BSN Midterm Review: NCLEX-RN Clinical Judgment Model (2026
Update)
1. The nurse is caring for a client with shortness of breath. Which action
represents the ‘Recognizing Cues’ step of the Clinical Judgment Measurement
Model?
A. Noting that the client’s oxygen saturation is 88% on room air.
B. Administering 2 liters of oxygen via nasal cannula.
C. Determining that the client is experiencing impaired gas exchange.
D. Checking the client’s lung sounds 30 minutes after intervention.
Answer: A
Rationale: Recognizing cues involves identifying relevant information from different
sources (assessment). Noting the O2 saturation is data collection/cue recognition.
2. A nurse is assigned to four clients. Which client should be assessed first?
A. A client with a history of asthma who is requesting a PRN bronchodilator.
B. A client who underwent a total knee replacement and reports pain as 7/10.
C. A client with a suspected spinal cord injury who is experiencing sudden bradycardia and sweating.
D. A client with chronic obstructive pulmonary disease (COPD) with a stable O2 saturation of 91%.
Answer: C
Rationale: Sudden bradycardia and sweating in a spinal cord injury patient suggest
Autonomic Dysreflexia, a medical emergency requiring immediate intervention.
,3. Which task is most appropriate for the RN to delegate to an Unlicensed
Assistive Personnel (UAP)?
A. Feeding a client who has just returned from a swallow study for dysphagia.
B. Performing a sterile dressing change on a post-operative wound.
C. Assisting a stable client with ambulation for the second time today.
D. Teaching a client how to use an incentive spirometer.
Answer: C
Rationale: UAPs can assist stable clients with activities of daily living (ADLs) like
ambulation. Feeding a dysphagic client, sterile changes, and teaching require nursing
judgment.
4. The nurse is reviewing lab results for a client receiving Digoxin. Which value is
the priority to report to the provider?
A. Sodium level of 138 mEq/L.
B. Glucose level of 110 mg/dL.
C. Potassium level of 3.2 mEq/L.
D. Calcium level of 9.5 mg/dL.
Answer: C
Rationale: Hypokalemia (low potassium) significantly increases the risk of Digoxin
toxicity, even if the Digoxin level is within normal range.
5. In the ‘Prioritize Hypotheses’ phase of clinical judgment, what is the nurse
primarily doing?
A. Ranking the patient’s problems based on urgency and risk.
B. Implementing the nursing care plan.
C. Evaluating if the patient’s condition improved.
D. Clustering data to see patterns in symptoms.
Answer: A
, Rationale: Prioritizing hypotheses involves evaluating the urgency of various potential
issues and deciding which needs to be addressed first (e.g., using ABCs).
6. A client is admitted with Diabetic Ketoacidosis (DKA). Which clinical cue does
the nurse expect to find?
A. Bradycardia and hypertension.
B. Kussmaul’s respirations and fruity breath.
C. Shallow, slow respirations.
D. Increased urine specific gravity.
Answer: B
Rationale: DKA typically manifests with Kussmaul’s respirations (rapid/deep) to
compensate for acidosis and a fruity odor from ketone production.
7. A client is scheduled for a surgical procedure. The nurse notices the informed
consent has not been signed. What is the nurse’s primary responsibility?
A. Explain the risks and benefits of the surgery to the client.
B. Witness the client’s signature and ensure they understand the procedure.
C. Obtain the signature and file it in the chart immediately.
D. Notify the surgeon that the consent has not been signed.
Answer: D
Rationale: The surgeon is responsible for explaining the procedure. The nurse’s role is to
witness the signature and verify that the patient has been informed; if not, the surgeon
must be notified.
Update)
1. The nurse is caring for a client with shortness of breath. Which action
represents the ‘Recognizing Cues’ step of the Clinical Judgment Measurement
Model?
A. Noting that the client’s oxygen saturation is 88% on room air.
B. Administering 2 liters of oxygen via nasal cannula.
C. Determining that the client is experiencing impaired gas exchange.
D. Checking the client’s lung sounds 30 minutes after intervention.
Answer: A
Rationale: Recognizing cues involves identifying relevant information from different
sources (assessment). Noting the O2 saturation is data collection/cue recognition.
2. A nurse is assigned to four clients. Which client should be assessed first?
A. A client with a history of asthma who is requesting a PRN bronchodilator.
B. A client who underwent a total knee replacement and reports pain as 7/10.
C. A client with a suspected spinal cord injury who is experiencing sudden bradycardia and sweating.
D. A client with chronic obstructive pulmonary disease (COPD) with a stable O2 saturation of 91%.
Answer: C
Rationale: Sudden bradycardia and sweating in a spinal cord injury patient suggest
Autonomic Dysreflexia, a medical emergency requiring immediate intervention.
,3. Which task is most appropriate for the RN to delegate to an Unlicensed
Assistive Personnel (UAP)?
A. Feeding a client who has just returned from a swallow study for dysphagia.
B. Performing a sterile dressing change on a post-operative wound.
C. Assisting a stable client with ambulation for the second time today.
D. Teaching a client how to use an incentive spirometer.
Answer: C
Rationale: UAPs can assist stable clients with activities of daily living (ADLs) like
ambulation. Feeding a dysphagic client, sterile changes, and teaching require nursing
judgment.
4. The nurse is reviewing lab results for a client receiving Digoxin. Which value is
the priority to report to the provider?
A. Sodium level of 138 mEq/L.
B. Glucose level of 110 mg/dL.
C. Potassium level of 3.2 mEq/L.
D. Calcium level of 9.5 mg/dL.
Answer: C
Rationale: Hypokalemia (low potassium) significantly increases the risk of Digoxin
toxicity, even if the Digoxin level is within normal range.
5. In the ‘Prioritize Hypotheses’ phase of clinical judgment, what is the nurse
primarily doing?
A. Ranking the patient’s problems based on urgency and risk.
B. Implementing the nursing care plan.
C. Evaluating if the patient’s condition improved.
D. Clustering data to see patterns in symptoms.
Answer: A
, Rationale: Prioritizing hypotheses involves evaluating the urgency of various potential
issues and deciding which needs to be addressed first (e.g., using ABCs).
6. A client is admitted with Diabetic Ketoacidosis (DKA). Which clinical cue does
the nurse expect to find?
A. Bradycardia and hypertension.
B. Kussmaul’s respirations and fruity breath.
C. Shallow, slow respirations.
D. Increased urine specific gravity.
Answer: B
Rationale: DKA typically manifests with Kussmaul’s respirations (rapid/deep) to
compensate for acidosis and a fruity odor from ketone production.
7. A client is scheduled for a surgical procedure. The nurse notices the informed
consent has not been signed. What is the nurse’s primary responsibility?
A. Explain the risks and benefits of the surgery to the client.
B. Witness the client’s signature and ensure they understand the procedure.
C. Obtain the signature and file it in the chart immediately.
D. Notify the surgeon that the consent has not been signed.
Answer: D
Rationale: The surgeon is responsible for explaining the procedure. The nurse’s role is to
witness the signature and verify that the patient has been informed; if not, the surgeon
must be notified.
