NURS 316 CLINICAL JUDGMENT EXAM NCLEX-STYLE CASES QUESTIONS AND CORRECT
ANSWERS (VERIFIED ANSWERS) PLUS RATIONALES 2026 Q&A | LATEST EXAM UPDATE
2026/2027
Section One: Questions 1–100
A nurse is caring for a client who is 24 hours postoperative following an abdominal hysterectomy.
The client reports severe abdominal pain and a feeling of abdominal fullness. On assessment, the
nurse notes abdominal distension and absent bowel sounds. Which of the following actions should
the nurse take first?
A. Administer a prescribed opioid analgesic.
B. Encourage the client to ambulate in the hallway.
C. Insert a nasogastric tube to low intermittent suction.
D. Notify the primary care provider of the findings.
🟢 Correct answer: D. Notify the primary care provider of the findings.
🔴 RATIONALE: The client is exhibiting manifestations of a paralytic ileus, a potential complication
following abdominal surgery. The priority action using the nursing process is to notify the provider
immediately so that appropriate interventions, such as making the client NPO or ordering
decompression, can be initiated.
A nurse is reviewing the laboratory results of a client who is receiving a continuous intravenous
heparin infusion for a deep vein thrombosis. The client's activated partial thromboplastin time
(aPTT) is 95 seconds. The control value is 30 seconds. Which of the following actions should the
nurse anticipate taking?
A. Increase the heparin infusion rate.
B. Decrease or hold the heparin infusion.
C. Administer vitamin K intramuscularly.
D. Continue the infusion at the current rate.
🟢 Correct answer: B. Decrease or hold the heparin infusion.
,🔴 RATIONALE: The therapeutic range for aPTT during heparin therapy is typically 1.5 to 2.5
times the control value. With a control value of 30 seconds, the therapeutic range is 45 to 75
seconds. An aPTT of 95 seconds is critically elevated, placing the client at high risk for bleeding,
requiring the infusion to be held or decreased per facility protocol.
A nurse in the emergency department is assessing an older adult client who was brought in by a
family member. The nurse notes multiple bruises in various stages of healing on the client's back
and upper arms, and the client appears unkempt and withdrawn. Which of the following actions is
the nurse's legal and ethical obligation?
A. Confront the family member about the suspected abuse.
B. Document the findings and reassess the client at the next visit.
C. Report the suspected elder abuse to the appropriate state agency.
D. Discuss the findings with the charge nurse to determine if a report is needed.
🟢 Correct answer: C. Report the suspected elder abuse to the appropriate state agency.
🔴 RATIONALE: Nurses are mandated reporters for suspected abuse or neglect of vulnerable
populations, including older adults. Legally and ethically, the nurse must report suspected abuse
directly to the designated protective or state regulatory agency according to local statutes.
A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the
following electrolyte imbalances should the nurse monitor for closely?
A. Hypokalemia
B. Hyperkalemia
C. Hypocalcemia
D. Hypernatremia
🟢 Correct answer: B. Hyperkalemia
🔴 RATIONALE: During the oliguric phase of acute kidney injury, the kidneys are unable to
,adequately excrete potassium, leading to potassium retention and hyperkalemia. Hyperkalemia is a
life-threatening complication due to its potential to cause severe cardiac dysrhythmias.
A nurse enters a client's room and finds the client lying on the floor. After assessing the client and
verifying that the client is stable and uninjured, the nurse assists the client back to bed. Which of
the following documentation actions should the nurse perform next?
A. Complete an incident report and document in the medical record that an incident report was
filed.
B. Document the facts of the event in the client's medical record and complete an internal incident
report.
C. Record in the medical record that the client fell due to slippery floors and staff negligence.
D. Fill out an incident report only, omitting any entry in the progress notes to avoid legal discovery.
🟢 Correct answer: B. Document the facts of the event in the client's medical record and complete
an internal incident report.
🔴 RATIONALE: The nurse must objectively document the facts of the event (e.g., finding the
client on the floor, assessments, vital signs, interventions, notification of provider) in the client's
permanent medical record. An incident or variance report is an internal quality improvement tool
and should not be referenced in the medical record to preserve its privileged status.
A nurse is assessing a client who has a chest tube connected to a water-seal drainage system.
The nurse notes continuous bubbling in the water-seal chamber. How should the nurse interpret
this finding?
A. The system is functioning normally.
B. There is an air leak in the system or the client's thoracic cavity.
C. The suction pressure applied to the system is too high.
D. The client's lung has fully re-expanded.
🟢 Correct answer: B. There is an air leak in the system or the client's thoracic cavity.
, 🔴 RATIONALE: Continuous bubbling in the water-seal chamber indicates a constant entry of air
into the system, which signifies an air leak. Intermittent bubbling is normal during exhalation,
coughing, or sneezing, but continuous bubbling requires immediate troubleshooting to locate the
leak.
A nurse is preparing to administer an intramuscular injection to an adult client. Which of the
following sites is the safest and preferred choice for deep intramuscular injections to avoid major
blood vessels and nerves?
A. Dorsogluteal
B. Ventrogluteal
C. Deltoid
D. Vastus lateralis
🟢 Correct answer: B. Ventrogluteal
🔴 RATIONALE: The ventrogluteal site is the preferred and safest site for deep intramuscular
injections in adults because it lacks major nerves and blood vessels, has a thick muscle mass, and
is sealed off by bone structures, minimizing the risk of tissue injury.
A nurse is caring for a client who is experiencing a severe panic attack. Which of the following
interventions should the nurse implement first?
A. Administer a prescribed oral antianxiety medication.
B. Teach the client deep-breathing and relaxation exercises.
C. Stay with the client and speak using short, simple sentences.
D. Ask the client to explain what triggered the panic attack.
🟢 Correct answer: C. Stay with the client and speak using short, simple sentences.
🔴 RATIONALE: During a severe panic attack, the client's anxiety level impairs their ability to
process complex information. The priority intervention is to ensure safety and reduce anxiety by
ANSWERS (VERIFIED ANSWERS) PLUS RATIONALES 2026 Q&A | LATEST EXAM UPDATE
2026/2027
Section One: Questions 1–100
A nurse is caring for a client who is 24 hours postoperative following an abdominal hysterectomy.
The client reports severe abdominal pain and a feeling of abdominal fullness. On assessment, the
nurse notes abdominal distension and absent bowel sounds. Which of the following actions should
the nurse take first?
A. Administer a prescribed opioid analgesic.
B. Encourage the client to ambulate in the hallway.
C. Insert a nasogastric tube to low intermittent suction.
D. Notify the primary care provider of the findings.
🟢 Correct answer: D. Notify the primary care provider of the findings.
🔴 RATIONALE: The client is exhibiting manifestations of a paralytic ileus, a potential complication
following abdominal surgery. The priority action using the nursing process is to notify the provider
immediately so that appropriate interventions, such as making the client NPO or ordering
decompression, can be initiated.
A nurse is reviewing the laboratory results of a client who is receiving a continuous intravenous
heparin infusion for a deep vein thrombosis. The client's activated partial thromboplastin time
(aPTT) is 95 seconds. The control value is 30 seconds. Which of the following actions should the
nurse anticipate taking?
A. Increase the heparin infusion rate.
B. Decrease or hold the heparin infusion.
C. Administer vitamin K intramuscularly.
D. Continue the infusion at the current rate.
🟢 Correct answer: B. Decrease or hold the heparin infusion.
,🔴 RATIONALE: The therapeutic range for aPTT during heparin therapy is typically 1.5 to 2.5
times the control value. With a control value of 30 seconds, the therapeutic range is 45 to 75
seconds. An aPTT of 95 seconds is critically elevated, placing the client at high risk for bleeding,
requiring the infusion to be held or decreased per facility protocol.
A nurse in the emergency department is assessing an older adult client who was brought in by a
family member. The nurse notes multiple bruises in various stages of healing on the client's back
and upper arms, and the client appears unkempt and withdrawn. Which of the following actions is
the nurse's legal and ethical obligation?
A. Confront the family member about the suspected abuse.
B. Document the findings and reassess the client at the next visit.
C. Report the suspected elder abuse to the appropriate state agency.
D. Discuss the findings with the charge nurse to determine if a report is needed.
🟢 Correct answer: C. Report the suspected elder abuse to the appropriate state agency.
🔴 RATIONALE: Nurses are mandated reporters for suspected abuse or neglect of vulnerable
populations, including older adults. Legally and ethically, the nurse must report suspected abuse
directly to the designated protective or state regulatory agency according to local statutes.
A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of the
following electrolyte imbalances should the nurse monitor for closely?
A. Hypokalemia
B. Hyperkalemia
C. Hypocalcemia
D. Hypernatremia
🟢 Correct answer: B. Hyperkalemia
🔴 RATIONALE: During the oliguric phase of acute kidney injury, the kidneys are unable to
,adequately excrete potassium, leading to potassium retention and hyperkalemia. Hyperkalemia is a
life-threatening complication due to its potential to cause severe cardiac dysrhythmias.
A nurse enters a client's room and finds the client lying on the floor. After assessing the client and
verifying that the client is stable and uninjured, the nurse assists the client back to bed. Which of
the following documentation actions should the nurse perform next?
A. Complete an incident report and document in the medical record that an incident report was
filed.
B. Document the facts of the event in the client's medical record and complete an internal incident
report.
C. Record in the medical record that the client fell due to slippery floors and staff negligence.
D. Fill out an incident report only, omitting any entry in the progress notes to avoid legal discovery.
🟢 Correct answer: B. Document the facts of the event in the client's medical record and complete
an internal incident report.
🔴 RATIONALE: The nurse must objectively document the facts of the event (e.g., finding the
client on the floor, assessments, vital signs, interventions, notification of provider) in the client's
permanent medical record. An incident or variance report is an internal quality improvement tool
and should not be referenced in the medical record to preserve its privileged status.
A nurse is assessing a client who has a chest tube connected to a water-seal drainage system.
The nurse notes continuous bubbling in the water-seal chamber. How should the nurse interpret
this finding?
A. The system is functioning normally.
B. There is an air leak in the system or the client's thoracic cavity.
C. The suction pressure applied to the system is too high.
D. The client's lung has fully re-expanded.
🟢 Correct answer: B. There is an air leak in the system or the client's thoracic cavity.
, 🔴 RATIONALE: Continuous bubbling in the water-seal chamber indicates a constant entry of air
into the system, which signifies an air leak. Intermittent bubbling is normal during exhalation,
coughing, or sneezing, but continuous bubbling requires immediate troubleshooting to locate the
leak.
A nurse is preparing to administer an intramuscular injection to an adult client. Which of the
following sites is the safest and preferred choice for deep intramuscular injections to avoid major
blood vessels and nerves?
A. Dorsogluteal
B. Ventrogluteal
C. Deltoid
D. Vastus lateralis
🟢 Correct answer: B. Ventrogluteal
🔴 RATIONALE: The ventrogluteal site is the preferred and safest site for deep intramuscular
injections in adults because it lacks major nerves and blood vessels, has a thick muscle mass, and
is sealed off by bone structures, minimizing the risk of tissue injury.
A nurse is caring for a client who is experiencing a severe panic attack. Which of the following
interventions should the nurse implement first?
A. Administer a prescribed oral antianxiety medication.
B. Teach the client deep-breathing and relaxation exercises.
C. Stay with the client and speak using short, simple sentences.
D. Ask the client to explain what triggered the panic attack.
🟢 Correct answer: C. Stay with the client and speak using short, simple sentences.
🔴 RATIONALE: During a severe panic attack, the client's anxiety level impairs their ability to
process complex information. The priority intervention is to ensure safety and reduce anxiety by
