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
A 75-year-old man is being discharged to his home following a fall in his kitchen that resulted in a fractured pelvis. The home health nurse makes a home assessment that will be used to design interventions to meet which priority need?
A. sleep and rest
B. support from family members
C. protection from potential harm
D. feeling a sense of accomplishment
Show answer and rationale
Correct answer: C — protection from potential harm
The correct answer is C: protection from potential harm. Following a fractured pelvis from a fall, the priority need is ensuring the patient's safety at home to prevent further harm. The home assessment will focus on identifying and addressing potential hazards that could lead to additional falls or injuries. This includes assessing the home environment for safety modifications, such as installing grab bars in the bathroom or removing tripping hazards. Ensuring protection from potential harm is essential for the patient's recovery and overall well-being.
Choices A, B, and D are incorrect because they do not address the immediate safety concerns associated with the patient's fractured pelvis. While sleep and rest, support from family members, and feeling a sense of accomplishment are important aspects of care, they are not the priority in this scenario where the main focus should be on preventing further injury and ensuring the patient's safety at home.
Question 2
A 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70 mm Hg. In reviewing her previous examination, the nurse notes that her blood pressure in her second month was 124/80 mm Hg. In evaluating this change, what does the nurse know to be true?
A. This decline in blood pressure is the result of peripheral vasodilatation and is an expected change.
B. This decline in blood pressure is the result of the parasympathetic effect of hormones secreted during pregnancy and is an expected change.
C. This change in blood pressure is not an expected finding because it means a decrease in cardiac output.
D. This decline in blood pressure means a decrease in circulating blood volume, which is dangerous for the fetus.
Show answer and rationale
Correct answer: A — This decline in blood pressure is the result of peripheral vasodilatation and is an expected change.
Step-by-step rationale:
1. During pregnancy, blood pressure tends to decrease due to hormonal and physiological changes.
2. The decline in blood pressure is attributed to peripheral vasodilatation, allowing for increased blood flow to the placenta.
3. This vasodilatation is a normal adaptive response to support the growing fetus.
4. The parasympathetic effect of pregnancy hormones contributes to the vasodilatation and helps regulate blood pressure.
5. Therefore, choice A is correct as it aligns with the physiological changes expected during pregnancy.
Summary of other choices:
- Choice B incorrectly attributes the decline solely to the parasympathetic effect, ignoring the role of vasodilatation.
- Choice C is incorrect as a decrease in blood pressure does not necessarily mean a decrease in cardiac output during pregnancy.
- Choice D is incorrect as a decrease in blood pressure does not always indicate a dangerous decrease in blood volume for the fetus.
Question 3
Adam is a very successful 15-year-old student and athlete. His mother brings him in today because he no longer studies, works out, or sees his friends. This has gone on for a month and a half. When you speak with him alone in the room, he states it "would be better if he were not here." What would you do next?
A. Tell him that he has a very promising career in anything he chooses and soon he will feel better.
B. Tell him that he needs an antidepressant and it will take about 4 weeks to work.
C. Speak with his mother about getting him together more with his friends.
D. Assess his suicide risk
Show answer and rationale
Correct answer: D — Assess his suicide risk
The correct answer is D: Assess his suicide risk. Given Adam's statement about it being better if he were not here and his recent behavioral changes, there are clear signs of potential suicidal ideation. It is crucial to prioritize assessing his immediate safety. This involves asking direct questions about suicide, assessing the presence of a suicide plan, means, and intent. This step is essential in ensuring Adam's safety and providing appropriate support and intervention if needed.
Other choices are incorrect because:
A: Offering vague reassurance about his promising future does not address the immediate concerns of potential suicide risk.
B: Jumping to prescribing antidepressants without a thorough evaluation and risk assessment is premature and does not address the urgency of the situation.
C: Speaking with his mother about getting him together with friends overlooks the seriousness of Adam's statement and the need for immediate intervention.
Question 4
The nurse is preparing to measure the vital signs of a 6-month-old infant. Which action by the nurse is correct?
A. Respirations are measured; then pulse and temperature.
B. Vital signs should be measured more frequently than in an adult.
C. Procedures are explained to the parent, and the infant is encouraged to handle the equipment.
D. The nurse should first perform the physical examination to allow the infant to become more familiar with her and then measure the infant's vital signs.
Show answer and rationale
Correct answer: A — Respirations are measured; then pulse and temperature.
The correct answer is A because in infants, it is recommended to measure respirations first, followed by pulse and temperature. Infants have irregular breathing patterns, so measuring respirations first allows for the most accurate reading. Pulse and temperature can be affected by handling the infant, so they should be measured after respirations.
Choice B is incorrect because vital signs in infants are typically measured at the same frequency as in adults, unless there are specific concerns or conditions.
Choice C is incorrect because involving the parent in the procedure and encouraging the infant to handle the equipment may not be appropriate or necessary for measuring vital signs accurately.
Choice D is incorrect because it is not necessary to perform a physical examination before measuring vital signs in an infant. It is important to follow the standard sequence of measuring respirations, then pulse, and temperature for accurate readings.
Question 5
The nurse is performing a musculoskeletal assessment and notes that the patient has a decreased range of motion in the shoulder with pain on movement. What is the most likely cause of this finding?
A. Osteoarthritis.
B. Frozen shoulder (adhesive capsulitis).
C. Rheumatoid arthritis.
D. Bursitis.
Show answer and rationale
Correct answer: B — Frozen shoulder (adhesive capsulitis).
The correct answer is B: Frozen shoulder (adhesive capsulitis). Frozen shoulder is characterized by decreased range of motion in the shoulder joint with pain on movement. This is due to inflammation and thickening of the shoulder joint capsule, leading to adhesions that restrict movement. Other choices are incorrect because:
A: Osteoarthritis primarily affects the joints, causing pain and stiffness but typically doesn't lead to severe restriction of range of motion like in frozen shoulder.
C: Rheumatoid arthritis is a systemic autoimmune disorder that can affect multiple joints, causing inflammation and deformities, but it doesn't typically present with the characteristic pattern of restricted movement seen in frozen shoulder.
D: Bursitis involves inflammation of the bursae (fluid-filled sacs) around joints, leading to pain and swelling, but it doesn't typically result in the severe restriction of movement and pain on movement seen in frozen shoulder.
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Question 6
The second phase in the critical thinking process entails:
A. Exploration of the issue
B. Induction of an event
C. Appraisal of the situation
D. Integration of decision
Correct answer:
The correct answer is C: Appraisal of the situation. In the second phase of the critical thinking process, it is essential to evaluate and assess all relevant information and perspectives regarding the issue at hand. This helps in understanding the complexity of the situation, identifying biases or assumptions, and determining the credibility of sources. By appraising the situation, one can make informed decisions based on logical reasoning and evidence.
Summary:
A: Exploration of the issue - This is typically done in the initial phase of critical thinking where the problem or question is identified.
B: Induction of an event - Induction involves making generalizations based on specific observations and is not specifically related to the second phase of critical thinking.
D: Integration of decision - This is a later stage where decisions are synthesized based on the appraisal of the situation, making it an incorrect choice for the second phase.
A 55-year-old secretary with a recent history of breast cancer, for which she underwent surgery and radiation therapy, and a history of hypertension comes to your office for a routine checkup. Which of the following aspects of the physical are important to note when assessing the patient for peripheral vascular disease in the arms?
A. Femoral pulse, popliteal pulse
B. Dorsalis pedis pulse, posterior tibial pulse
C. Carotid pulse
D. Radial pulse, brachial pulse
Correct answer:
The correct answer is D: Radial pulse, brachial pulse. When assessing for peripheral vascular disease in the arms, it is important to check the radial and brachial pulses. The radial pulse is located at the wrist and is an indicator of arterial flow to the hand, while the brachial pulse is located in the upper arm and is important for assessing arterial flow to the forearm. In this patient with a history of breast cancer and hypertension, checking these pulses can provide valuable information about blood flow to the arms, especially after surgery and radiation therapy.
Choices A, B, and C are incorrect because:
A: Femoral and popliteal pulses are located in the lower extremities and are not relevant for assessing peripheral vascular disease in the arms.
B: Dorsalis pedis and posterior tibial pulses are also located in the lower extremities and do not provide information about arterial flow to the arms.
C: Carotid pulse is located in the neck and is
You are called to assist a 20-year-old male for a severe headache. On-scene, you learn the patient was involved in an accident that caused a potential closed head injury. However, at the time of the accident, the patient refused EMS care, stating he felt fine. Today, he is experiencing headache, confusion, and visual disturbances. Which of the following injuries is most likely to cause this type presentation?
A. Coup-contra-coup injury
B. Diffuse axonal injury
C. Subdural hematoma
D. Epidural hematoma
Correct answer:
The correct answer is C: Subdural hematoma. A subdural hematoma is a collection of blood between the dura mater and arachnoid mater layers of the meninges. This type of injury typically occurs due to acceleration-deceleration forces causing tearing of bridging veins, common in closed head injuries. The symptoms described (headache, confusion, visual disturbances) are consistent with the presentation of a subdural hematoma. Other choices are less likely: A) Coup-contra-coup injury involves impact forces causing brain injury at the site of impact and opposite side, typically seen in motor vehicle accidents. B) Diffuse axonal injury is caused by shearing forces leading to widespread damage throughout the brain, often resulting in a comatose state. D) Epidural hematoma is a collection of blood between the dura mater and the skull, usually due to arterial bleeding, and is more commonly associated with a lucid interval followed by rapid deterioration, but
The nurse is performing an assessment on a patient brought to the emergency department for treatment for dehydration. The nurse assesses a respiratory rate of 26 breaths/minute, a heart rate of 110 beats/minute, a blood pressure of 86/50 mm Hg, and a temperature of 39.5 C. The patient becomes dizzy when transferred from the wheelchair to a bed. The nurse notes cool, clammy skin. Which diagnosis does the nurse suspect?
A. Fluid volume deficit (FVD)
B. Fluid volume excess (FVE)
C. Mild extracellular fluid (ECF) deficit
D. Renal failure
Correct answer:
The correct diagnosis is A: Fluid volume deficit (FVD). The patient's vital signs and symptoms indicate hypovolemia. A respiratory rate of 26 breaths/minute, heart rate of 110 beats/minute, low blood pressure, high temperature, dizziness upon position change, and cool, clammy skin are all indicative of FVD. The increased respiratory and heart rates are compensatory mechanisms to maintain oxygen delivery in response to decreased circulating volume. The low blood pressure and cool, clammy skin suggest poor perfusion due to decreased fluid volume. These findings align with the clinical presentation of dehydration.
Summary of other choices:
B: Fluid volume excess (FVE) - Contradicted by the patient's low blood pressure, cool, clammy skin, and symptoms of dehydration.
C: Mild extracellular fluid (ECF) deficit - Symptoms and vital signs are indicative of severe rather than mild fluid deficit.
D: Renal failure - Not supported by the information provided;
A patient has pitting pedal edema, crackles, and an elevated blood pressure. The nurse concludes that the patient has fluid volume excess. Which type of reasoning did the nurse use?
A. Theoretical
B. Inductive
C. Deductive
D. Conceptual
Correct answer:
The correct answer is B: Inductive reasoning. The nurse used inductive reasoning by observing specific signs and symptoms (pitting pedal edema, crackles, elevated blood pressure) and making a general conclusion (fluid volume excess). Inductive reasoning involves deriving general principles from specific observations.
A: Theoretical reasoning involves applying established theories or principles to a situation. In this case, the nurse is not applying a theoretical framework but rather drawing a conclusion from observed data.
C: Deductive reasoning involves starting with a general principle and applying it to a specific situation to reach a specific conclusion. This is not the case here as the nurse started with specific symptoms and reached a general conclusion.
D: Conceptual reasoning involves using abstract concepts or ideas to analyze a situation. The nurse's reasoning was more based on concrete observations rather than abstract concepts.
Your adult patient sustained a right index finger amputation at work. On arrival, first responders have the bleeding controlled with sterile dressings, and the patient is conscious, alert, and oriented. What is the best way to manage the patient's amputated finger during transport to the hospital?
A. Do not wrap the finger. Gently place it in a sealed plastic bag, and place it on a towel in ice.
B. Wrap the finger in gauze (moistened with normal saline), and seal the finger in a plastic bag before placing it on ice
C. Rinse the gauze-wrapped finger using water, and place it in a plastic bag with ice
D. Wrap it in gauze, and place the finger in close proximity to the patient's core to maintain the appropriate body temperature for re-attachment
Correct answer:
The correct answer is B: Wrap the finger in gauze (moistened with normal saline), and seal the finger in a plastic bag before placing it on ice. This method helps preserve the amputated part by keeping it moist and cool, which can improve the chances of successful reattachment. Here's a step-by-step rationale:
1. Moistening the gauze with normal saline helps prevent the tissue from drying out, maintaining its viability.
2. Sealing the finger in a plastic bag helps protect it from contamination and further damage during transport.
3. Placing the sealed finger on ice helps keep it cool, which slows down metabolic processes and reduces tissue damage.
4. Avoiding direct contact of the finger with ice prevents frostbite and tissue damage from extreme cold.
In summary, option B is the best choice as it optimally preserves the amputated finger for potential reattachment. Option A does not maintain moisture, leading to tissue damage. Option C's use of water
You are called to assist a 20-year-old male for a severe headache. On-scene, you learn the patient was involved in an accident that caused a potential closed head injury. However, at the time of the accident, the patient refused EMS care, stating he felt fine. Today, he is experiencing headache, confusion, and visual disturbances. Which of the following injuries is most likely to cause this type presentation?
A. Coup-contra-coup injury
B. Diffuse axonal injury
C. Subdural hematoma
D. Epidural hematoma
Correct answer:
The correct answer is C: Subdural hematoma. A subdural hematoma is a collection of blood between the dura mater and arachnoid mater layers of the meninges. This type of injury typically occurs due to acceleration-deceleration forces causing tearing of bridging veins, common in closed head injuries. The symptoms described (headache, confusion, visual disturbances) are consistent with the presentation of a subdural hematoma. Other choices are less likely: A) Coup-contra-coup injury involves impact forces causing brain injury at the site of impact and opposite side, typically seen in motor vehicle accidents. B) Diffuse axonal injury is caused by shearing forces leading to widespread damage throughout the brain, often resulting in a comatose state. D) Epidural hematoma is a collection of blood between the dura mater and the skull, usually due to arterial bleeding, and is more commonly associated with a lucid interval followed by rapid deterioration, but
M.J., age 85, has been diagnosed with terminal lung cancer. During report you were told that the family does not want her to know the diagnosis. M.J. asks you, "Am I going to die?" Which of the following is the best therapeutic response from you, the nurse?
A. "Tell me what prompted that question."
B. "I will ask your physician to discuss this matter with you."
C. "Let's take each day as it comes."
D. "I think you should discuss that with your family."
Correct answer:
The correct answer is A: "Tell me what prompted that question." This response shows empathy, encourages open communication, and allows M.J. to express her concerns. By asking for clarification, the nurse can assess M.J.'s understanding and emotional state, providing an opportunity to address her fears and offer support. This approach respects M.J.'s autonomy and allows her to share her feelings.
Choice B: "I will ask your physician to discuss this matter with you." This response avoids addressing M.J.'s concerns directly and may not respect her preferences for communication.
Choice C: "Let's take each day as it comes." This response does not directly address M.J.'s question and may come across as dismissive of her concerns.
Choice D: "I think you should discuss that with your family." This response does not acknowledge M.J.'s feelings or provide direct support, potentially undermining the therapeutic relationship between the nurse and M.J.
A client is admitted to a cardiac care unit for chronic hypertension. The client has been struggling to take their medications appropriately and acute management was required to gain control of the client’s hypertension. The client had recently been having several high blood pressures in the morning and was prescribed amlodipine (Norvasc®) 5 mg PO daily. Prior to the first administration of the amlodipine (Norvasc), the client’s vitals read: heart rate 80, respiratory rate 10, 100%, and blood pressure 80/50. Which action by the nurse is most appropriate?
A. Administer the amlodipine (Norvasc®).
B. Chart that the client refused the medication.
C. Hold the amlodipine (Norvasc®) and notify the provider.
D. Hold the amlodipine (Norvasc®) for 30 minutes and then administer the medication.
Correct answer:
The correct answer is C: Hold the amlodipine (Norvasc®) and notify the provider. The client's blood pressure of 80/50 is significantly low, indicating hypotension. Amlodipine is a calcium channel blocker that can further lower blood pressure. Therefore, administering amlodipine in this situation could worsen the hypotension and lead to potential complications such as dizziness, fainting, or even shock. By holding the medication and notifying the provider, the nurse ensures that the provider can assess the situation and determine the appropriate course of action, which may include adjusting the medication dosage or considering alternative treatments. This approach prioritizes patient safety and prevents harm.
Summary of other choices:
A: Administering the amlodipine could worsen the hypotension, leading to potential complications.
B: Charting that the client refused the medication does not address the critical issue of the client's hypotension.
D:
A 30-year-old woman presents with a complaint of a red, painful, and swollen knee. She has a history of gout. On examination, the knee is warm, erythematous, and tender to touch. What is the most likely diagnosis?
A. Osteoarthritis
B. Rheumatoid arthritis
C. Gout
D. Septic arthritis
Correct answer:
The most likely diagnosis is gout (Choice C) based on the patient's presentation of red, painful, and swollen knee, with a history of gout. Gout is a form of inflammatory arthritis caused by the deposition of uric acid crystals in the joints, leading to acute flares of pain and swelling. The characteristic features of gout include sudden onset of symptoms, typically affecting one joint at a time, with warmth, erythema, and tenderness. In this case, the patient's history of gout and the classic presentation of an acutely inflamed joint support the diagnosis.
Osteoarthritis (Choice A) is a chronic degenerative joint disease characterized by gradual onset of joint pain, stiffness, and limited range of motion. It typically affects weight-bearing joints and is not associated with acute inflammation as seen in gout.
Rheumatoid arthritis (Choice B) is an autoimmune disease that causes symmetrical joint pain, morning stiffness, and joint deformities
RN exams fundamentals practice questions, set 14 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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