RN exams end-of-life practice questions

Correct answer:

Deep-vein thrombosis (DVT) involves a blood clot in a deep vein, typically in the leg, obstructing venous return and causing impaired blood flow. The nursing diagnosis 'Altered peripheral tissue perfusion related to venous congestion' (Choice D) takes priority because it directly addresses the primary pathophysiological issue: reduced circulation distal to the clot, risking tissue ischemia or infarction. Impaired gas exchange (Choice A) is incorrect because DVT primarily affects venous, not arterial, flow, and gas exchange relates to pulmonary issues like embolism, not the initial DVT state. Fluid volume excess (Choice B) isn't indicated, as DVT doesn't inherently cause systemic fluid overload; edema is localized. Risk for injury related to edema (Choice C) is a concern but secondary, as it's a symptom rather than the core problem. Prioritizing tissue perfusion aligns with the ABCs (airway, breathing, circulation) and Maslow's hierarchy, where physiological needs like circulation supersede safety risks. If untreated, poor perfusion can lead to tissue damage or pulmonary embolism, making Choice D the most urgent and correct diagnosis.

Correct answer:

Sleep is a natural, recurring state distinct from wakefulness, and its definition hinges on physiological and perceptual changes. 'Altered consciousness, relative inactivity' best captures this, reflecting sleep's reduced awareness and minimal physical movement, as seen in EEG shifts from beta to delta waves during non-REM stages. Choice A, 'decreased state of activity, refreshed,' partially appliesactivity drops, and waking often refreshesbut it omits the critical consciousness shift, making it incomplete. Choice C, 'comatose, immobility,' describes a pathological state, not normal sleep; coma lacks the reversibility and cycles (REM/NREM) of sleep. Choice D, 'alert, responsive,' defines wakefulness, the opposite of sleep. For example, during NREM stage 3, a sleeper's consciousness alters (less responsive to stimuli), and muscle tone decreases, yet they can awakenunlike coma. Nursing texts like Taylor's Fundamentals emphasize sleep as a dynamic state of altered consciousness with reduced, not absent, activity, aligning with circadian biology. Thus, Choice B is the most accurate and comprehensive descriptor.

Correct answer:

Sleep is a natural, recurring state distinct from wakefulness, and its definition hinges on physiological and perceptual changes. 'Altered consciousness, relative inactivity' best captures this, reflecting sleep's reduced awareness and minimal physical movement, as seen in EEG shifts from beta to delta waves during non-REM stages. Choice A, 'decreased state of activity, refreshed,' partially appliesactivity drops, and waking often refreshesbut it omits the critical consciousness shift, making it incomplete. Choice C, 'comatose, immobility,' describes a pathological state, not normal sleep; coma lacks the reversibility and cycles (REM/NREM) of sleep. Choice D, 'alert, responsive,' defines wakefulness, the opposite of sleep. For example, during NREM stage 3, a sleeper's consciousness alters (less responsive to stimuli), and muscle tone decreases, yet they can awakenunlike coma. Nursing texts like Taylor's Fundamentals emphasize sleep as a dynamic state of altered consciousness with reduced, not absent, activity, aligning with circadian biology. Thus, Choice B is the most accurate and comprehensive descriptor.

Correct answer:

When assessing a patient's abdomen, the nurse must follow a systematic approach to ensure accurate findings, starting with the least invasive technique. Inspection (Choice B) is the first step because it involves observing the abdomen for visible signs like distension, scars, or asymmetry without altering the body's natural state. Auscultation (Choice A) comes next, as it listens to bowel sounds, but performing percussion (Choice C) or palpation (Choice D) first could stimulate bowel motility or cause discomfort, potentially skewing the auscultation results. Inspection provides a baseline visual assessment, allowing the nurse to note abnormalities before proceeding to hands-on techniques. For instance, palpating or percussing too early might increase peristalsis, leading to misleading bowel sound interpretations. This sequenceinspection, auscultation, percussion, palpationis a standard protocol in nursing practice to maintain accuracy and patient comfort. Therefore, starting with inspection (Choice B) ensures the assessment is both logical and effective, making it the correct answer.

Correct answer:

When assessing a patient's abdomen, the nurse must follow a systematic approach to ensure accurate findings, starting with the least invasive technique. Inspection (Choice B) is the first step because it involves observing the abdomen for visible signs like distension, scars, or asymmetry without altering the body's natural state. Auscultation (Choice A) comes next, as it listens to bowel sounds, but performing percussion (Choice C) or palpation (Choice D) first could stimulate bowel motility or cause discomfort, potentially skewing the auscultation results. Inspection provides a baseline visual assessment, allowing the nurse to note abnormalities before proceeding to hands-on techniques. For instance, palpating or percussing too early might increase peristalsis, leading to misleading bowel sound interpretations. This sequenceinspection, auscultation, percussion, palpationis a standard protocol in nursing practice to maintain accuracy and patient comfort. Therefore, starting with inspection (Choice B) ensures the assessment is both logical and effective, making it the correct answer.

Correct answer:

Primary prevention focuses on preventing health issues before they occur, such as through immunizations or health education. Administering a measles, mumps, and rubella (MMR) immunization to an infant (Choice B) is a classic example of primary prevention because it protects against diseases before exposure. In contrast, administering digoxin (Choice A) is a treatment for an existing condition (heart failure), making it tertiary prevention aimed at managing or reducing complications. Obtaining a Papanicolaou smear (Choice C) is secondary prevention, as it involves early detection of cervical cancer rather than preventing it outright. Similarly, using occupational therapy for arthritis (Choice D) is tertiary prevention, helping a patient manage an existing condition rather than preventing its onset. The distinction lies in the timing and intent: primary prevention occurs before any disease process begins, and the MMR vaccine fits this definition perfectly by building immunity proactively. Thus, Choice B is correct, aligning with the goal of stopping health problems at their root.

Correct answer:

Primary prevention focuses on preventing health issues before they occur, such as through immunizations or health education. Administering a measles, mumps, and rubella (MMR) immunization to an infant (Choice B) is a classic example of primary prevention because it protects against diseases before exposure. In contrast, administering digoxin (Choice A) is a treatment for an existing condition (heart failure), making it tertiary prevention aimed at managing or reducing complications. Obtaining a Papanicolaou smear (Choice C) is secondary prevention, as it involves early detection of cervical cancer rather than preventing it outright. Similarly, using occupational therapy for arthritis (Choice D) is tertiary prevention, helping a patient manage an existing condition rather than preventing its onset. The distinction lies in the timing and intent: primary prevention occurs before any disease process begins, and the MMR vaccine fits this definition perfectly by building immunity proactively. Thus, Choice B is correct, aligning with the goal of stopping health problems at their root.

Correct answer:

Furosemide (Lasix) is a loop diuretic that increases urine output, commonly used to treat edema or hypertension, but it also causes significant potassium loss, a condition called hypokalemia. The nurse must educate the patient to consume potassium-rich foods to counteract this side effect. Bananas and oranges (Choice B) are excellent sources of potassiumbananas contain about 400 mg per medium fruit, and oranges around 240 mgmaking them ideal choices to maintain electrolyte balance. Fresh green vegetables (Choice A) like spinach offer some potassium but are less concentrated than bananas and oranges, and their primary benefit lies in vitamins like A and C. Lean red meat (Choice C) is rich in protein and iron but low in potassium, while creamed corn (Choice D) is high in carbohydrates and sodium, not potassium. Hypokalemia can lead to muscle cramps, arrhythmias, or fatigue, so prioritizing potassium intake is critical. Teaching the patient to include bananas and oranges ensures they address the diuretic's most significant electrolyte impact, making Choice B the best answer.

Correct answer:

Furosemide (Lasix) is a loop diuretic that increases urine output, commonly used to treat edema or hypertension, but it also causes significant potassium loss, a condition called hypokalemia. The nurse must educate the patient to consume potassium-rich foods to counteract this side effect. Bananas and oranges (Choice B) are excellent sources of potassiumbananas contain about 400 mg per medium fruit, and oranges around 240 mgmaking them ideal choices to maintain electrolyte balance. Fresh green vegetables (Choice A) like spinach offer some potassium but are less concentrated than bananas and oranges, and their primary benefit lies in vitamins like A and C. Lean red meat (Choice C) is rich in protein and iron but low in potassium, while creamed corn (Choice D) is high in carbohydrates and sodium, not potassium. Hypokalemia can lead to muscle cramps, arrhythmias, or fatigue, so prioritizing potassium intake is critical. Teaching the patient to include bananas and oranges ensures they address the diuretic's most significant electrolyte impact, making Choice B the best answer.

Correct answer:

The nursing process is a systematic framework with five steps: assessment, nursing diagnosis, planning, implementation, and evaluation. The nursing diagnosis step (Choice B) is where the nurse analyzes data collected during assessment to identify the patient's responses to actual or potential health problems, such as 'Risk for Infection' or 'Acute Pain.' Assessment (Choice A) involves gathering subjective and objective data (e.g., vital signs, patient history), but it doesn't involve interpreting those findings into specific responsesthat happens in the nursing diagnosis phase. Planning (Choice C) follows, where the nurse sets goals and interventions based on the diagnosis, while evaluation (Choice D) assesses whether those goals were met. For example, if a patient reports pain and the nurse notes a fever, the nursing diagnosis might be 'Acute Pain related to inflammation,' a conclusion drawn only after assessment data is analyzed. Thus, identifying responseswhether current or at-riskoccurs distinctly in the nursing diagnosis step, making Choice B the correct answer.