1
Clinical Judgment NCLEX Questions and Answers | Latest Version | 2025/2026 | Correct & Verified
A nurse is caring for a patient with a history of chronic obstructive pulmonary disease (COPD).The nurse notices the patient is becoming increasingly short of breath. What should the nurse do first?✔✔ A. Assess the patient’s oxygen saturation and respiratory rate
- Administer prescribed bronchodilators
- Encourage the patient to drink more fluids
- Call the healthcare provider for further orders
A nurse is caring for a postoperative patient who reports nausea and dizziness. The nurse notices that the patient’s vital signs are within normal limits. What should the nurse do next?
- Administer an antiemetic medication
- Encourage deep breathing exercises
- Take a complete set of vital signs every hour
- / 2
✔✔ B. Assess for any changes in the surgical site
2
A nurse is caring for a patient who is post-operative following abdominal surgery. The patient reports sharp pain in the lower abdomen, and the nurse notices that the abdomen is distended.What is the nurse's priority action?✔✔ A. Assess the patient for signs of paralytic ileus
- Reassure the patient that this is normal post-surgery
- Administer pain medication as ordered
- Encourage the patient to move their bowels
A nurse is caring for a patient who is receiving opioid pain medication. The nurse observes that the patient’s respiratory rate is 8 breaths per minute. What should the nurse do first?
- Administer supplemental oxygen via a nasal cannula
- Call the healthcare provider immediately
- Reassure the patient that this is a normal side effect of the medication
✔✔ B. Administer naloxone (Narcan) and assess the patient’s response
A nurse is caring for a patient with heart failure who reports increasing shortness of breath and swelling in the legs. What is the nurse’s priority action?✔✔ A. Assess the patient's lung sounds and oxygen saturation
- Administer diuretics as prescribed
- / 2