-threatening
and takes priority over stable, chronic issues. The nurse must use clinical judgment to
identify which clients are unstable and require immediate intervention .
Question 4:
A nurse is assessing a client 2 days post-operative following a total hip arthroplasty.
Which finding requires immediate intervention?
A) Pain score 4/10 with movement
B) Mild swelling of the operative leg
C) Shortness of breath and chest pain
D) Temperature 99.2°F (37.3°C)
Correct Answer: C) Shortness of breath and chest pain
Rationale: This suggests a pulmonary embolism (PE), a risk after hip surgery. The other
findings are expected post-op. A life-threatening event is always assessed first .
,Question 5:
A client fell out of bed 30 minutes ago and is now sleeping. What is the nurse's priority
action?
A) Document the incident
B) Assess the client immediately
C) Notify the provider
D) Complete an incident report
Correct Answer: B) Assess the client immediately
Rationale: Any change in level of consciousness after a fall requires immediate
assessment for potential head injury. Assessment always precedes documentation,
reporting, or completing incident reports .
Question 6:
Which patient should the nurse assess first?
A) A patient who fell out of bed 30 minutes ago and is now sleeping
B) A patient with a new leg amputation who is crying
C) A patient with a new tracheostomy with an SpO₂ of 88%
D) A patient needing pain medication
Correct Answer: C) A patient with a new tracheostomy with an SpO₂ of 88%
Rationale: The patient with a new tracheostomy and an SpO₂ of 88% has an immediate
airway and oxygenation concern. This is a life-threatening emergency that takes priority
over the other patients .
Question 7:
What is the priority framework for clinical decision-making in emergency situations?
A) Maslow's Hierarchy
B) Airway, Breathing, Circulation (ABCs)
C) Safety, Comfort, Rest
D) Acute before Chronic
, Correct Answer: B) Airway, Breathing, Circulation (ABCs)
Rationale: The ABC priority framework is the standard for emergency and clinical
decision-making. Airway is always first, followed by breathing, then circulation. Life-
threatening issues take precedence over other concerns .
Question 8:
What is the correct order of the clinical judgment steps?
A) Analyze cues → Recognize cues → Prioritize hypotheses → Generate solutions → Take
action → Evaluate outcomes
B) Recognize cues → Analyze cues → Prioritize hypotheses → Generate solutions → Take
action → Evaluate outcomes
C) Generate solutions → Recognize cues → Analyze cues → Prioritize hypotheses → Take
action → Evaluate outcomes
D) Prioritize hypotheses → Recognize cues → Analyze cues → Generate solutions → Take
action → Evaluate outcomes
Correct Answer: B) Recognize cues → Analyze cues → Prioritize hypotheses →
Generate solutions → Take action → Evaluate outcomes
Rationale: The NCSBN Clinical Judgment Measurement Model (NCJMM) organizes
thinking in this specific order to mirror how nurses process information. First, you notice
important data; then you interpret it, decide which problems are most pressing, plan
actions, perform them, and finally, check if your actions worked .
Question 9:
A nurse receives a report from the physical therapist that a patient refused morning
therapy and appears more confused than usual. What is the nurse's best action?
A) Thank the therapist and document the refusal without further assessment
B) Reassure the therapist that confusion is expected in elderly patients
C) Treat the therapist's observation as a significant clinical cue and assess the patient for
acute changes in mental status
D) Reschedule therapy for the afternoon
TEST EXAM Complete Practice
Examination with Correct Answers &
Detailed Rationales | 2026/2027 Edition
Question 1:
A nurse is caring for a client who reports sudden, sharp chest pain that increases with
inspiration. The client is restless and has an SpO₂ of 89% on room air. Which action
should the nurse take first?
A) Administer oxygen at 2 L/min via nasal cannula
B) Position the client in high-Fowler's position
C) Assess lung sounds
D) Notify the provider immediately
Correct Answer: B) Position the client in high-Fowler's position
Rationale: The client is experiencing respiratory distress. High-Fowler's position
maximizes lung expansion and oxygenation. Positioning is a non-invasive, immediate
action that can improve breathing; while oxygen administration is necessary, it's not the
very first action. Airway and breathing are the priority .
Question 2:
A client with a history of seizures begins to have a generalized tonic-clonic seizure. What
is the nurse's priority action?
A) Restrain the client's limbs to prevent injury
B) Insert a padded tongue blade
C) Lower the client to the floor and protect the head
D) Administer IV lorazepam immediately
Correct Answer: C) Lower the client to the floor and protect the head
,Rationale: The priority during a seizure is to prevent injury. The nurse should ease the
client to the floor, clear the area, and protect the head. Never restrain a client or insert
anything into their mouth .
Question 3:
A nurse on a medical-surgical unit is assigned to four clients. Which client should the
nurse assess first?
A) Client with a scheduled wound dressing change
B) Client with new-onset chest pain radiating to the jaw
C) Client requesting discharge teaching
D) Client requesting pain medication
Correct Answer: B) Client with new-onset chest pain radiating to the jaw
Rationale: This is a classic sign of acute coronary syndrome (MI). This is life-threatening
and takes priority over stable, chronic issues. The nurse must use clinical judgment to
identify which clients are unstable and require immediate intervention .
Question 4:
A nurse is assessing a client 2 days post-operative following a total hip arthroplasty.
Which finding requires immediate intervention?
A) Pain score 4/10 with movement
B) Mild swelling of the operative leg
C) Shortness of breath and chest pain
D) Temperature 99.2°F (37.3°C)
Correct Answer: C) Shortness of breath and chest pain
Rationale: This suggests a pulmonary embolism (PE), a risk after hip surgery. The other
findings are expected post-op. A life-threatening event is always assessed first .
,Question 5:
A client fell out of bed 30 minutes ago and is now sleeping. What is the nurse's priority
action?
A) Document the incident
B) Assess the client immediately
C) Notify the provider
D) Complete an incident report
Correct Answer: B) Assess the client immediately
Rationale: Any change in level of consciousness after a fall requires immediate
assessment for potential head injury. Assessment always precedes documentation,
reporting, or completing incident reports .
Question 6:
Which patient should the nurse assess first?
A) A patient who fell out of bed 30 minutes ago and is now sleeping
B) A patient with a new leg amputation who is crying
C) A patient with a new tracheostomy with an SpO₂ of 88%
D) A patient needing pain medication
Correct Answer: C) A patient with a new tracheostomy with an SpO₂ of 88%
Rationale: The patient with a new tracheostomy and an SpO₂ of 88% has an immediate
airway and oxygenation concern. This is a life-threatening emergency that takes priority
over the other patients .
Question 7:
What is the priority framework for clinical decision-making in emergency situations?
A) Maslow's Hierarchy
B) Airway, Breathing, Circulation (ABCs)
C) Safety, Comfort, Rest
D) Acute before Chronic
, Correct Answer: B) Airway, Breathing, Circulation (ABCs)
Rationale: The ABC priority framework is the standard for emergency and clinical
decision-making. Airway is always first, followed by breathing, then circulation. Life-
threatening issues take precedence over other concerns .
Question 8:
What is the correct order of the clinical judgment steps?
A) Analyze cues → Recognize cues → Prioritize hypotheses → Generate solutions → Take
action → Evaluate outcomes
B) Recognize cues → Analyze cues → Prioritize hypotheses → Generate solutions → Take
action → Evaluate outcomes
C) Generate solutions → Recognize cues → Analyze cues → Prioritize hypotheses → Take
action → Evaluate outcomes
D) Prioritize hypotheses → Recognize cues → Analyze cues → Generate solutions → Take
action → Evaluate outcomes
Correct Answer: B) Recognize cues → Analyze cues → Prioritize hypotheses →
Generate solutions → Take action → Evaluate outcomes
Rationale: The NCSBN Clinical Judgment Measurement Model (NCJMM) organizes
thinking in this specific order to mirror how nurses process information. First, you notice
important data; then you interpret it, decide which problems are most pressing, plan
actions, perform them, and finally, check if your actions worked .
Question 9:
A nurse receives a report from the physical therapist that a patient refused morning
therapy and appears more confused than usual. What is the nurse's best action?
A) Thank the therapist and document the refusal without further assessment
B) Reassure the therapist that confusion is expected in elderly patients
C) Treat the therapist's observation as a significant clinical cue and assess the patient for
acute changes in mental status
D) Reschedule therapy for the afternoon
