You practice vitals, infection control, documentation, and the first nursing action when a patient is unstable. Five of the 15 questions include the correct answer and rationale. The other ten keep answers in the study hub. Continue with the RN exams exam guide or more RN exams practice questions.
Five fundamentals questions with answers
Cover the key. Write the first action. Then open the rationale and name why the other choices fail.
Question 1
The nurse is assessing a patient's respiratory status and notes that the patient is using their neck muscles to breathe. What is the most likely cause of this finding?
A. Severe respiratory distress.
B. Hyperventilation.
C. Pneumothorax.
D. Acute bronchitis.
Show answer and rationale
Correct answer: A — Severe respiratory distress.
The correct answer is A: Severe respiratory distress. When a patient is using their neck muscles to breathe, it indicates that they are struggling to breathe effectively. This is a sign of increased work of breathing, which is commonly seen in severe respiratory distress. The neck muscles are recruited as accessory muscles to help with breathing when the respiratory system is compromised. This finding can be seen in conditions such as severe asthma, acute respiratory failure, or severe pneumonia. Therefore, the most likely cause of a patient using their neck muscles to breathe is severe respiratory distress.
Summary:
- Choice B (Hyperventilation): Hyperventilation is characterized by rapid and deep breathing, not necessarily the use of neck muscles to breathe.
- Choice C (Pneumothorax): Pneumothorax typically presents with chest pain and shortness of breath, but not specifically with the use of neck muscles to breathe.
- Choice D (Acute bronchitis): Acute bronchitis
Question 2
Which of the following are examples of characteristics of evidence-based practice? Select all that apply.
A. It is a problem-solving approach.
B. It uses the best evidence available.
C. It is generally accepted in clinical practice.
D. It is based on current institutional protocols.
Show answer and rationale
Correct answer: A — It is a problem-solving approach.
Step-by-step rationale for why option A is correct:
1. Evidence-based practice is a problem-solving approach as it involves identifying, critically evaluating, and applying the best available evidence to make informed decisions.
2. By using a systematic problem-solving approach, practitioners can integrate research evidence, clinical expertise, and patient values to deliver optimal care.
3. This approach helps healthcare professionals make decisions based on the most current and relevant evidence, leading to improved patient outcomes.
4. Options B, C, and D are incorrect:
- Option B: While evidence-based practice uses the best evidence available, it is not the only defining characteristic.
- Option C: Acceptance in clinical practice may vary, as evidence-based practice requires critical appraisal of evidence rather than blind acceptance.
- Option D: Evidence-based practice is not solely based on institutional protocols but on a broader range of evidence sources.
Question 3
A patient with a head injury has admission vital signs of blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse?
A. Blood pressure 160/50, pulse 55, respirations 14
B. Blood pressure 110/70, pulse 120, respirations 30
C. Blood pressure 148/78, pulse 112, respirations 28
D. Blood pressure 150/72, pulse 60, respirations 32
The correct answer is A. The significant change in blood pressure from 128/68 to 160/50, along with a significant decrease in pulse from 110 to 55, and a decrease in respirations from 26 to 14, indicates potential signs of deteriorating condition. A drop in blood pressure paired with a significant decrease in pulse and respirations could signify shock, which is a life-threatening condition that requires immediate intervention.
Option B shows an increase in pulse and respirations, but the blood pressure remains within an acceptable range. Option C shows a slight increase in blood pressure with minimal changes in pulse and respirations. Option D shows a moderate decrease in pulse and a significant increase in respirations, but the blood pressure remains relatively stable.
In summary, option A is the most concerning as it shows a combination of significant changes in blood pressure, pulse, and respirations, indicating a potential deterioration in the patient's condition.
Question 4
You are treating and transporting a 26-year-old female involved in an MVA. She has multiple injuries, but all associated hemorrhage is controlled. The patient is exhibiting signs and symptoms of hypovolemic shock. During treatment and transport, you infuse one liter of lactated Ringer's solution, and the patient remains hypotensive. Once at the hospital, which of the following is most likely to be administered immediately upon arrival?
A. O-negative whole blood containing plasma
B. O-negative packed red blood cells
C. O-positive packed red blood cells
D. O-positive whole blood without plasma
Show answer and rationale
Correct answer: B — O-negative packed red blood cells
The correct answer is B: O-negative packed red blood cells. In hypovolemic shock, the primary issue is a significant loss of red blood cells leading to decreased oxygen-carrying capacity and subsequent hypotension. Packed red blood cells contain a concentrated amount of red blood cells, which can help improve the patient's oxygenation status and hemodynamic stability more effectively than whole blood or other blood products. O-negative blood is used to avoid potential reactions due to ABO incompatibility. Administering packed red blood cells upon arrival at the hospital is crucial to rapidly address the underlying cause of hypovolemic shock.
Choices A, C, and D are incorrect because whole blood or packed red blood cells without plasma may not provide the necessary oxygen-carrying capacity to address the patient's condition effectively. Additionally, using O-positive blood products for a female patient can lead to potentially harmful reactions due to ABO incompatibility.
Question 5
Which of the following are examples of characteristics of evidence-based practice? Select all that apply.
A. It is a problem-solving approach.
B. It uses the best evidence available.
C. It is generally accepted in clinical practice.
D. It is based on current institutional protocols.
Show answer and rationale
Correct answer: A — It is a problem-solving approach.
Step-by-step rationale for why option A is correct:
1. Evidence-based practice is a problem-solving approach as it involves identifying, critically evaluating, and applying the best available evidence to make informed decisions.
2. By using a systematic problem-solving approach, practitioners can integrate research evidence, clinical expertise, and patient values to deliver optimal care.
3. This approach helps healthcare professionals make decisions based on the most current and relevant evidence, leading to improved patient outcomes.
4. Options B, C, and D are incorrect:
- Option B: While evidence-based practice uses the best evidence available, it is not the only defining characteristic.
- Option C: Acceptance in clinical practice may vary, as evidence-based practice requires critical appraisal of evidence rather than blind acceptance.
- Option D: Evidence-based practice is not solely based on institutional protocols but on a broader range of evidence sources.
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Question 6
The charge nurse is preparing to admit a client with acute confusion secondary to UTI. The client has been known to be combative at times and tries frequently to get out of bed. Which of the following beds should the nurse assign to the client?
A. a bed distanced from the nursing station and other client rooms
B. a bed in a shared room with a client recovering from abdominal laparoscopy
C. a bed near the elevators
D. a bed near the nurses’ station
Correct answer:
The correct answer is D: a bed near the nurses' station. This choice is the safest option for a client with acute confusion and combative behavior. Placing the client near the nurses' station allows for closer monitoring and quicker intervention if the client tries to get out of bed or becomes agitated. The proximity to the nursing staff can help prevent falls, ensure prompt assistance, and maintain a safe environment.
Choice A: a bed distanced from the nursing station and other client rooms, is incorrect because it can lead to delayed response time and increased risk of falls or injury for the client.
Choice B: a bed in a shared room with a client recovering from abdominal laparoscopy, is incorrect because the other client's condition may not be conducive to a safe environment for a combative client.
Choice C: a bed near the elevators, is incorrect as it does not provide the necessary supervision and support for a client with acute confusion and combative behavior.
For the following situations, state the type of data collection you would perform (i.e., complete database, focused or problem-centered database, follow-up database, emergency database). c. first visit to a health care provider for a checkup
A. Complete database
B. Focused or problem-centered database
C. Follow-up database
D. Emergency database
Correct answer:
The correct answer is A: Complete database. During the first visit for a checkup, a complete database is necessary to gather comprehensive information about the patient's medical history, current health status, family history, medications, allergies, and lifestyle factors. This type of data collection allows the healthcare provider to establish a baseline for the patient's health and identify any potential risks or issues.
Choice B (Focused or problem-centered database) would not be appropriate for the first visit as it involves gathering information related to a specific health issue or concern, which may not capture all relevant information for a new patient.
Choice C (Follow-up database) is used to track changes or progress over time for established patients, so it is not suitable for the initial visit.
Choice D (Emergency database) is designed for urgent situations where quick access to critical information is needed, which is not the case for a routine checkup.
You are on scene at a motor vehicle accident, and your 20-year-old patient is entrapped. He is unconscious, unresponsive, and has a palpable carotid pulse that is weak and thready. His breathing is slow and shallow at four times a minute with equal chest wall expansion. There are no obvious deformity injuries or hemorrhage noted. Fire department on-scene has stabilized the vehicle and provided you and your partner a relatively safe environment to manage the entrapped patient. However, access is limited to the seated patient, and extrication is expected to take another twenty minutes. After having your partner maintain cervical spine stabilization, which of the following would be the best choice for securing the patient's airway?
A. Insert a nasal airway and administer high-flow oxygen therapy
B. Use nasotracheal intubation techniques to gain complete control of the patient's airway and assist ventilation
C. Intubate the patient using the blind orotracheal intubation technique to maintain in-line mobilization of the spine, then assist ventilation
D. Insert a King LTD and begin assisting ventilations with a bag-valve mask
Correct answer:
The correct answer is C: Intubate the patient using the blind orotracheal intubation technique to maintain in-line mobilization of the spine, then assist ventilation. In this scenario, the patient is entrapped with limited access and expected extrication time of 20 minutes. Given the patient's unconsciousness, unresponsiveness, weak carotid pulse, and slow, shallow breathing, securing the airway is crucial to ensure adequate oxygenation and ventilation. Intubating the patient using the blind orotracheal technique allows for maintaining in-line mobilization of the spine, reducing the risk of further spinal injury during the extrication process. This approach provides a more definitive airway management compared to nasal airway insertion or bag-valve mask ventilation. Nasotracheal intubation (choice B) may not be feasible due to limited access and potential for further injury. Using a King LTD (choice D) is not recommended in this situation as it does not provide the same
Under which of the following conditions should a nursing assistant not take an oral temperature on a person?
A. The person has influenza.
B. The person almost certainly has a fever.
C. The person is over six years old.
D. The person is confused or disoriented.
Correct answer:
The correct answer is D because taking an oral temperature on a person who is confused or disoriented could lead to inaccurate results. A person who is confused may not be able to cooperate or keep the thermometer in their mouth properly, affecting the reading. It is crucial to ensure the person is alert and able to follow instructions for an accurate oral temperature.
Choice A (The person has influenza): This is not a valid reason to avoid taking an oral temperature as having influenza does not necessarily impact the accuracy of the reading.
Choice B (The person almost certainly has a fever): While the person likely has a fever, it does not directly affect the process of taking an oral temperature if the person is alert and can follow instructions.
Choice C (The person is over six years old): Age alone does not determine whether a person should not have their oral temperature taken. It is the person's ability to cooperate and follow instructions that matters.
You are on scene at a motor vehicle accident, and your 20-year-old patient is entrapped. He is unconscious, unresponsive, and has a palpable carotid pulse that is weak and thready. His breathing is slow and shallow at four times a minute with equal chest wall expansion. There are no obvious deformity injuries or hemorrhage noted. Fire department on-scene has stabilized the vehicle and provided you and your partner a relatively safe environment to manage the entrapped patient. However, access is limited to the seated patient, and extrication is expected to take another twenty minutes. After having your partner maintain cervical spine stabilization, which of the following would be the best choice for securing the patient's airway?
A. Insert a nasal airway and administer high-flow oxygen therapy
B. Use nasotracheal intubation techniques to gain complete control of the patient's airway and assist ventilation
C. Intubate the patient using the blind orotracheal intubation technique to maintain in-line mobilization of the spine, then assist ventilation
D. Insert a King LTD and begin assisting ventilations with a bag-valve mask
Correct answer:
The correct answer is C: Intubate the patient using the blind orotracheal intubation technique to maintain in-line mobilization of the spine, then assist ventilation. In this scenario, the patient is entrapped with limited access and expected extrication time of 20 minutes. Given the patient's unconsciousness, unresponsiveness, weak carotid pulse, and slow, shallow breathing, securing the airway is crucial to ensure adequate oxygenation and ventilation. Intubating the patient using the blind orotracheal technique allows for maintaining in-line mobilization of the spine, reducing the risk of further spinal injury during the extrication process. This approach provides a more definitive airway management compared to nasal airway insertion or bag-valve mask ventilation. Nasotracheal intubation (choice B) may not be feasible due to limited access and potential for further injury. Using a King LTD (choice D) is not recommended in this situation as it does not provide the same
A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this patient?
A. Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema.
B. Rasping cough, thick mucoid sputum, wheezing, and bronchitis.
C. Productive cough, dyspnea, weight loss, anorexia, and tuberculosis.
D. Fever, dry nonproductive cough, and diminished breath sounds.
Correct answer:
The correct answer is A. In a severe exacerbation of heart failure, the patient is likely to exhibit symptoms such as shortness of breath, orthopnea (difficulty breathing lying flat), paroxysmal nocturnal dyspnea (sudden onset of difficulty breathing at night), and ankle edema (swelling). These symptoms are classic signs of heart failure exacerbation due to fluid overload and poor cardiac function.
Explanation for why the other choices are incorrect:
- B: Rasping cough, thick mucoid sputum, wheezing, and bronchitis are more indicative of respiratory conditions such as chronic obstructive pulmonary disease or pneumonia, not heart failure exacerbation.
- C: Productive cough, dyspnea, weight loss, anorexia, and tuberculosis suggest a different diagnosis related to a respiratory infection like tuberculosis rather than heart failure exacerbation.
- D: Fever, dry nonproductive cough, and diminished breath sounds are more suggestive of a respiratory infection like pneumonia,
What is one guideline for a nursing assistant who is caring for a resident receiving oxygen therapy?
A. The NA should limit smoking to certain areas.
B. The NA should reduce the number of pillows the resident uses.
C. The NA should report changes in the resident's respiratory rate.
D. The NA should use petroleum-based lip balms to help with irritation.
Correct answer:
Correct Answer: C - The NA should report changes in the resident's respiratory rate.
Rationale: Reporting changes in the resident's respiratory rate is crucial in oxygen therapy monitoring. It helps identify any potential respiratory distress or improvement. This information allows healthcare providers to adjust oxygen levels accordingly and provide appropriate care. Monitoring respiratory rate is a key aspect of ensuring the resident's safety and well-being.
Summary of other choices:
A: The NA should limit smoking to certain areas. - Smoking should be completely avoided near a resident receiving oxygen therapy to prevent fire hazards.
B: The NA should reduce the number of pillows the resident uses. - Adjusting the number of pillows may affect the resident's comfort but does not directly relate to oxygen therapy.
D: The NA should use petroleum-based lip balms to help with irritation. - Petroleum-based lip balms are flammable and should be avoided near oxygen therapy.
During a physical examination, a 45-year-old woman states that she has had a crusty, itchy rash on her breast for approximately 2 weeks. In trying to find the cause of the rash, which question would be important for the nurse to ask?
A. "Is the rash raised and red?"
B. "Does it appear to be cyclic?"
C. "Where did the rash first appear—on the nipple, the areola, or the surrounding skin?"
D. "What was she doing when she first noticed the rash, and do her actions make it worse?"
Correct answer:
The correct answer is C: "Where did the rash first appear—on the nipple, the areola, or the surrounding skin?" This question is crucial because the location of the rash can provide valuable clues about the potential cause. For example, a rash on the nipple may point towards issues like Paget's disease, while a rash on the areola could suggest eczema or contact dermatitis. On the other hand, a rash on the surrounding skin may indicate a fungal infection or allergic reaction. By identifying the precise location of the rash, the nurse can narrow down the differential diagnosis and develop an appropriate care plan.
Summary:
A: "Is the rash raised and red?" - This question focuses on the appearance of the rash but does not provide specific information about its location, which is more critical in determining the cause.
B: "Does it appear to be cyclic?" - This question is not as directly relevant to identifying the cause of the rash compared to pinpointing its location.
D
The nurse notes darker skin pigmentation in the skinfolds of a middle-aged patient who has a body mass index of 40 kg/m2. What is the nurse’s appropriate action?
A. Discuss the use of drying agents to minimize infection risk.
B. Instruct the patient about the use of mild soap to clean skinfolds.
C. Teach the patient about treating fungal infections in the skinfolds.
D. Ask the patient about a personal or family history of type 2 diabetes.
Correct answer:
The correct answer is D: Ask the patient about a personal or family history of type 2 diabetes. This is important because individuals with darker skin pigmentation and obesity are at higher risk for developing type 2 diabetes. By inquiring about the patient's personal or family history of type 2 diabetes, the nurse can gather important information to assess the patient's risk factors and potentially intervene early.
Summary of other choices:
A: Discussing the use of drying agents to minimize infection risk may not address the underlying health concern related to darker skin pigmentation and obesity.
B: Instructing the patient about the use of mild soap to clean skinfolds is important for hygiene but does not address the potential risk of type 2 diabetes.
C: Teaching the patient about treating fungal infections in the skinfolds may be relevant if there is a current infection but does not address the broader health implications of darker skin pigmentation and obesity.
The nurse is assessing a patient's respiratory status and notes that the patient is using their neck muscles to breathe. What is the most likely cause of this finding?
A. Severe respiratory distress.
B. Hyperventilation.
C. Pneumothorax.
D. Acute bronchitis.
Correct answer:
The correct answer is A: Severe respiratory distress. When a patient is using their neck muscles to breathe, it indicates that they are struggling to breathe effectively. This is a sign of increased work of breathing, which is commonly seen in severe respiratory distress. The neck muscles are recruited as accessory muscles to help with breathing when the respiratory system is compromised. This finding can be seen in conditions such as severe asthma, acute respiratory failure, or severe pneumonia. Therefore, the most likely cause of a patient using their neck muscles to breathe is severe respiratory distress.
Summary:
- Choice B (Hyperventilation): Hyperventilation is characterized by rapid and deep breathing, not necessarily the use of neck muscles to breathe.
- Choice C (Pneumothorax): Pneumothorax typically presents with chest pain and shortness of breath, but not specifically with the use of neck muscles to breathe.
- Choice D (Acute bronchitis): Acute bronchitis
RN exams fundamentals practice questions, set 11 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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