COMPREHENSIVE NCLEX-PN REVIEW MODULE 8
EXAMINATION | CLINICAL JUDGMENT (NGN), TEST-
TAKING STRATEGIES & COMPREHENSIVE PRACTICE
| 150 NCLEX-PN PRACTICE QUESTIONS & ANSWERS
| INTERMEDIATE TO ADVANCED STUDY GUIDE
SECTION A: CLINICAL JUDGMENT AND NURSING PROCESS
Questions 1-30
1. A nurse is caring for a client with pneumonia who reports increasing shortness of
breath and chest pain. Which of the following actions represents the first step of the
nursing process?
A. Administer prescribed oxygen
B. Auscultate lung sounds
C. Notify the healthcare provider
D. Elevate the head of the bed
,Answer: B. Auscultate lung sounds
Rationale: The nursing process begins with assessment. Before implementing any
interventions, the nurse must collect data through physical assessment, including
auscultating lung sounds to establish baseline data.
2. A practical nurse is evaluating a client's response to pain medication administered
30 minutes ago. This action represents which phase of the nursing process?
A. Assessment
B. Diagnosis
C. Planning
D. Evaluation
Answer: D. Evaluation
Rationale: Evaluation is the final step of the nursing process where the nurse determines if
the client's goals and outcomes have been met following interventions.
3. A client with heart failure has an order for furosemide 40mg IV push. Which nursing
action demonstrates appropriate clinical judgment before administration?
A. Administer the medication immediately
B. Check the client's potassium level and vital signs
C. Ask the client if they have taken this medication before
D. Verify the medication with another nurse
Answer: B. Check the client's potassium level and vital signs
Rationale: Furosemide is a loop diuretic that can cause hypokalemia and hypotension. The
nurse must assess potassium levels and blood pressure before administration to ensure
safe administration.
4. A nurse notices that a client's surgical incision is red, swollen, and warm to touch.
Which nursing diagnosis is most appropriate?
A. Impaired Skin Integrity
B. Risk for Infection
,C. Impaired Tissue Integrity
D. Risk for Impaired Skin Integrity
Answer: C. Impaired Tissue Integrity
Rationale: The client is exhibiting signs of infection (redness, swelling, warmth) at the
surgical site, indicating actual tissue damage rather than risk.
5. A client with diabetes mellitus is experiencing hypoglycemia. The nurse administers
15g of fast-acting carbohydrate. Which action demonstrates appropriate clinical
judgment in reassessment?
A. Reassess blood glucose in 15 minutes
B. Reassess blood glucose in 30 minutes
C. Reassess blood glucose in 60 minutes
D. Reassess blood glucose immediately
Answer: A. Reassess blood glucose in 15 minutes
Rationale: The standard treatment for hypoglycemia is the 15-15 rule: administer 15g of
fast-acting carbohydrate and reassess in 15 minutes.
6. A practical nurse is prioritizing care for four clients. Which client should the nurse
assess first?
A. Client with pneumonia with a temperature of 101.2°F
B. Client with chest tube with continuous bubbling in water seal chamber
C. Client with diabetes mellitus with blood glucose of 180mg/dL
D. Client with pressure injury requiring dressing change
Answer: B. Client with chest tube with continuous bubbling in water seal chamber
Rationale: Continuous bubbling in the water seal chamber indicates an air leak, which is a
potential emergency requiring immediate intervention.
7. A client with chronic obstructive pulmonary disease (COPD) has an oxygen
saturation of 88%. Which action should the nurse take first?
A. Administer oxygen at 2L/min via nasal cannula
B. Encourage the client to cough and deep breathe
, C. Notify the healthcare provider
D. Position the client in high Fowler's position
Answer: D. Position the client in high Fowler's position
Rationale: Positioning the client in high Fowler's position promotes lung expansion and
improves oxygenation. This is the first action the nurse should take.
8. A nurse is developing a care plan for a client with impaired mobility. Which short-
term goal is appropriate?
A. Client will maintain joint mobility
B. Client will walk to the bathroom independently by discharge
C. Client will perform range of motion exercises three times daily
D. Client will prevent complications of immobility
Answer: C. Client will perform range of motion exercises three times daily
Rationale: This is a specific, measurable, achievable, realistic, and time-bound (SMART)
goal that can be evaluated.
9. A client with hypertension reports a headache and blurred vision. The nurse obtains
a blood pressure reading of 190/110 mmHg. Which action demonstrates appropriate
clinical judgment?
A. Reassess blood pressure in 15 minutes
B. Administer prescribed antihypertensive medication
C. Notify the healthcare provider immediately
D. Place the client in a dark, quiet room
Answer: C. Notify the healthcare provider immediately
Rationale: This blood pressure reading indicates a hypertensive emergency requiring
immediate medical intervention.
10. A nurse is providing education to a client with newly diagnosed type 2 diabetes.
Which statement indicates the need for further teaching?
A. "I should check my blood glucose before meals"
B. "I can stop my medication when my blood glucose is normal"
EXAMINATION | CLINICAL JUDGMENT (NGN), TEST-
TAKING STRATEGIES & COMPREHENSIVE PRACTICE
| 150 NCLEX-PN PRACTICE QUESTIONS & ANSWERS
| INTERMEDIATE TO ADVANCED STUDY GUIDE
SECTION A: CLINICAL JUDGMENT AND NURSING PROCESS
Questions 1-30
1. A nurse is caring for a client with pneumonia who reports increasing shortness of
breath and chest pain. Which of the following actions represents the first step of the
nursing process?
A. Administer prescribed oxygen
B. Auscultate lung sounds
C. Notify the healthcare provider
D. Elevate the head of the bed
,Answer: B. Auscultate lung sounds
Rationale: The nursing process begins with assessment. Before implementing any
interventions, the nurse must collect data through physical assessment, including
auscultating lung sounds to establish baseline data.
2. A practical nurse is evaluating a client's response to pain medication administered
30 minutes ago. This action represents which phase of the nursing process?
A. Assessment
B. Diagnosis
C. Planning
D. Evaluation
Answer: D. Evaluation
Rationale: Evaluation is the final step of the nursing process where the nurse determines if
the client's goals and outcomes have been met following interventions.
3. A client with heart failure has an order for furosemide 40mg IV push. Which nursing
action demonstrates appropriate clinical judgment before administration?
A. Administer the medication immediately
B. Check the client's potassium level and vital signs
C. Ask the client if they have taken this medication before
D. Verify the medication with another nurse
Answer: B. Check the client's potassium level and vital signs
Rationale: Furosemide is a loop diuretic that can cause hypokalemia and hypotension. The
nurse must assess potassium levels and blood pressure before administration to ensure
safe administration.
4. A nurse notices that a client's surgical incision is red, swollen, and warm to touch.
Which nursing diagnosis is most appropriate?
A. Impaired Skin Integrity
B. Risk for Infection
,C. Impaired Tissue Integrity
D. Risk for Impaired Skin Integrity
Answer: C. Impaired Tissue Integrity
Rationale: The client is exhibiting signs of infection (redness, swelling, warmth) at the
surgical site, indicating actual tissue damage rather than risk.
5. A client with diabetes mellitus is experiencing hypoglycemia. The nurse administers
15g of fast-acting carbohydrate. Which action demonstrates appropriate clinical
judgment in reassessment?
A. Reassess blood glucose in 15 minutes
B. Reassess blood glucose in 30 minutes
C. Reassess blood glucose in 60 minutes
D. Reassess blood glucose immediately
Answer: A. Reassess blood glucose in 15 minutes
Rationale: The standard treatment for hypoglycemia is the 15-15 rule: administer 15g of
fast-acting carbohydrate and reassess in 15 minutes.
6. A practical nurse is prioritizing care for four clients. Which client should the nurse
assess first?
A. Client with pneumonia with a temperature of 101.2°F
B. Client with chest tube with continuous bubbling in water seal chamber
C. Client with diabetes mellitus with blood glucose of 180mg/dL
D. Client with pressure injury requiring dressing change
Answer: B. Client with chest tube with continuous bubbling in water seal chamber
Rationale: Continuous bubbling in the water seal chamber indicates an air leak, which is a
potential emergency requiring immediate intervention.
7. A client with chronic obstructive pulmonary disease (COPD) has an oxygen
saturation of 88%. Which action should the nurse take first?
A. Administer oxygen at 2L/min via nasal cannula
B. Encourage the client to cough and deep breathe
, C. Notify the healthcare provider
D. Position the client in high Fowler's position
Answer: D. Position the client in high Fowler's position
Rationale: Positioning the client in high Fowler's position promotes lung expansion and
improves oxygenation. This is the first action the nurse should take.
8. A nurse is developing a care plan for a client with impaired mobility. Which short-
term goal is appropriate?
A. Client will maintain joint mobility
B. Client will walk to the bathroom independently by discharge
C. Client will perform range of motion exercises three times daily
D. Client will prevent complications of immobility
Answer: C. Client will perform range of motion exercises three times daily
Rationale: This is a specific, measurable, achievable, realistic, and time-bound (SMART)
goal that can be evaluated.
9. A client with hypertension reports a headache and blurred vision. The nurse obtains
a blood pressure reading of 190/110 mmHg. Which action demonstrates appropriate
clinical judgment?
A. Reassess blood pressure in 15 minutes
B. Administer prescribed antihypertensive medication
C. Notify the healthcare provider immediately
D. Place the client in a dark, quiet room
Answer: C. Notify the healthcare provider immediately
Rationale: This blood pressure reading indicates a hypertensive emergency requiring
immediate medical intervention.
10. A nurse is providing education to a client with newly diagnosed type 2 diabetes.
Which statement indicates the need for further teaching?
A. "I should check my blood glucose before meals"
B. "I can stop my medication when my blood glucose is normal"
