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
How do you measure for leg length discrepancy?
A. Anterior superior iliac spine (ASIS) to lateral malleolus
B. Posterior superior iliac spine (PSIS) to lateral malleolus
C. ASIS to medial malleolus
D. PSIS to medial malleolus
Show answer and rationale
Correct answer: C — ASIS to medial malleolus
To measure for leg length discrepancy accurately, you should measure from the Anterior Superior Iliac Spine (ASIS) to the Medial Malleolus. This is because the ASIS is a reliable and consistent bony landmark for measurement, and the medial malleolus is a stable reference point at the ankle joint. Measuring from ASIS to Medial Malleolus ensures that the entire length of the leg is accounted for, providing an accurate assessment of any potential length difference between the two legs. This measurement technique is commonly used in clinical practice and research studies to assess leg length inequality.
Summary:
A: Incorrect - Does not account for the full length of the leg.
B: Incorrect - PSIS is not commonly used as a reference point for leg length measurement.
C: Correct - ASIS to Medial Malleolus provides an accurate measurement of leg length discrepancy.
D: Incorrect - PSIS is not commonly used for measuring leg length, and measuring
Question 2
A 17-year-old high school senior presents to your clinic in acute respiratory distress with sudden right-sided chest pain and severe shortness of breath. On auscultation you hear no breath sounds on the right side of his superior chest wall. On percussion he is hyperresonant over the right upper lobe. With palpation he has absent fremitus over the right upper lobe.
A. Spontaneous pneumothorax
B. Chronic obstructive pulmonary disease (COPD)
C. Asthma
D. Pneumonia
Show answer and rationale
Correct answer: A — Spontaneous pneumothorax
The correct answer is A: Spontaneous pneumothorax. This condition involves the accumulation of air in the pleural space, leading to lung collapse. In this case, the absence of breath sounds, hyperresonance on percussion, and absent fremitus on palpation are classic signs of pneumothorax. The sudden onset of symptoms in a young individual, particularly with chest pain and shortness of breath, further support this diagnosis.
Choices B, C, and D can be ruled out:
B: Chronic obstructive pulmonary disease (COPD) is a chronic condition characterized by airflow limitation, typically seen in older individuals with a history of smoking. This does not fit the acute presentation in a young patient.
C: Asthma is a chronic inflammatory condition that causes reversible airway obstruction, often presenting with wheezing and cough, which are not seen in this patient.
D: Pneumonia is an infection of the lung tissue, usually presenting with fever,
Question 3
A client is having a lumbar puncture performed. The nurse would plan to place the client in which position?
A. Side-lying, with a pillow under the hip.
B. Prone, with a pillow under the abdomen.
C. Prone, in slight-Trendelenburg's position.
D. Side-lying, with the legs pulled up and head bent down onto chest.
Show answer and rationale
Correct answer: D — Side-lying, with the legs pulled up and head bent down onto chest.
The correct answer is D. During a lumbar puncture, the client should be positioned in a side-lying position with the legs pulled up and head bent down onto the chest. This position helps to open up the spaces between the vertebrae, making it easier for the healthcare provider to access the lumbar area. Placing the legs up also helps to widen the spaces between the vertebrae, making it easier to insert the needle without damaging the spinal cord. The head bent down onto the chest helps to round the back, further increasing the space between the vertebrae.
Choice A is incorrect because placing a pillow under the hip does not provide the necessary positioning for a lumbar puncture. Choice B is incorrect as the prone position with a pillow under the abdomen would not facilitate access to the lumbar area. Choice C is incorrect as the Trendelenburg's position is not recommended for lumbar punctures as it can increase intracranial pressure.
Question 4
One way for a nursing assistant to communicate effectively with a resident who has a visual impairment is to
A. Wait until the resident speaks to her before identifying herself
B. Touch the resident on the arm before identifying herself to let her know the NA is there
C. Speak as little as possible while providing care
D. Use the face of an imaginary clock to explain the position of objects
Show answer and rationale
Correct answer: B — Touch the resident on the arm before identifying herself to let her know the NA is there
The correct answer is B: Touch the resident on the arm before identifying herself to let her know the NA is there. This approach is effective because it helps the visually impaired resident to be aware of the nursing assistant's presence before verbal communication. By gently touching the resident's arm, the nursing assistant establishes physical contact and ensures the resident is prepared for interaction. This gesture shows respect for the resident's personal space and helps build trust and rapport.
A: Waiting until the resident speaks is not proactive and may lead to confusion or frustration for the visually impaired resident.
C: Speaking as little as possible is not helpful as communication is essential for providing care and addressing the resident's needs.
D: Using the face of an imaginary clock may be confusing and unnecessary for the resident, as simple and direct communication through touch and verbal cues is more effective.
Question 5
The nurse is performing a presurgical admission assessment of the client. Which client statement needs the most immediate follow-up?
A. “I feel very hungry, I haven't eaten foods or had fluids for the past 12 hours.â€
B. “I donated my own blood in case I need a transfusion; the last donation was 4 days ago.â€
C. “I took all my meds including warfarin and atenolol with a sip of water this morning.â€
D. “I brought a copy of my health care directive in case my heart stops during surgery.â€
Show answer and rationale
Correct answer: C — “I took all my meds including warfarin and atenolol with a sip of water this morning.â€
The correct answer is C. The client statement "I took all my meds including warfarin and atenolol with a sip of water this morning" needs immediate follow-up because warfarin is a blood thinner and atenolol is a beta-blocker, both of which can have implications for surgery. Warfarin increases the risk of bleeding during surgery and atenolol can affect heart function. The nurse needs to assess the timing of medication intake and coordinate with the healthcare team to manage these medications appropriately before surgery to prevent complications.
Choice A is not the most immediate concern since it is common practice to fast before surgery to reduce the risk of aspiration. Choice B, while important, does not require immediate follow-up as long as the donation meets the facility's guidelines. Choice D, bringing a health care directive, is important but not as urgent as addressing medication intake that can directly impact the surgery.
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Question 6
An examiner is using an ophthalmoscope to examine a patient's eyes. Which technique indicates that the examination is being correctly performed?
A. Using the large full circle of light when assessing pupils that are not dilated.
B. Rotating the lens selector dial to the black numbers to compensate for astigmatism.
C. Using the grid on the lens aperture dial to visualize the external structures of the eye.
D. Rotating the lens selector dial to the red numbers to compensate for myopia.
Correct answer:
The correct answer is D: Rotating the lens selector dial to the red numbers to compensate for myopia. This is the correct technique because red numbers on the lens selector dial indicate the adjustment for nearsightedness (myopia) by adding concave lenses. This adjustment helps in achieving a clear view of the retina in myopic patients.
A: Using the large full circle of light when assessing pupils that are not dilated is incorrect because a smaller circle of light is preferred for assessing undilated pupils to reduce glare.
B: Rotating the lens selector dial to the black numbers to compensate for astigmatism is incorrect because astigmatism is corrected by adjusting the cylindrical power, not by using black numbers on the lens selector dial.
C: Using the grid on the lens aperture dial to visualize the external structures of the eye is incorrect as the grid is typically used for focusing and not for visualizing external structures.
The nurse is caring for a patient who has a bloodborne pathogen. The nurse splashes blood above the glove to intact skin while discontinuing an intravenous (IV) infusion. Which step(s) will the nurse take next?
A. Obtain an alcohol swab, remove the blood with an alcohol swab, and continue care.
B. Immediately wash the site with soap and running water, and seek guidance from the manager.
C. Do nothing; accidentally getting splashed with blood happens frequently and is part of the job.
D. Delay washing of the site until the nurse is finished providing care to the patient.
Correct answer:
The correct answer is B. Immediately washing the site with soap and running water is essential to reduce the risk of transmission of bloodborne pathogens. This step helps to remove any potentially infectious material and decreases the likelihood of infection. Seeking guidance from the manager is also important as they can provide support and further instructions on reporting the incident.
Choice A is incorrect because using an alcohol swab alone may not effectively remove all bloodborne pathogens, and continuing care without proper cleaning increases the risk of transmission.
Choice C is incorrect as ignoring a blood splashing incident can lead to serious health consequences for both the nurse and the patient. It is not acceptable to consider it a normal part of the job.
Choice D is incorrect because delaying washing the site can allow pathogens to enter the body through breaks in the skin, increasing the risk of infection.
The nurse is performing a presurgical admission assessment of the client. Which client statement needs the most immediate follow-up?
A. “I feel very hungry, I haven't eaten foods or had fluids for the past 12 hours.”
B. “I donated my own blood in case I need a transfusion; the last donation was 4 days ago.”
C. “I took all my meds including warfarin and atenolol with a sip of water this morning.”
D. “I brought a copy of my health care directive in case my heart stops during surgery.”
Correct answer:
The correct answer is C. The client statement "I took all my meds including warfarin and atenolol with a sip of water this morning" needs immediate follow-up because warfarin is a blood thinner and atenolol is a beta-blocker, both of which can have implications for surgery. Warfarin increases the risk of bleeding during surgery and atenolol can affect heart function. The nurse needs to assess the timing of medication intake and coordinate with the healthcare team to manage these medications appropriately before surgery to prevent complications.
Choice A is not the most immediate concern since it is common practice to fast before surgery to reduce the risk of aspiration. Choice B, while important, does not require immediate follow-up as long as the donation meets the facility's guidelines. Choice D, bringing a health care directive, is important but not as urgent as addressing medication intake that can directly impact the surgery.
A 35-year-old man is brought to the emergency department after a motorcycle accident. He is conscious but has pain in his chest. His vital signs are as follows: BP 100/60 mm Hg, pulse 120 bpm, and respiratory rate 22 breaths/min. Physical examination reveals bruising and tenderness over the left side of his chest. Which of the following is the most likely cause of his pain?
A. Rib fracture
B. Pneumothorax
C. Pericarditis
D. Myocardial infarction
Correct answer:
The correct answer is A: Rib fracture.
Rationale:
1. The patient's presentation with chest pain, tenderness, and bruising after a motorcycle accident is highly suggestive of a traumatic injury like a rib fracture.
2. Rib fractures are common in blunt chest trauma and can cause significant pain with breathing and movement.
3. Tenderness over the affected area and pain on palpation are typical findings in rib fractures.
4. The vital signs of a stable blood pressure and tachycardia are consistent with a rib fracture without significant hemodynamic instability.
Summary of incorrect choices:
B: Pneumothorax - Less likely in this case as there is no mention of decreased breath sounds or respiratory distress.
C: Pericarditis - Unlikely given the acute presentation after trauma and absence of classic pericarditis symptoms.
D: Myocardial infarction - Not likely in a young patient with trauma and no risk factors for heart disease.
The nurse is reviewing percussion techniques with a newly graduated nurse. Which technique indicates that more review is needed?
A. Percussing once over each area
B. Quickly lifting the striking finger after each stroke
C. Striking with the fingertip, not the finger pad
D. Using the wrist to make the strikes, not the arm
Correct answer:
Correct Answer: A
Rationale:
1. Percussing once over each area is incorrect because percussion should involve multiple strikes to accurately assess underlying structures.
2. Percussion requires a series of light and rapid strikes to elicit different sounds based on tissue density.
3. By percussing only once, the nurse may miss subtle differences in sound pitch and quality, leading to inaccurate assessments.
4. Therefore, more review is needed to ensure the nurse understands the importance of multiple percussion strikes for proper assessment.
Summary of other choices:
B. Quickly lifting the striking finger after each stroke is a correct technique to enhance the accuracy of percussion.
C. Striking with the fingertip, not the finger pad, is important to produce clear sounds during percussion.
D. Using the wrist to make the strikes, not the arm, is the correct technique to achieve controlled and precise percussion strikes.
A 17-year-old high school senior presents to your clinic in acute respiratory distress with sudden right-sided chest pain and severe shortness of breath. On auscultation you hear no breath sounds on the right side of his superior chest wall. On percussion he is hyperresonant over the right upper lobe. With palpation he has absent fremitus over the right upper lobe.
A. Spontaneous pneumothorax
B. Chronic obstructive pulmonary disease (COPD)
C. Asthma
D. Pneumonia
Correct answer:
The correct answer is A: Spontaneous pneumothorax. This condition involves the accumulation of air in the pleural space, leading to lung collapse. In this case, the absence of breath sounds, hyperresonance on percussion, and absent fremitus on palpation are classic signs of pneumothorax. The sudden onset of symptoms in a young individual, particularly with chest pain and shortness of breath, further support this diagnosis.
Choices B, C, and D can be ruled out:
B: Chronic obstructive pulmonary disease (COPD) is a chronic condition characterized by airflow limitation, typically seen in older individuals with a history of smoking. This does not fit the acute presentation in a young patient.
C: Asthma is a chronic inflammatory condition that causes reversible airway obstruction, often presenting with wheezing and cough, which are not seen in this patient.
D: Pneumonia is an infection of the lung tissue, usually presenting with fever,
A nurse is admitting a patient to the hospital for surgery. Which of the following pieces of information must be obtained from the patient? Select all that apply.
A. address
B. date of birth
C. admitting physician
D. symptoms experienced
Correct answer:
The correct answer is B: date of birth. It is essential to obtain the patient's date of birth for accurate identification and to ensure the correct patient receives the appropriate care. This information is crucial for confirming the patient's identity and preventing medical errors.
Explanation for Incorrect Choices:
A: Address - While obtaining the patient's address is important for communication and follow-up purposes, it is not a critical piece of information that must be obtained during the admission process.
C: Admitting physician - Knowing the admitting physician is important for coordination of care, but it is not crucial information that must be obtained directly from the patient.
D: Symptoms experienced - While knowing the symptoms experienced by the patient is important for medical history and assessment, it is not a piece of information that must be obtained directly from the patient during the admission process.
When assessing a patient's pulse, the nurse notes that the amplitude is weaker during inspiration and stronger during expiration. When the nurse measures the blood pressure, the reading decreases 20 mm Hg during inspiration and increases with expiration. This patient is experiencing pulsus:
A. Alternans.
B. Bisferiens.
C. Bigeminus.
D. Paradoxus.
Correct answer:
Step-by-step rationale for why the correct answer is D (Paradoxus):
1. Pulsus paradoxus is characterized by a decrease in pulse strength during inspiration and an increase during expiration, as seen in the patient's pulse assessment.
2. The blood pressure reading decreasing by 20 mm Hg during inspiration is indicative of pulsus paradoxus, as it reflects an exaggeration of the normal inspiratory drop in blood pressure.
3. Pulsus paradoxus is commonly associated with conditions like cardiac tamponade and severe asthma, which can cause this paradoxical pulse and blood pressure pattern.
Summary of why the other choices are incorrect:
A. Alternans: Alternating strong and weak pulse amplitudes, not related to the respiratory cycle.
B. Bisferiens: Pulse with double systolic peaks, not related to respiratory cycle changes.
C. Bigeminus: A pattern of every other heartbeat occurring prematurely, not related to respiratory cycle influences.
You are transporting a 20-year-old pregnant female from a local hospital to a medical facility that specializes in high-risk pregnancies when you note the patient is experiencing unexplained hypotension and bradycardia. The patient has a patent IV and is being administered magnesium that was initiated by hospital staff. On the cardiac monitor, the patient presents with a lengthening PR interval and signs of an impending high-degree nodal block. Which of the following interventions would be most appropriate in this case?
A. Increase the magnesium sulfate infusion rate, and administer a 1,000 mL normal saline bolus to support the patient's blood pressure
B. Stop the magnesium sulfate infusion immediately, and administer the appropriate dose of calcium chloride to correct the adverse effects of magnesium toxicity
C. Continue the infusion, but administer potassium chloride to counteract the adverse effects of the magnesium chloride administration
D. Reduce the infusion by half, and administer dextrose 50% to counteract the adverse cardiac effects caused by the magnesium chloride infusion
Correct answer:
The correct answer is B: Stop the magnesium sulfate infusion immediately, and administer the appropriate dose of calcium chloride to correct the adverse effects of magnesium toxicity.
Rationale:
1. Magnesium toxicity can lead to hypotension, bradycardia, and cardiac conduction abnormalities.
2. Stopping the magnesium infusion is crucial to prevent further adverse effects.
3. Calcium chloride is the antidote for magnesium toxicity as it competes with magnesium for binding sites on cardiac cells, restoring normal cardiac function.
4. Administering a normal saline bolus (choice A) would not address the underlying cause of magnesium toxicity.
5. Administering potassium chloride (choice C) is not appropriate as it can exacerbate the cardiac effects of magnesium toxicity.
6. Reducing the magnesium infusion and administering dextrose 50% (choice D) would not address the magnesium toxicity and may not reverse the cardiac effects.
The nurse is obtaining a health history on a 3-month-old infant. During the interview, the mother states, "I think she is getting her first tooth because she has started drooling a lot." The nurse's best response would be:
A. "You're right, drooling is usually a sign of the first tooth."
B. "It would be unusual for a 3 month old to be getting her first tooth."
C. "This could be the sign of a problem with the salivary glands."
D. "She is just starting to salivate and hasn't learned to swallow the saliva."
Correct answer:
The correct response is D: "She is just starting to salivate and hasn't learned to swallow the saliva." At 3 months old, infants often start drooling due to increased salivation as their salivary glands develop. This response acknowledges normal infant development and provides an explanation for the observed behavior.
Choice A (You're right, drooling is usually a sign of the first tooth) is incorrect because while drooling can be associated with teething, it is not the primary reason for drooling in a 3-month-old.
Choice B (It would be unusual for a 3-month-old to be getting her first tooth) is incorrect because teething can start as early as 3 months, although it is more common around 6 months.
Choice C (This could be the sign of a problem with the salivary glands) is incorrect as it jumps to a less likely conclusion of a salivary gland issue without considering the normal developmental process of salivation in infants
RN exams fundamentals practice questions, set 17 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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