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 a total hip arthroplasty. Which
of the following actions should the nurse take to prevent deep vein thrombosis?
A. Place a pillow under the client's knees.
B. Restrict fluid intake to 1,000 mL per day.
🟢 C. Administer prescribed prophylactic low-molecular-weight heparin.
D. Maintain the client on strict bed rest for 72 hours.
🔴 RATIONALE: Prophylactic anticoagulants such as low-molecular-weight heparin are standard
interventions to prevent deep vein thrombosis in high-risk postoperative orthopedic clients.
A nurse encounters a client's family member who is visibly angry and shouting about the quality of
care the client is receiving. Which of the following responses should the nurse make first?
🟢 A. "I can see that you are upset. Let's move to a private area to discuss your concerns."
B. "You need to stop shouting immediately or I will have to call security."
C. "I assure you that our staff is providing the best possible care for your family member."
D. "Why do you think the care provided has been inadequate?"
🔴 RATIONALE: De-escalation starts with acknowledging the person's feelings and moving to a
private space to protect confidentiality and reduce environmental stimuli.
A nurse is reviewing the laboratory results of a client who is receiving lithium carbonate for bipolar
disorder. The client's lithium level is 1.8 mEq/L. Which of the following actions should the nurse
take?
A. Administer the next scheduled dose of lithium carbonate.
B. Increase the client's daily fluid restriction.
,C. Report the level as within the expected therapeutic range.
🟢 D. Hold the medication and notify the provider immediately.
🔴 RATIONALE: A lithium level of 1.8 mEq/L indicates lithium toxicity (expected therapeutic range
is 0.6 to 1.2 mEq/L). The medication must be held to prevent worsening toxicity.
A nurse is caring for 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. An air leak is present in the system.
B. The system is functioning normally.
C. The client's lung has fully re-expanded.
D. The suction pressure needs to be increased.
🔴 RATIONALE: Continuous bubbling in the water-seal chamber indicates an air leak in the
drainage system or from the client's thoracic cavity, requiring immediate assessment.
A nurse is assigned to care for a group of clients. Which of the following clients should the nurse
assess first?
A. A client with diabetes mellitus whose morning blood glucose is 140 mg/dL.
🟢 B. A client with a fractures femur who reports sudden chest pain and shortness of breath.
C. A client who is 2 days postoperative and reports a pain level of 6 on a scale of 0 to 10.
D. A client with chronic obstructive pulmonary disease who has an oxygen saturation of 91%.
🔴 RATIONALE: Sudden chest pain and dyspnea in a client with a fractured long bone are classic
signs of a pulmonary embolism, which is a life-threatening emergency requiring immediate
intervention.
A nurse is preparing to administer an intramuscular injection to an infant. Which of the following
sites should the nurse select?
,A. Deltoid muscle
B. Dorsogluteal muscle
🟢 C. Ventrogluteal muscle
D. Vastus lateralis muscle
🔴 RATIONALE: The vastus lateralis muscle is the preferred and safest site for intramuscular
injections in infants because it is the most developed muscle mass at this stage of growth.
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 expect?
A. Hypokalemia
🟢 B. Hyperkalemia
C. Hypercalcemia
D. Hyponatremia
🔴 RATIONALE: In the oliguric phase of acute kidney injury, the kidneys cannot adequately
excrete potassium, leading to a high risk of life-threatening hyperkalemia.
A nurse is reinforcing teaching with a client who has a new prescription for sublingual nitroglycerin
tablets for angina pectoris. Which of the following instructions should the nurse include?
A. Swallow the tablet with a full glass of water.
🟢 B. Place one tablet under the tongue at the onset of chest pain.
C. Take up to five tablets 10 minutes apart if pain persists.
D. Discard unused tablets 12 months after opening the bottle.
🔴 RATIONALE: Sublingual nitroglycerin must dissolve under the tongue for rapid absorption at
the onset of chest pain. A maximum of three doses, 5 minutes apart, can be taken before seeking
emergency care.
, A nurse is assessing a client who has graves' disease. Which of the following clinical
manifestations should the nurse expect?
🟢 A. Weight loss despite an increased appetite.
B. Bradycardia and cold intolerance.
C. Lethargy and dry, coarse skin.
D. Periorbital edema and weight gain.
🔴 RATIONALE: Graves' disease causes hyperthyroidism, which accelerates metabolism, leading
to weight loss, tachycardia, heat intolerance, and an increased appetite.
A nurse is participating in an interprofessional care conference for a client who had a stroke and
has residual dysphagia. Which of the following providers should the nurse consult first?
A. Physical therapist
B. Occupational therapist
🟢 C. Speech-language pathologist
D. Registered dietitian
🔴 RATIONALE: A speech-language pathologist specializes in assessing and managing
swallowing disorders (dysphagia) to prevent aspiration pneumonia.
A nurse is preparing to perform tracheostomy care for a client. Which of the following actions
should the nurse plan to take?
A. Clean the inner cannula with full-strength hydrogen peroxide.
🟢 B. Use sterile technique when cleaning and suctioning the tracheostomy.
C. Cut a gauze pad to place under the tracheostomy ties.
D. Secure the new ties before removing the old ones.
🔴 RATIONALE: Sterile technique must be maintained during tracheostomy care to prevent
introducing pathogens directly into the lower respiratory tract.
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 a total hip arthroplasty. Which
of the following actions should the nurse take to prevent deep vein thrombosis?
A. Place a pillow under the client's knees.
B. Restrict fluid intake to 1,000 mL per day.
🟢 C. Administer prescribed prophylactic low-molecular-weight heparin.
D. Maintain the client on strict bed rest for 72 hours.
🔴 RATIONALE: Prophylactic anticoagulants such as low-molecular-weight heparin are standard
interventions to prevent deep vein thrombosis in high-risk postoperative orthopedic clients.
A nurse encounters a client's family member who is visibly angry and shouting about the quality of
care the client is receiving. Which of the following responses should the nurse make first?
🟢 A. "I can see that you are upset. Let's move to a private area to discuss your concerns."
B. "You need to stop shouting immediately or I will have to call security."
C. "I assure you that our staff is providing the best possible care for your family member."
D. "Why do you think the care provided has been inadequate?"
🔴 RATIONALE: De-escalation starts with acknowledging the person's feelings and moving to a
private space to protect confidentiality and reduce environmental stimuli.
A nurse is reviewing the laboratory results of a client who is receiving lithium carbonate for bipolar
disorder. The client's lithium level is 1.8 mEq/L. Which of the following actions should the nurse
take?
A. Administer the next scheduled dose of lithium carbonate.
B. Increase the client's daily fluid restriction.
,C. Report the level as within the expected therapeutic range.
🟢 D. Hold the medication and notify the provider immediately.
🔴 RATIONALE: A lithium level of 1.8 mEq/L indicates lithium toxicity (expected therapeutic range
is 0.6 to 1.2 mEq/L). The medication must be held to prevent worsening toxicity.
A nurse is caring for 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. An air leak is present in the system.
B. The system is functioning normally.
C. The client's lung has fully re-expanded.
D. The suction pressure needs to be increased.
🔴 RATIONALE: Continuous bubbling in the water-seal chamber indicates an air leak in the
drainage system or from the client's thoracic cavity, requiring immediate assessment.
A nurse is assigned to care for a group of clients. Which of the following clients should the nurse
assess first?
A. A client with diabetes mellitus whose morning blood glucose is 140 mg/dL.
🟢 B. A client with a fractures femur who reports sudden chest pain and shortness of breath.
C. A client who is 2 days postoperative and reports a pain level of 6 on a scale of 0 to 10.
D. A client with chronic obstructive pulmonary disease who has an oxygen saturation of 91%.
🔴 RATIONALE: Sudden chest pain and dyspnea in a client with a fractured long bone are classic
signs of a pulmonary embolism, which is a life-threatening emergency requiring immediate
intervention.
A nurse is preparing to administer an intramuscular injection to an infant. Which of the following
sites should the nurse select?
,A. Deltoid muscle
B. Dorsogluteal muscle
🟢 C. Ventrogluteal muscle
D. Vastus lateralis muscle
🔴 RATIONALE: The vastus lateralis muscle is the preferred and safest site for intramuscular
injections in infants because it is the most developed muscle mass at this stage of growth.
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 expect?
A. Hypokalemia
🟢 B. Hyperkalemia
C. Hypercalcemia
D. Hyponatremia
🔴 RATIONALE: In the oliguric phase of acute kidney injury, the kidneys cannot adequately
excrete potassium, leading to a high risk of life-threatening hyperkalemia.
A nurse is reinforcing teaching with a client who has a new prescription for sublingual nitroglycerin
tablets for angina pectoris. Which of the following instructions should the nurse include?
A. Swallow the tablet with a full glass of water.
🟢 B. Place one tablet under the tongue at the onset of chest pain.
C. Take up to five tablets 10 minutes apart if pain persists.
D. Discard unused tablets 12 months after opening the bottle.
🔴 RATIONALE: Sublingual nitroglycerin must dissolve under the tongue for rapid absorption at
the onset of chest pain. A maximum of three doses, 5 minutes apart, can be taken before seeking
emergency care.
, A nurse is assessing a client who has graves' disease. Which of the following clinical
manifestations should the nurse expect?
🟢 A. Weight loss despite an increased appetite.
B. Bradycardia and cold intolerance.
C. Lethargy and dry, coarse skin.
D. Periorbital edema and weight gain.
🔴 RATIONALE: Graves' disease causes hyperthyroidism, which accelerates metabolism, leading
to weight loss, tachycardia, heat intolerance, and an increased appetite.
A nurse is participating in an interprofessional care conference for a client who had a stroke and
has residual dysphagia. Which of the following providers should the nurse consult first?
A. Physical therapist
B. Occupational therapist
🟢 C. Speech-language pathologist
D. Registered dietitian
🔴 RATIONALE: A speech-language pathologist specializes in assessing and managing
swallowing disorders (dysphagia) to prevent aspiration pneumonia.
A nurse is preparing to perform tracheostomy care for a client. Which of the following actions
should the nurse plan to take?
A. Clean the inner cannula with full-strength hydrogen peroxide.
🟢 B. Use sterile technique when cleaning and suctioning the tracheostomy.
C. Cut a gauze pad to place under the tracheostomy ties.
D. Secure the new ties before removing the old ones.
🔴 RATIONALE: Sterile technique must be maintained during tracheostomy care to prevent
introducing pathogens directly into the lower respiratory tract.
