Mastering NGN Clinical Judgment: A
**
Comprehensive NCLEX-RN Case Study & SATA
Bootcamp**
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**Question 1**
A nurse is caring for a client with heart failure who reports sudden shortness of breath and a new onset
of cough. The nurse auscultates fine crackles in all lung fields and notes an oxygen saturation of 88% on
room air. Which of the following actions should the nurse take first?
A. Administer furosemide 40 mg IV push
B. Place the client in high-Fowler’s position
C. Prepare for endotracheal intubation
D. Increase the IV fluid rate to 150 mL/hr
💫ANSWER✔️✔️: B. Placing the client in high-Fowler’s position reduces preload and facilitates
respiratory mechanics, improving oxygenation. This is the immediate, non-invasive, first-line
intervention for respiratory distress in heart failure.
💫RATIONALE✔️✔️: Airway and breathing are the priority. High-Fowler’s position uses gravity to decrease
venous return (preload) and lung congestion. While furosemide is indicated, it is not the first action;
positioning occurs in seconds. Intubation is a later step if non-invasive measures fail. Increasing IV fluids
would worsen fluid overload.
---
**Question 2**
,A nurse is reviewing laboratory results for a client receiving gentamicin. Which finding requires
immediate notification to the healthcare provider?
A. Serum creatinine 1.8 mg/dL (baseline 0.9 mg/dL)
B. Gentamicin trough level 1.0 mcg/mL
C. White blood cell count 11,000/mm³
D. Blood urea nitrogen 18 mg/dL
💫ANSWER✔️✔️: A. Serum creatinine 1.8 mg/dL (doubled from baseline) indicates acute kidney injury, a
known adverse effect of aminoglycosides like gentamicin.
💫RATIONALE✔️✔️: Nephrotoxicity is a serious complication of gentamicin. A rising serum creatinine is a
critical finding requiring dose adjustment or discontinuation. A trough level of 1.0 mcg/mL is actually
below the typical target (1-2 mcg/mL for severe infections), not a concern. WBC 11,000 is mildly
elevated but expected with infection. BUN 18 is within normal limits.
---
**Question 3**
A client with major depressive disorder has been taking phenelzine (Nardil) for 6 weeks. The nurse’s
dietary teaching should include avoiding which of the following foods? (Select all that apply.)
A. Aged cheddar cheese
B. Smoked salmon
C. Bananas
D. Soy sauce
E. Plain yogurt
,💫ANSWER✔️✔️: A, B, D. Aged cheddar cheese, smoked salmon, and soy sauce are high in tyramine,
which can precipitate a hypertensive crisis when combined with monoamine oxidase inhibitors (MAOIs)
like phenelzine.
💫RATIONALE✔️✔️: MAOIs inhibit the breakdown of tyramine. Tyramine-rich foods (aged cheeses, cured
meats, fermented products, soy products) can cause sudden severe hypertension. Bananas are safe
unless overripe. Plain yogurt is generally low in tyramine unless aged.
---
**Question 4**
A nurse is preparing to administer a blood transfusion of packed red blood cells to a client. Which of the
following actions is most important to take first?
A. Verify the client’s blood type and crossmatch with the unit
B. Obtain baseline vital signs
C. Prime the blood tubing with 0.9% sodium chloride
D. Ask the client about previous transfusion reactions
💫ANSWER✔️✔️: A. Verifying blood type and crossmatch with the unit is the critical safety step to
prevent ABO incompatibility, a fatal hemolytic reaction.
💫RATIONALE✔️✔️: The “two-nurse check” of the blood product against the client’s identifying
information and blood type is the highest priority safety measure. Baseline vitals (B) are important but
secondary. Priming with normal saline (C) is correct but not the first or most important step. Asking
about history (D) provides useful data but does not prevent immediate misadministration.
---
**Question 5**
, A nurse is assessing a client 2 hours after a thoracentesis. Which finding requires immediate
intervention?
A. Heart rate 98 bpm
B. Oxygen saturation 94% on 2 L nasal cannula
C. Client reports sharp chest pain worse with inspiration
D. Blood pressure 118/76 mm Hg
💫ANSWER✔️✔️: C. Sharp chest pain worse with inspiration (pleuritic chest pain) is a key sign of a post-
procedural pneumothorax, a serious complication of thoracentesis.
💫RATIONALE✔️✔️: Pneumothorax can occur if the needle punctures the lung. Pleuritic chest pain,
sudden dyspnea, or absent breath sounds require immediate chest x-ray and potential chest tube
insertion. HR 98 is mildly elevated but non-specific. SpO2 94% on oxygen is acceptable post-procedure.
BP 118/76 is normal.
---
**Question 6**
A nurse on a medical-surgical unit is delegating tasks to an unlicensed assistive personnel (UAP). Which
of the following tasks is appropriate for the UAP to perform?
A. Assess the pain level of a client who had abdominal surgery
B. Empty a client’s indwelling urinary catheter drainage bag
C. Teach a client how to self-administer insulin
D. Change the dressing on a client’s pressure injury
💫ANSWER✔️✔️: B. Emptying a urinary drainage bag is a standard, non-invasive, task-oriented skill
within the UAP’s scope of practice under nurse supervision.
**
Comprehensive NCLEX-RN Case Study & SATA
Bootcamp**
---
**Question 1**
A nurse is caring for a client with heart failure who reports sudden shortness of breath and a new onset
of cough. The nurse auscultates fine crackles in all lung fields and notes an oxygen saturation of 88% on
room air. Which of the following actions should the nurse take first?
A. Administer furosemide 40 mg IV push
B. Place the client in high-Fowler’s position
C. Prepare for endotracheal intubation
D. Increase the IV fluid rate to 150 mL/hr
💫ANSWER✔️✔️: B. Placing the client in high-Fowler’s position reduces preload and facilitates
respiratory mechanics, improving oxygenation. This is the immediate, non-invasive, first-line
intervention for respiratory distress in heart failure.
💫RATIONALE✔️✔️: Airway and breathing are the priority. High-Fowler’s position uses gravity to decrease
venous return (preload) and lung congestion. While furosemide is indicated, it is not the first action;
positioning occurs in seconds. Intubation is a later step if non-invasive measures fail. Increasing IV fluids
would worsen fluid overload.
---
**Question 2**
,A nurse is reviewing laboratory results for a client receiving gentamicin. Which finding requires
immediate notification to the healthcare provider?
A. Serum creatinine 1.8 mg/dL (baseline 0.9 mg/dL)
B. Gentamicin trough level 1.0 mcg/mL
C. White blood cell count 11,000/mm³
D. Blood urea nitrogen 18 mg/dL
💫ANSWER✔️✔️: A. Serum creatinine 1.8 mg/dL (doubled from baseline) indicates acute kidney injury, a
known adverse effect of aminoglycosides like gentamicin.
💫RATIONALE✔️✔️: Nephrotoxicity is a serious complication of gentamicin. A rising serum creatinine is a
critical finding requiring dose adjustment or discontinuation. A trough level of 1.0 mcg/mL is actually
below the typical target (1-2 mcg/mL for severe infections), not a concern. WBC 11,000 is mildly
elevated but expected with infection. BUN 18 is within normal limits.
---
**Question 3**
A client with major depressive disorder has been taking phenelzine (Nardil) for 6 weeks. The nurse’s
dietary teaching should include avoiding which of the following foods? (Select all that apply.)
A. Aged cheddar cheese
B. Smoked salmon
C. Bananas
D. Soy sauce
E. Plain yogurt
,💫ANSWER✔️✔️: A, B, D. Aged cheddar cheese, smoked salmon, and soy sauce are high in tyramine,
which can precipitate a hypertensive crisis when combined with monoamine oxidase inhibitors (MAOIs)
like phenelzine.
💫RATIONALE✔️✔️: MAOIs inhibit the breakdown of tyramine. Tyramine-rich foods (aged cheeses, cured
meats, fermented products, soy products) can cause sudden severe hypertension. Bananas are safe
unless overripe. Plain yogurt is generally low in tyramine unless aged.
---
**Question 4**
A nurse is preparing to administer a blood transfusion of packed red blood cells to a client. Which of the
following actions is most important to take first?
A. Verify the client’s blood type and crossmatch with the unit
B. Obtain baseline vital signs
C. Prime the blood tubing with 0.9% sodium chloride
D. Ask the client about previous transfusion reactions
💫ANSWER✔️✔️: A. Verifying blood type and crossmatch with the unit is the critical safety step to
prevent ABO incompatibility, a fatal hemolytic reaction.
💫RATIONALE✔️✔️: The “two-nurse check” of the blood product against the client’s identifying
information and blood type is the highest priority safety measure. Baseline vitals (B) are important but
secondary. Priming with normal saline (C) is correct but not the first or most important step. Asking
about history (D) provides useful data but does not prevent immediate misadministration.
---
**Question 5**
, A nurse is assessing a client 2 hours after a thoracentesis. Which finding requires immediate
intervention?
A. Heart rate 98 bpm
B. Oxygen saturation 94% on 2 L nasal cannula
C. Client reports sharp chest pain worse with inspiration
D. Blood pressure 118/76 mm Hg
💫ANSWER✔️✔️: C. Sharp chest pain worse with inspiration (pleuritic chest pain) is a key sign of a post-
procedural pneumothorax, a serious complication of thoracentesis.
💫RATIONALE✔️✔️: Pneumothorax can occur if the needle punctures the lung. Pleuritic chest pain,
sudden dyspnea, or absent breath sounds require immediate chest x-ray and potential chest tube
insertion. HR 98 is mildly elevated but non-specific. SpO2 94% on oxygen is acceptable post-procedure.
BP 118/76 is normal.
---
**Question 6**
A nurse on a medical-surgical unit is delegating tasks to an unlicensed assistive personnel (UAP). Which
of the following tasks is appropriate for the UAP to perform?
A. Assess the pain level of a client who had abdominal surgery
B. Empty a client’s indwelling urinary catheter drainage bag
C. Teach a client how to self-administer insulin
D. Change the dressing on a client’s pressure injury
💫ANSWER✔️✔️: B. Emptying a urinary drainage bag is a standard, non-invasive, task-oriented skill
within the UAP’s scope of practice under nurse supervision.
