NCLEX RN Clinical Judgment Exam 2
Questions And Correct Answers (Verified
Answers) Plus Rationales 2026 Q&A |
Instant Download Pdf
SECTION 1: Management of Care (Questions 1-15)
1. A nurse is caring for a client who has a new prescription for mechanical
restraints. Which of the following actions should the nurse take?
A) Obtain a written prescription from the provider within 24 hours of applying
restraints
B) Document the client's behavior every 4 hours while in restraints
C) Remove restraints at least every 2 hours to assess circulation and provide range
of motion
D) Apply restraints to all four extremities for safety
Correct Answer: C
Rationale: Restraints must be removed at least every 2 hours to allow for
assessment of circulation, skin integrity, and to provide range of motion exercises. A
written prescription must be obtained within 1 hour (not 24 hours) of applying
restraints. Documentation should occur every 15-30 minutes, not every 4 hours.
Restraints should only be applied to the minimum number of extremities necessary,
never all four unless specifically ordered.
2. A charge nurse is making client assignments for the upcoming shift. Which client
should the charge nurse assign to the most experienced nurse?
A) A client with diabetes mellitus requiring insulin administration
B) A client with pneumonia receiving oxygen therapy
,C) A client with unstable angina who is experiencing chest pain
D) A client with a fractured tibia requiring pain medication
Correct Answer: C
Rationale: The client with unstable angina experiencing chest pain is the most
unstable and requires the most experienced nurse. This client is at risk for
myocardial infarction and requires expert assessment and intervention. The other
clients are more stable and appropriate for less experienced staff.
3. A nurse is preparing to discharge a client who has a new colostomy. Which of the
following actions should the nurse take first?
A) Provide written instructions about colostomy care
B) Ask the client to demonstrate colostomy pouch changes
C) Schedule a follow-up appointment with a wound ostomy nurse
D) Give the client a list of community resources
Correct Answer: B
Rationale: The first action should be to assess the client's ability to perform the skill
by asking for a return demonstration. This evaluates the client's understanding and
skill acquisition before discharge. The other actions are important but should occur
after assessing the client's competency.
4. A nurse is caring for a client who refuses to take prescribed medication. Which of
the following actions should the nurse take?
A) Crush the medication and hide it in the client's food
B) Explain the risks and benefits of the medication to the client
C) Ask the provider to change the route of administration
D) Notify the family member about the refusal
Correct Answer: B
Rationale: The nurse should respect the client's autonomy and provide education
about the risks and benefits of the medication. The client has the right to refuse
,treatment. Coercion (crushing medication in food) is unethical and illegal. Changing
the route or notifying family does not address the client's right to refuse.
5. A nurse is delegating tasks to assistive personnel (AP). Which of the following
tasks is appropriate for the nurse to delegate?
A) Administering oral medications to a stable client
B) Performing a sterile dressing change
C) Assisting a client with ambulation using a gait belt
D) Inserting a urinary catheter
Correct Answer: C
Rationale: Assisting with ambulation using a gait belt is within the scope of practice
for AP. Administration of medications, sterile dressing changes, and urinary catheter
insertion are nursing tasks that require clinical judgment and cannot be delegated
to AP.
6. A nurse is caring for a client who is in isolation for a communicable disease.
Which of the following actions should the nurse take first?
A) Post a sign on the door indicating the type of isolation precautions
B) Ensure that personal protective equipment is available outside the room
C) Place the client in a private room with negative air pressure
D) Perform hand hygiene before leaving the client's room
Correct Answer: C
Rationale: The first action is to place the client in appropriate isolation, which for
airborne or droplet precautions may require a private room with negative air
pressure. This prevents transmission to others. The other actions are important but
should follow room placement.
7. A nurse is planning care for a client who has a terminal illness. The client states,
"I want to die at home." Which of the following actions should the nurse take?
A) Tell the client that staying in the hospital is safer
B) Discuss the client's wishes with the healthcare provider
, C) Inform the client that hospice care is available
D) Ask the client to discuss this with family members
Correct Answer: C
Rationale: The nurse should provide information about available resources,
including hospice care, which supports dying at home. This respects the client's
autonomy and provides options. The nurse should not dismiss the client's wishes,
delay discussion, or make assumptions about safety.
8. A nurse is reviewing advance directives with a client. The client asks, "What is a
durable power of attorney for healthcare?" Which of the following responses
should the nurse make?
A) It names a person to make financial decisions on your behalf
B) It names a person to make healthcare decisions when you are unable to do so
C) It states your wishes regarding life-sustaining treatment
D) It appoints a guardian to manage your property
Correct Answer: B
Rationale: A durable power of attorney for healthcare designates a specific
individual to make healthcare decisions for the client when they are unable to make
decisions themselves. A living will states wishes regarding life-sustaining treatment.
The other options refer to financial power of attorney.
9. A nurse is caring for a client who has a new tracheostomy. Which of the
following actions should the nurse take first when the client experiences difficulty
breathing?
A) Assess the client's oxygen saturation
B) Suction the tracheostomy tube
C) Call the rapid response team
D) Remove the inner cannula
Correct Answer: A
Questions And Correct Answers (Verified
Answers) Plus Rationales 2026 Q&A |
Instant Download Pdf
SECTION 1: Management of Care (Questions 1-15)
1. A nurse is caring for a client who has a new prescription for mechanical
restraints. Which of the following actions should the nurse take?
A) Obtain a written prescription from the provider within 24 hours of applying
restraints
B) Document the client's behavior every 4 hours while in restraints
C) Remove restraints at least every 2 hours to assess circulation and provide range
of motion
D) Apply restraints to all four extremities for safety
Correct Answer: C
Rationale: Restraints must be removed at least every 2 hours to allow for
assessment of circulation, skin integrity, and to provide range of motion exercises. A
written prescription must be obtained within 1 hour (not 24 hours) of applying
restraints. Documentation should occur every 15-30 minutes, not every 4 hours.
Restraints should only be applied to the minimum number of extremities necessary,
never all four unless specifically ordered.
2. A charge nurse is making client assignments for the upcoming shift. Which client
should the charge nurse assign to the most experienced nurse?
A) A client with diabetes mellitus requiring insulin administration
B) A client with pneumonia receiving oxygen therapy
,C) A client with unstable angina who is experiencing chest pain
D) A client with a fractured tibia requiring pain medication
Correct Answer: C
Rationale: The client with unstable angina experiencing chest pain is the most
unstable and requires the most experienced nurse. This client is at risk for
myocardial infarction and requires expert assessment and intervention. The other
clients are more stable and appropriate for less experienced staff.
3. A nurse is preparing to discharge a client who has a new colostomy. Which of the
following actions should the nurse take first?
A) Provide written instructions about colostomy care
B) Ask the client to demonstrate colostomy pouch changes
C) Schedule a follow-up appointment with a wound ostomy nurse
D) Give the client a list of community resources
Correct Answer: B
Rationale: The first action should be to assess the client's ability to perform the skill
by asking for a return demonstration. This evaluates the client's understanding and
skill acquisition before discharge. The other actions are important but should occur
after assessing the client's competency.
4. A nurse is caring for a client who refuses to take prescribed medication. Which of
the following actions should the nurse take?
A) Crush the medication and hide it in the client's food
B) Explain the risks and benefits of the medication to the client
C) Ask the provider to change the route of administration
D) Notify the family member about the refusal
Correct Answer: B
Rationale: The nurse should respect the client's autonomy and provide education
about the risks and benefits of the medication. The client has the right to refuse
,treatment. Coercion (crushing medication in food) is unethical and illegal. Changing
the route or notifying family does not address the client's right to refuse.
5. A nurse is delegating tasks to assistive personnel (AP). Which of the following
tasks is appropriate for the nurse to delegate?
A) Administering oral medications to a stable client
B) Performing a sterile dressing change
C) Assisting a client with ambulation using a gait belt
D) Inserting a urinary catheter
Correct Answer: C
Rationale: Assisting with ambulation using a gait belt is within the scope of practice
for AP. Administration of medications, sterile dressing changes, and urinary catheter
insertion are nursing tasks that require clinical judgment and cannot be delegated
to AP.
6. A nurse is caring for a client who is in isolation for a communicable disease.
Which of the following actions should the nurse take first?
A) Post a sign on the door indicating the type of isolation precautions
B) Ensure that personal protective equipment is available outside the room
C) Place the client in a private room with negative air pressure
D) Perform hand hygiene before leaving the client's room
Correct Answer: C
Rationale: The first action is to place the client in appropriate isolation, which for
airborne or droplet precautions may require a private room with negative air
pressure. This prevents transmission to others. The other actions are important but
should follow room placement.
7. A nurse is planning care for a client who has a terminal illness. The client states,
"I want to die at home." Which of the following actions should the nurse take?
A) Tell the client that staying in the hospital is safer
B) Discuss the client's wishes with the healthcare provider
, C) Inform the client that hospice care is available
D) Ask the client to discuss this with family members
Correct Answer: C
Rationale: The nurse should provide information about available resources,
including hospice care, which supports dying at home. This respects the client's
autonomy and provides options. The nurse should not dismiss the client's wishes,
delay discussion, or make assumptions about safety.
8. A nurse is reviewing advance directives with a client. The client asks, "What is a
durable power of attorney for healthcare?" Which of the following responses
should the nurse make?
A) It names a person to make financial decisions on your behalf
B) It names a person to make healthcare decisions when you are unable to do so
C) It states your wishes regarding life-sustaining treatment
D) It appoints a guardian to manage your property
Correct Answer: B
Rationale: A durable power of attorney for healthcare designates a specific
individual to make healthcare decisions for the client when they are unable to make
decisions themselves. A living will states wishes regarding life-sustaining treatment.
The other options refer to financial power of attorney.
9. A nurse is caring for a client who has a new tracheostomy. Which of the
following actions should the nurse take first when the client experiences difficulty
breathing?
A) Assess the client's oxygen saturation
B) Suction the tracheostomy tube
C) Call the rapid response team
D) Remove the inner cannula
Correct Answer: A
