Free Clinical Judgement and Prioritisation MCQs with Answers
50 Clinical Judgement and Prioritisation MCQs from International Nursing Practice, each with the correct answer and a written explanation of why it is correct. Free and unlimited, with no account needed.
Clinical judgement links assessment findings, nursing knowledge and patient responses to a safe decision. Coverage includes ABCDE assessment, recognising actual or potential instability, prioritising airway, breathing and circulation, using urgency and risk rather than routine order, reassessing after intervention, and distinguishing a nursing priority from a medical diagnosis or a task that can wait.
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50 questions · page 2 of 3
- A. Assess airway and breathing while calling for urgent help
- B. Ask the patient to take several deep breaths
- C. Document the sedation score and reassess in 30 minutes
- D. Give the next prescribed dose to prevent withdrawal symptoms
Explanation: Reduced consciousness, slow breathing, and falling oxygen saturation indicate possible respiratory depression.
Correct answer: Assess airway and breathing while calling for urgent help- A. Assess vital signs and notify the nurse in charge promptly
- B. Ask the patient to walk slowly to improve circulation
- C. Restrict fluids until the stoma output decreases
- D. Give an antidiarrhoeal medicine without further assessment
Explanation: High ileostomy output with dizziness and dry mucous membranes suggests fluid and electrolyte loss.
Correct answer: Assess vital signs and notify the nurse in charge promptly- A. Sit the patient upright and assess for a triggering stimulus
- B. Place the patient flat and encourage oral fluids
- C. Give a prescribed sedative and reassess the blood pressure later
- D. Apply a warm blanket and ask the patient to rest quietly
Explanation: This pattern suggests autonomic dysreflexia, which is an emergency after spinal cord injury.
Correct answer: Sit the patient upright and assess for a triggering stimulus- A. Stop oral intake and assess the patient's airway
- B. Encourage smaller sips of water through a straw
- C. Continue the drink while documenting the coughing
- D. Place food at the bedside for the patient to try later
Explanation: Coughing and a wet voice during drinking are signs of possible aspiration and impaired swallowing.
Correct answer: Stop oral intake and assess the patient's airway- A. Assess the airway and suction the tracheostomy as indicated
- B. Offer oral fluids and reassess the oxygen saturation later
- C. Remove the tracheostomy tube to inspect the airway
- D. Ask the patient to lie flat and breathe slowly
Explanation: Restlessness, noisy breathing, and visible thick secretions suggest airway obstruction.
Correct answer: Assess the airway and suction the tracheostomy as indicated- A. Cover the exposed organs with sterile saline dressings
- B. Place the patient in a high-Fowler position
- C. Attempt to gently replace the organs into the abdomen
- D. Offer oral fluids to prevent dehydration
Explanation: Sterile saline dressings protect the exposed organs from drying and contamination.
Correct answer: Cover the exposed organs with sterile saline dressings- A. Protect the patient from injury and lower them safely
- B. Insert a padded tongue blade between the teeth
- C. Restrain the arms and legs to stop the movements
- D. Give oral water when the movements begin to slow
Explanation: The immediate priority during a seizure is preventing injury while maintaining airway safety.
Correct answer: Protect the patient from injury and lower them safely- A. Check the tubing for kinks or dependent loops
- B. Increase the irrigation rate to its maximum setting
- C. Remove the catheter and insert a new one
- D. Administer an opioid and reassess in one hour
Explanation: Suprapubic pressure with absent drainage suggests obstruction of the irrigation system.
Correct answer: Check the tubing for kinks or dependent loops- A. Stop the infusion and leave the cannula in place
- B. Flush the cannula rapidly with normal saline
- C. Remove the cannula and apply firm pressure
- D. Apply heat before checking the infusion site
Explanation: Burning and swelling suggest possible extravasation. The nurse stops the infusion immediately but leaves the cannula in place so any…
Correct answer: Stop the infusion and leave the cannula in place- A. Activate the emergency response and remain with the patient
- B. Give the prescribed oral antiemetic and reassess
- C. Place the patient in a chair to improve lung expansion
- D. Ask the patient to walk to the bathroom for a stool sample
Explanation: The patient shows signs of haemorrhagic shock with deteriorating consciousness and severe hypotension.
Correct answer: Activate the emergency response and remain with the patient- A. Stop the potassium infusion immediately
- B. Encourage the patient to drink additional fluids
- C. Recheck the potassium level at the next routine time
- D. Ask the patient to walk to assess muscle strength
Explanation: Widened QRS complexes during potassium administration indicate potentially life-threatening potassium toxicity.
Correct answer: Stop the potassium infusion immediately- A. Massage the uterine fundus
- B. Place the patient in a sitting position
- C. Offer a warm drink and observe the bleeding
- D. Apply an abdominal ice pack without assessing the uterus
Explanation: A boggy uterus with heavy bleeding indicates uterine atony, a common cause of postpartum haemorrhage.
Correct answer: Massage the uterine fundus- A. Raise the head of the bed and assess breathing
- B. Remove the tracheostomy tube to improve airflow
- C. Give oral fluids to loosen airway secretions
- D. Ask the patient to walk to improve ventilation
Explanation: Raising the head of the bed can immediately improve lung expansion and reduce the work of breathing.
Correct answer: Raise the head of the bed and assess breathing- A. Place the patient on continuous cardiac monitoring
- B. Offer a high-potassium snack to improve energy
- C. Encourage ambulation to assess functional strength
- D. Document the result and wait for the next ward round
Explanation: Severe hyperkalaemia can cause sudden, fatal cardiac dysrhythmias, even before other symptoms appear.
Correct answer: Place the patient on continuous cardiac monitoring- A. Apply firm pressure to the bleeding site
- B. Remove the dressing to inspect the wound fully
- C. Offer prescribed analgesia before taking action
- D. Place the patient in a standing position
Explanation: Fresh heavy bleeding with signs of poor perfusion requires immediate control of external haemorrhage.
Correct answer: Apply firm pressure to the bleeding site- A. Raise the head of the bed and apply prescribed oxygen
- B. Increase the intravenous fluid rate to improve circulation
- C. Ask the patient to walk to assess exercise tolerance
- D. Document the findings and reassess at the next round
Explanation: The findings suggest acute fluid overload with impaired oxygenation. Sitting the patient upright and supporting oxygenation addresses…
Correct answer: Raise the head of the bed and apply prescribed oxygen- A. Stop the feeding and assess the patient's breathing
- B. Flush the feeding tube with additional sterile water
- C. Lower the head of the bed to reduce abdominal pressure
- D. Continue the feeding while requesting a chest radiograph
Explanation: Coughing, a wet voice, and falling oxygen saturation suggest aspiration during feeding.
Correct answer: Stop the feeding and assess the patient's breathing- A. Activate the emergency response system for urgent review
- B. Ask the patient to perform slow breathing exercises
- C. Offer oral fluids and repeat the blood pressure later
- D. Record the rhythm and continue the scheduled observations
Explanation: The dysrhythmia is accompanied by hypotension and chest discomfort, indicating haemodynamic instability.
Correct answer: Activate the emergency response system for urgent review- A. Call for emergency assistance and provide high-flow oxygen
- B. Place the patient in a sitting position and offer reassurance
- C. Ask the patient to cough while checking the catheter dressing
- D. Leave the patient briefly to obtain a portable chest radiograph
Explanation: Sudden symptoms after catheter removal may indicate an air embolism or another life-threatening complication.
Correct answer: Call for emergency assistance and provide high-flow oxygen- A. Notify the prescriber urgently and activate the febrile neutropenia pathway
- B. Give an antipyretic and wait to see whether the temperature falls
- C. Place the patient in a shared room for closer observation
- D. Encourage fluids and repeat the temperature in four hours
Explanation: Fever with severe neutropenia is a medical emergency because infection can progress rapidly with few localising signs.
Correct answer: Notify the prescriber urgently and activate the febrile neutropenia pathway