NSG 100 TEST 2 CLINICAL JUDGMENT AND THE
NURSING PROCESS QUESTIONS WITH VERIFIED
ANSWERS 2026
D) Flush the tubing with 30 mL of water every 4 hours. -This action will verify
placement of the tube and help maintain patency of the tube.
Incorrect Answers and Rationals:
A) Keep the head of the bed flat. - This position is not safe for the client. This
position increases the risk of aspiration of the tube feeding.
B) Add the client's medication to the enteral feeding- This action is not safe for
administering medication when a client is receiving continuous tube feedings.
C) Check gastric residual every 12 hrs.- This action is not safe. The nurse should
check gastric residual more frequently every 4-6 hrs to monitor how well the
client is tolerating the feeding. - CORRECT ANSWER Nursing Process Step 4-
Implementation Question- Select the correct action.
A nurse is caring for a client who is receiving continuous enteral feedings via a
nasogastric tube with an open system. Which of the following actions should the
nurse take?
NCLEX TIP: To successfully answer this item you must recall appropriate
techniques for administering continuous enteral feedings as well as risks and
actions you should take to decrease these risks.
,A) Keep the head of the bed flat.
B) Add the client's medication to the enteral feeding
C) Check gastric residual every 12 hrs
D) Flush the tubing with 30 mL of water every 4 hours.
D) Sitting on the side of the bed leaning on an overbed table. - This position would
be effective in alleviating dyspnea as it places the client in a position that allows
full expansion of the lungs as well as letting her rest the upper body on the
overbed table.
Incorrect Answers and Rationals:
A) Knee-chest position with pillows under head and stomach. - This position does
not alleviate dyspnea
B) Sitting in a straight back chair- This would allow expansion of the clients lung
but would cause fatigue for the lack of support.
C) Lying supine with knees flexed- This would increase dyspnea due to the
pressure on the abdominal organs on the diaphragm and the lungs. - CORRECT
ANSWER Nursing Process Step 4- Implementation Question- Client Education
A nurse is caring for a client who has emphysema and is experiencing severe
dyspnea. Which of the following positions should the nurse instruct the client to
assume?
NCLEX TIP: To correctly answer this question you must recall nursing knowledge
regarding effects the emphysema has on the lungs and the effect different client
positions has on lung expansion.
,A) Knee-chest position with pillows under head and stomach.
B) Sitting in a straight back chair
C) Lying supine with knees flexed
D) Sitting on the side of the bed leaning on an overbed table.
B) "I will give myself a shot of regular insulin 30 minutes before I eat breakfast." -
The client understands the teaching. She should administer regular insulin 30
minutes before meals so that the onset coincides with food intake. This allows
time for the absorption of insulin and for it to work at in the appropriate time.
Incorrect answers and rationals:
A) "I will puncture the pad of my finger when I am testing blood glucose." - The
client doesn't. understand the teaching. The pads of the fingers have fewer blood
vessels and more nerve fibers, so the client should avoid this. Instead she should
puncture the skin to either side to promote blood flow and decrease pain.
C) "I will eat a snack of 5 grams of carbohydrates if my blood glucose is low." - The
client does not understand the teaching. She should eat a snack of 10-15 grams of
carbs such as 120 mL or 4 ounces of fruit juice. This is necessary to rapidly ele -
CORRECT ANSWER Critical Thinking Skills Question- Clinical Judgement
A nurse is teaching a client who has a new diagnosis of type 1 diabetes mellitus.
The nurse should identify which of the following statements as an indication that
the teaching is effective?
, NCLEX TIP: Critical thinking involves applying knowledge to Analyze, Evaluate, and
Create a plan of action. Refer to the Critical Thinking steps to answer this
question. See the steps below as it pertains to this question.
Step 1. Evaluate the clients statement to determine if she understands how to
manage her new diagnosis of diabetes mellitus.
Step 2. Recall information you need to solve this problem. In this case, you need
to know how to perform self blood glucose monitoring, the onset times of regular
insulin, how to treat a hypoglycemia reaction, and how to manage sick days.
Step 3: Evaluate each option.
A) "I will puncture the pad of my finger when I am testing bloo
D) "Let's talk about some ways you have handled other stressors in your life." -
The nurse is using the therapeutic technique of offering general leads. She does
this to allow the client to express his feelings as well as helping him to focus on
ways he can cope with the current situation.
Incorrect Answers with Rationals:
A) "It is important that you provide emotional support for your family at this
time." - The nurse is not using therapeutic communication and is giving her
opinion on how the client should behave. This response can make the client feel
as if he has to behave as the nurse does.
B) "You will regret making this decision after your child's death." - The nurse is not
using therapeutic communication. She is challenging the client by telling him how
he will feel if he takes this action without regard for his feelings.
NURSING PROCESS QUESTIONS WITH VERIFIED
ANSWERS 2026
D) Flush the tubing with 30 mL of water every 4 hours. -This action will verify
placement of the tube and help maintain patency of the tube.
Incorrect Answers and Rationals:
A) Keep the head of the bed flat. - This position is not safe for the client. This
position increases the risk of aspiration of the tube feeding.
B) Add the client's medication to the enteral feeding- This action is not safe for
administering medication when a client is receiving continuous tube feedings.
C) Check gastric residual every 12 hrs.- This action is not safe. The nurse should
check gastric residual more frequently every 4-6 hrs to monitor how well the
client is tolerating the feeding. - CORRECT ANSWER Nursing Process Step 4-
Implementation Question- Select the correct action.
A nurse is caring for a client who is receiving continuous enteral feedings via a
nasogastric tube with an open system. Which of the following actions should the
nurse take?
NCLEX TIP: To successfully answer this item you must recall appropriate
techniques for administering continuous enteral feedings as well as risks and
actions you should take to decrease these risks.
,A) Keep the head of the bed flat.
B) Add the client's medication to the enteral feeding
C) Check gastric residual every 12 hrs
D) Flush the tubing with 30 mL of water every 4 hours.
D) Sitting on the side of the bed leaning on an overbed table. - This position would
be effective in alleviating dyspnea as it places the client in a position that allows
full expansion of the lungs as well as letting her rest the upper body on the
overbed table.
Incorrect Answers and Rationals:
A) Knee-chest position with pillows under head and stomach. - This position does
not alleviate dyspnea
B) Sitting in a straight back chair- This would allow expansion of the clients lung
but would cause fatigue for the lack of support.
C) Lying supine with knees flexed- This would increase dyspnea due to the
pressure on the abdominal organs on the diaphragm and the lungs. - CORRECT
ANSWER Nursing Process Step 4- Implementation Question- Client Education
A nurse is caring for a client who has emphysema and is experiencing severe
dyspnea. Which of the following positions should the nurse instruct the client to
assume?
NCLEX TIP: To correctly answer this question you must recall nursing knowledge
regarding effects the emphysema has on the lungs and the effect different client
positions has on lung expansion.
,A) Knee-chest position with pillows under head and stomach.
B) Sitting in a straight back chair
C) Lying supine with knees flexed
D) Sitting on the side of the bed leaning on an overbed table.
B) "I will give myself a shot of regular insulin 30 minutes before I eat breakfast." -
The client understands the teaching. She should administer regular insulin 30
minutes before meals so that the onset coincides with food intake. This allows
time for the absorption of insulin and for it to work at in the appropriate time.
Incorrect answers and rationals:
A) "I will puncture the pad of my finger when I am testing blood glucose." - The
client doesn't. understand the teaching. The pads of the fingers have fewer blood
vessels and more nerve fibers, so the client should avoid this. Instead she should
puncture the skin to either side to promote blood flow and decrease pain.
C) "I will eat a snack of 5 grams of carbohydrates if my blood glucose is low." - The
client does not understand the teaching. She should eat a snack of 10-15 grams of
carbs such as 120 mL or 4 ounces of fruit juice. This is necessary to rapidly ele -
CORRECT ANSWER Critical Thinking Skills Question- Clinical Judgement
A nurse is teaching a client who has a new diagnosis of type 1 diabetes mellitus.
The nurse should identify which of the following statements as an indication that
the teaching is effective?
, NCLEX TIP: Critical thinking involves applying knowledge to Analyze, Evaluate, and
Create a plan of action. Refer to the Critical Thinking steps to answer this
question. See the steps below as it pertains to this question.
Step 1. Evaluate the clients statement to determine if she understands how to
manage her new diagnosis of diabetes mellitus.
Step 2. Recall information you need to solve this problem. In this case, you need
to know how to perform self blood glucose monitoring, the onset times of regular
insulin, how to treat a hypoglycemia reaction, and how to manage sick days.
Step 3: Evaluate each option.
A) "I will puncture the pad of my finger when I am testing bloo
D) "Let's talk about some ways you have handled other stressors in your life." -
The nurse is using the therapeutic technique of offering general leads. She does
this to allow the client to express his feelings as well as helping him to focus on
ways he can cope with the current situation.
Incorrect Answers with Rationals:
A) "It is important that you provide emotional support for your family at this
time." - The nurse is not using therapeutic communication and is giving her
opinion on how the client should behave. This response can make the client feel
as if he has to behave as the nurse does.
B) "You will regret making this decision after your child's death." - The nurse is not
using therapeutic communication. She is challenging the client by telling him how
he will feel if he takes this action without regard for his feelings.
