NCLEX next generation clinical judgment model practice questions
This study set features NCLEX practice questions focused on the next generation clinical judgment model, covering critical nursing actions, safety measures, and normal values important for exam success.
Quiz(64 questions)
1. What is the normal range for adult heart rate?
Terms in this Study Set(64)
Patient Safety and Prioritization(20)
Identify the priority action for a patient with chest pain.
Assess vital signs immediately and obtain an ECG.
True or False: Safety protocols are optional in patient care.
False. Safety protocols are mandatory to prevent harm.
Fill in the blank: The nurse must prioritize ___ in any emergency situation.
patient safety.
What should a nurse do first for a patient who is unresponsive?
Check for responsiveness and initiate CPR if needed.
Compare the urgency of a patient with a fever vs. a patient with an airway obstruction.
Airway obstruction is more urgent; it requires immediate intervention.
Identify a high-risk patient scenario.
Elderly patient with fall risk due to medication side effects.
If a patient reports dizziness after standing, what action is a priority?
Assist the patient to sit or lie down to prevent falls.
True or False: Only registered nurses are responsible for patient safety.
False. All healthcare team members share responsibility for safety.
What is the first step in addressing a medication error?
Assess the patient for any adverse effects.
Identify a common cause of hospital-acquired infections.
Poor hand hygiene practices in healthcare settings.
Fill in the blank: Always verify a patient's ___ before administering medications.
identity.
What nursing action prevents patient falls?
Ensure the call light is within reach and beds are low.
True or False: Restraining a patient can always prevent injury.
False. Restraints can increase risk of injury if not monitored.
What should a nurse do with a patient who is confused and wandering?
Redirect the patient to a safe area and assess mental status.
Identify the effect of a nurse ignoring safety protocols.
Increased risk of patient harm and liability issues.
Compare the priority of addressing pain versus assessing vital signs.
Assessing vital signs is the priority in acute situations.
What is the role of patient education in safety?
Educates patients on self-care and potential risks.
Fill in the blank: Use ___ to identify patients at risk for falls.
fall risk assessments.
Identify a key component of effective hand hygiene.
Wash hands for at least 20 seconds with soap and water.
What action should be taken for a patient exhibiting signs of choking?
Perform the Heimlich maneuver immediately.
Clinical Judgments and Interventions(20)
Clinical judgment involves which key components?
Assessment, diagnosis, planning, implementation, evaluation.
True or False: Delegation is unnecessary in nursing.
False: Delegation is essential for efficiency and patient care.
Fill in the blank: Nursing interventions should be _______.
evidence-based.
What is the first step in the nursing process?
Assessment: Collecting comprehensive data pertinent to the patient's health.
List three types of nursing interventions.
- Independent - Dependent - Interdependent
Compare assessment and evaluation in nursing.
Assessment: Gathering data. Evaluation: Determining outcomes.
What acronym helps remember nursing interventions?
ADPIE: Assessment, Diagnosis, Planning, Implementation, Evaluation.
Identify a primary nursing intervention for pain management.
Administer prescribed analgesics as ordered.
True or False: Nursing diagnosis is the same as medical diagnosis.
False: Nursing diagnosis focuses on patient responses to health issues.
What is an example of a dependent nursing action?
Administering medication as prescribed by a physician.
Cause → Effect: Inadequate patient education leads to _______.
Increased readmission rates.
What should a nurse do before implementing a care plan?
Evaluate patient readiness and understanding.
Define 'nursing process' in one sentence.
A systematic approach to provide patient-centered care.
What is a common rationale for patient education?
Empowers patients to manage their health effectively.
Fill in the blank: Effective clinical judgments are based on _______.
Critical thinking and clinical reasoning.
What should a nurse consider when prioritizing care?
Urgency of the patient's condition and potential for harm.
Example of a nursing intervention for infection prevention?
Maintain strict hand hygiene protocols.
True or False: All nursing interventions require a physician's order.
False: Independent interventions do not.
Identify a key aspect of patient-centered care.
Involving patients in their own care decisions.
What is the purpose of nursing outcomes?
To measure the effectiveness of interventions.
Normal Values and Assessments(16)
What is the normal range for adult heart rate?
60-100 beats per minute (bpm).
True or False: A normal adult respiratory rate is 12-20 breaths per minute.
True. This is the normal range for adult respiratory rate.
Fill in the blank: Normal blood pressure is _____ mmHg.
120/80 mmHg.
What is the normal range for fasting blood glucose?
70-99 mg/dL.
What does a low sodium level indicate?
Can suggest hyponatremia; may cause confusion or seizures.
Normal INR range for patients on anticoagulants is:
2.0-3.0.
Identify the normal respiratory assessment technique.
- Observe chest movement - Auscultate lung sounds - Assess for dyspnea
What is the normal range for adult body temperature?
97°F to 100.4°F (36.1°C to 38°C).
True or False: A normal hemoglobin level for adult males is 13.5-17.5 g/dL.
True. This is the normal range for adult males.
Normal urinalysis pH range is:
4.6 to 8.0.
What does an elevated potassium level result in?
Can cause hyperkalemia; may lead to cardiac arrhythmias.
Fill in the blank: The normal range for adult respiratory rate is _____ breaths/min.
12-20 breaths/min.
Compare normal lab values for LDL and HDL.
- LDL: less than 100 mg/dL - HDL: 40-60 mg/dL
What is the normal range for adult white blood cell count?
4,500-11,000 cells/mcL.
True or False: Bilirubin levels are normally 0.1-1.2 mg/dL.
True. This is the normal range for total bilirubin.
What is the normal range for creatinine in adults?
0.6-1.2 mg/dL.
Pharmacology and Medication Administration(8)
What is the maximum safe dosage of acetaminophen?
The maximum safe dosage for adults is 4,000 mg per day. - Monitor liver function - Assess for signs of overdose.
True or False: Insulin can be given intramuscularly.
False. Insulin should only be administered subcutaneously or intravenously due to absorption rates.
Fill in the blank: The 'Five Rights' of medication administration are __________.
1. Right patient 2. Right drug 3. Right dose 4. Right route 5. Right time.
What should you assess before administering a beta blocker?
- Heart rate - Blood pressure - Signs of asthma or COPD.
Compare oral vs. intravenous medication administration.
Oral: slower onset, easier, non-invasive. - IV: rapid onset, more immediate effects, invasive.
True or False: All medications can be crushed for easier administration.
False. Some medications (e.g., enteric-coated, extended-release) should not be crushed.
What are common side effects of opioids?
- Respiratory depression - Sedation - Constipation - Nausea.
Cause → Effect: What happens if a patient takes warfarin and NSAIDs together?
Increased risk of bleeding due to additive anticoagulant effects.
Questions in this Study Set(64)
1. What is the normal range for adult heart rate?
2. What is the priority action for a patient experiencing shortness of breath?
3. Which of the following is NOT a component of the nursing process?
4. What is the maximum daily dose of ibuprofen for adults?
5. True or False: A normal adult respiratory rate is 12-20 breaths per minute.
6. True or False: It is acceptable to leave a patient who is at risk for falls unattended.
7. What is the priority nursing action when a patient shows signs of respiratory distress?
8. Which route of administration is NOT suitable for nitroglycerin?
9. Fill in the blank: Normal blood pressure is _____ mmHg.
10. Fill in the blank: The nurse should always assess ___ before administering blood products.
11. Fill in the blank: Nursing interventions should be based on _______.
12. Before administering digoxin, which of the following should be assessed?
13. What is the normal range for fasting blood glucose?
14. Which action should a nurse take first for a patient with a suspected stroke?
15. What is the main focus of a nursing diagnosis?
16. Fill in the blank: The 'Three Checks' of medication administration are __________.
17. What condition may result from a low sodium level?
18. Which of the following is NOT a sign of infection?
19. Which of the following actions requires a physician's order?
20. Which medication should NOT be taken with grapefruit juice?
21. What is the normal INR range for patients on anticoagulants?
22. What is the first step a nurse should take after discovering a medication error?
23. True or False: Evaluation in the nursing process occurs only at the end of the care plan.
24. True or False: All antibiotics can be taken with food without affecting their absorption.
25. Which of the following is NOT a normal respiratory assessment technique?
26. True or False: Patient safety is the sole responsibility of the nursing staff.
27. What should a nurse do if a patient refuses a treatment that is necessary for their health?
28. What is one of the most common adverse effects of opioid medications?
29. What is the normal range for adult body temperature?
30. What nursing action is most important to reduce the risk of falls in hospitalized patients?
31. Which of the following is an independent nursing intervention?
32. Cause → Effect: What happens if a patient abruptly stops taking corticosteroids?
33. True or False: A normal hemoglobin level for adult males is 13.5-17.5 g/dL.
34. Which scenario poses the greatest risk for a patient in a healthcare setting?
35. Cause → Effect: Inadequate monitoring of a patient's vital signs can lead to _______.
36. What is the normal urinalysis pH range?
37. What should a nurse do if a patient suddenly becomes unresponsive?
38. Which of the following is true regarding delegation in nursing?
39. What may an elevated potassium level indicate?
40. Fill in the blank: Hand hygiene should be performed for at least ___ seconds.
41. What is the primary goal of patient education?
42. Fill in the blank: The normal range for adult respiratory rate is _____ breaths/min.
43. What is an appropriate nursing action to take for a patient experiencing anxiety?
44. Which nursing action is appropriate for infection control?
45. Compare normal lab values for LDL and HDL cholesterol.
46. Which of the following should be included in a fall prevention protocol?
47. What is a key aspect of critical thinking in nursing?
48. What is the normal range for adult white blood cell count?
49. True or False: Restraints should be used as a first-line intervention for agitated patients.
50. True or False: Nursing documentation is only necessary for legal purposes.
51. True or False: Bilirubin levels are normally 0.1-1.2 mg/dL.
52. What should a nurse do if a patient has a known allergy to latex?
53. When should a nurse reassess a patient after an intervention?
54. What is the normal range for creatinine in adults?
55. Which of the following is a key component of patient education related to safety?
56. Which of the following is NOT a factor in prioritizing nursing care?
57. What action should the nurse take for a patient showing signs of choking?
58. In the context of clinical judgment, what does the acronym ADPIE stand for?
59. Which of the following is the best way to verify a patient's identity before a procedure?
60. What is the significance of evidence-based practice in nursing?
61. What is the priority intervention for a patient exhibiting signs of anaphylaxis?
62. Which of the following best defines clinical judgment in nursing?
63. Which of the following actions is NOT a component of infection control practices?
64. In a scenario where a patient is experiencing acute pain, which nursing action should be prioritized?
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