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 nurse inadvertently administers the wrong dose of antibiotic to a patient recovering from surgery. Which of these is the correct course of action for the nurse when documenting this in the patient’s medical record?
A. The nurse should create an incident report and record the facts of the incident in the medical record, but does not have to include an actual copy of the incident report or reference its existence.
B. The nurse should create an incident report and include a copy of the report in the patient’s medical record.
C. The nurse should tell the patient of the incident and ask his or her preference on if an incident report should be created and if one is, it should be included in the patient’s medical record.
D. The nurse should just document the dosage given in the patient’s chart. An incident report is not necessary because it was simply the wrong dosage of a drug that was ordered.
Show answer and rationale
Correct answer: A — The nurse should create an incident report and record the facts of the incident in the medical record, but does not have to include an actual copy of the incident report or reference its existence.
The correct course of action is Answer A: The nurse should create an incident report and record the facts of the incident in the medical record, but does not have to include an actual copy of the incident report or reference its existence.
1. Creating an incident report is crucial for documenting errors to ensure transparency and learning opportunities within the healthcare system.
2. Recording the facts of the incident in the medical record helps in tracking the error, ensuring proper follow-up, and providing necessary information for future care of the patient.
3. Not including an actual copy of the incident report or referencing its existence helps maintain confidentiality and prevents unnecessary alarm or distress to the patient or other healthcare providers.
Incorrect choices:
B: Including a copy of the incident report in the patient’s medical record may breach confidentiality and is not necessary for routine documentation.
C: Involving the patient in deciding on the incident report is not standard practice and may not always be appropriate in such situations.
D: Failing to document the incident properly
Question 2
A patient is admitted to the unit after an automobile accident. The nurse begins the mental status examination and finds that the patient has dysarthric speech and is lethargic. The nurse's best approach regarding this examination is to:
A. Plan to defer the rest of the mental status examination
B. Skip the language portion of the examination, and proceed onto assessing mood and affect
C. Conduct an in-depth speech evaluation, and defer the mental status examination to another time
D. Proceed with the examination, and assess the patient for suicidal thoughts because dysarthria is often accompanied by severe depression
Show answer and rationale
Correct answer: A — Plan to defer the rest of the mental status examination
The correct answer is A: Plan to defer the rest of the mental status examination. Given the patient's dysarthric speech and lethargy, it is essential to prioritize the patient's physical well-being and safety over completing the mental status examination. Dysarthric speech may indicate a potential neurological issue that needs immediate attention. Deferring the examination allows for a more thorough assessment once the patient's physical condition stabilizes.
Choice B is incorrect because skipping the language portion and proceeding to mood and affect assessment neglects the importance of addressing the potential underlying medical issue causing the dysarthric speech.
Choice C is incorrect because conducting an in-depth speech evaluation and deferring the mental status examination may delay necessary medical intervention for the patient's condition.
Choice D is incorrect because assuming dysarthria is always associated with severe depression and jumping to assess for suicidal thoughts without addressing the immediate physical concerns is premature and may lead to overlooking critical medical issues.
Question 3
The nurse is assessing the mental status of a child. Which statement about children and mental status is true?
A. All aspects of mental status in children are interdependent
B. Children are highly labile and unstable until the age of 2 years
C. Children's mental status is largely a function of their parents' level of functioning until the age of 7 years
D. A child's mental status is impossible to assess until the child develops the ability to concentrate
Show answer and rationale
Correct answer: A — All aspects of mental status in children are interdependent
The correct answer is A because all aspects of mental status in children are indeed interdependent. This means that cognitive, emotional, and behavioral domains of mental status are interconnected and influence each other. It is crucial to assess all aspects together to gain a comprehensive understanding of a child's mental well-being.
Choice B is incorrect because children are not necessarily highly labile and unstable until the age of 2 years. While children may exhibit rapid changes in behavior due to developmental milestones, it is not accurate to generalize them as highly labile.
Choice C is incorrect as children's mental status is not solely a function of their parents' level of functioning. While parental influence plays a significant role, children's mental status is also influenced by various other factors such as genetics, environment, and individual experiences.
Choice D is incorrect as it is possible to assess a child's mental status even before they develop the ability to concentrate. Assessment tools and techniques exist to evaluate different aspects of mental status in children, even at a
Question 4
A nurse is preparing discharge instructions for an 89-year-old client with a stage 4 pressure injury on his coccyx. The caregiver has been trained on wound dressing changes and cleansing. The caregiver asks the nurse how they can prevent infection in the wound. Which answer by the nurse is most appropriate?
A. “Change the wound dressing only once a day.â€
B. “Use protective eyewear while changing the wound dressing.â€
C. “Pressure injuries rarely cause infections to worry about.â€
D. “Wear gloves and use the sterile or aseptic supplies provided to you when changing the client’s dressing.â€
Show answer and rationale
Correct answer: D — “Wear gloves and use the sterile or aseptic supplies provided to you when changing the client’s dressing.â€
The correct answer is D: “Wear gloves and use the sterile or aseptic supplies provided to you when changing the client’s dressing.†This answer is correct because wearing gloves and using sterile supplies help prevent introducing harmful bacteria into the wound, reducing the risk of infection. Gloves provide a barrier to protect both the caregiver's hands and the wound from contamination. Sterile supplies minimize the introduction of pathogens into the wound, promoting healing and preventing infection.
A: “Change the wound dressing only once a day.†- This answer is incorrect because the frequency of dressing changes should be based on the healthcare provider's instructions and the wound's condition, not a fixed schedule.
B: “Use protective eyewear while changing the wound dressing.†- While protective eyewear is important in certain situations, it is not directly related to preventing wound infection in this context.
C: “Pressure injuries rarely cause infections to worry about.†- This answer is incorrect because all wounds, including pressure injuries, are susceptible to infection
Question 5
A patient is admitted to the unit after an automobile accident. The nurse begins the mental status examination and finds that the patient has dysarthric speech and is lethargic. The nurse's best approach regarding this examination is to:
A. Plan to defer the rest of the mental status examination
B. Skip the language portion of the examination, and proceed onto assessing mood and affect
C. Conduct an in-depth speech evaluation, and defer the mental status examination to another time
D. Proceed with the examination, and assess the patient for suicidal thoughts because dysarthria is often accompanied by severe depression
Show answer and rationale
Correct answer: A — Plan to defer the rest of the mental status examination
The correct answer is A: Plan to defer the rest of the mental status examination. Given the patient's dysarthric speech and lethargy, it is essential to prioritize the patient's physical well-being and safety over completing the mental status examination. Dysarthric speech may indicate a potential neurological issue that needs immediate attention. Deferring the examination allows for a more thorough assessment once the patient's physical condition stabilizes.
Choice B is incorrect because skipping the language portion and proceeding to mood and affect assessment neglects the importance of addressing the potential underlying medical issue causing the dysarthric speech.
Choice C is incorrect because conducting an in-depth speech evaluation and deferring the mental status examination may delay necessary medical intervention for the patient's condition.
Choice D is incorrect because assuming dysarthria is always associated with severe depression and jumping to assess for suicidal thoughts without addressing the immediate physical concerns is premature and may lead to overlooking critical medical issues.
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Question 6
There is great variation among individual responses to the same stressor. In addition to age, nutritional status, and genetic inheritance, which additional factor influences the expression of stress response and reflects the complex psychological processing involved?
A. The type of stressor.
B. The amount of stress.
C. The context of the stressful event.
D. The individual9s appraisal of the stressor.
Correct answer:
The correct answer is D, the individual's appraisal of the stressor. This is because how a person perceives and interprets a stressor plays a significant role in determining their stress response. Individuals who appraise a stressor as a threat are more likely to experience a heightened stress response compared to those who view it as a challenge. This cognitive evaluation is crucial in shaping emotional and physiological reactions to stress.
A: The type of stressor is not the additional factor influencing stress response in this context. Different stressors may elicit different responses, but the question is asking for an additional factor beyond age, nutritional status, and genetic inheritance.
B: The amount of stress is not the primary focus here. While the intensity of stress can impact the response, the question is specifically asking for an additional factor influencing stress response beyond the factors mentioned.
C: The context of the stressful event is important but does not directly influence the expression of stress response as much as the individual's appraisal of the stress
There is great variation among individual responses to the same stressor. In addition to age, nutritional status, and genetic inheritance, which additional factor influences the expression of stress response and reflects the complex psychological processing involved?
A. The type of stressor.
B. The amount of stress.
C. The context of the stressful event.
D. The individual9s appraisal of the stressor.
Correct answer:
The correct answer is D, the individual's appraisal of the stressor. This is because how a person perceives and interprets a stressor plays a significant role in determining their stress response. Individuals who appraise a stressor as a threat are more likely to experience a heightened stress response compared to those who view it as a challenge. This cognitive evaluation is crucial in shaping emotional and physiological reactions to stress.
A: The type of stressor is not the additional factor influencing stress response in this context. Different stressors may elicit different responses, but the question is asking for an additional factor beyond age, nutritional status, and genetic inheritance.
B: The amount of stress is not the primary focus here. While the intensity of stress can impact the response, the question is specifically asking for an additional factor influencing stress response beyond the factors mentioned.
C: The context of the stressful event is important but does not directly influence the expression of stress response as much as the individual's appraisal of the stress
Suzanne, a 25 year old, comes to your clinic to establish care. You are the student preparing to go into the examination room to interview her. Which of the following is the most logical sequence for the patient-provider interview?
A. Establish the agenda, negotiate a plan, establish rapport, and invite the patient's story.
B. Invite the patient's story, negotiate a plan, establish the agenda, and establish rapport.
C. Greet the patient, establish rapport, invite the patient's story, establish the agenda, expand and clarify the patient's story, and negotiate a plan.
D. Negotiate a plan, establish an agenda, invite the patient's story, and establish rapport.
Correct answer:
The most logical sequence for the patient-provider interview is to greet the patient, establish rapport, invite the patient's story, establish the agenda, expand and clarify the patient's story, and negotiate a plan. This sequence ensures a patient-centered approach by first building a connection with the patient, allowing the patient to share their concerns and story, and then working collaboratively with the patient to address these concerns. It is important to start by building rapport to establish trust and a comfortable environment for the patient to open up about their health concerns. Inviting the patient's story allows the provider to understand the patient's perspective and how their symptoms are impacting their life. Establishing the agenda sets the priorities for the visit and ensures that both the provider and patient are on the same page. Expanding and clarifying the patient's story helps gather more detailed information, leading to a comprehensive assessment. Finally, negotiating a plan together with the patient ensures shared decision-making and a patient-centered approach
A nurse is preparing discharge instructions for an 89-year-old client with a stage 4 pressure injury on his coccyx. The caregiver has been trained on wound dressing changes and cleansing. The caregiver asks the nurse how they can prevent infection in the wound. Which answer by the nurse is most appropriate?
A. “Change the wound dressing only once a day.”
B. “Use protective eyewear while changing the wound dressing.”
C. “Pressure injuries rarely cause infections to worry about.”
D. “Wear gloves and use the sterile or aseptic supplies provided to you when changing the client’s dressing.”
Correct answer:
The correct answer is D: “Wear gloves and use the sterile or aseptic supplies provided to you when changing the client’s dressing.” This answer is correct because wearing gloves and using sterile supplies help prevent introducing harmful bacteria into the wound, reducing the risk of infection. Gloves provide a barrier to protect both the caregiver's hands and the wound from contamination. Sterile supplies minimize the introduction of pathogens into the wound, promoting healing and preventing infection.
A: “Change the wound dressing only once a day.” - This answer is incorrect because the frequency of dressing changes should be based on the healthcare provider's instructions and the wound's condition, not a fixed schedule.
B: “Use protective eyewear while changing the wound dressing.” - While protective eyewear is important in certain situations, it is not directly related to preventing wound infection in this context.
C: “Pressure injuries rarely cause infections to worry about.” - This answer is incorrect because all wounds, including pressure injuries, are susceptible to infection
The nurse recognizes that the concept of prevention in describing health is essential because:
A. Disease can be prevented by treating the external environment.
B. The majority of deaths among Americans under age 65 years are not preventable.
C. Prevention places the emphasis on the link between health and personal behavior.
D. The means to prevention is through treatment provided by primary health care practitioners.
Correct answer:
Rationale for Choice C (Correct Answer):
The nurse recognizes that prevention places emphasis on the link between health and personal behavior because an individual's actions and choices greatly influence their health outcomes. By focusing on prevention, individuals can proactively engage in healthy behaviors to reduce their risk of developing diseases or health complications. This approach empowers individuals to take control of their health and well-being, promoting long-term health benefits and reducing the burden on healthcare systems.
Summary of Other Choices:
A: Incorrect - Disease prevention involves more than just treating the external environment; it also includes individual behaviors and lifestyle choices.
B: Incorrect - While some deaths may be unavoidable, prevention strategies can significantly reduce the incidence of many diseases and health conditions.
D: Incorrect - Prevention is not solely reliant on treatment provided by primary health care practitioners; it involves a combination of individual behaviors, public health initiatives, and healthcare interventions.
The nurse recognizes that the concept of prevention in describing health is essential because:
A. Disease can be prevented by treating the external environment.
B. The majority of deaths among Americans under age 65 years are not preventable.
C. Prevention places the emphasis on the link between health and personal behavior.
D. The means to prevention is through treatment provided by primary health care practitioners.
Correct answer:
Rationale for Choice C (Correct Answer):
The nurse recognizes that prevention places emphasis on the link between health and personal behavior because an individual's actions and choices greatly influence their health outcomes. By focusing on prevention, individuals can proactively engage in healthy behaviors to reduce their risk of developing diseases or health complications. This approach empowers individuals to take control of their health and well-being, promoting long-term health benefits and reducing the burden on healthcare systems.
Summary of Other Choices:
A: Incorrect - Disease prevention involves more than just treating the external environment; it also includes individual behaviors and lifestyle choices.
B: Incorrect - While some deaths may be unavoidable, prevention strategies can significantly reduce the incidence of many diseases and health conditions.
D: Incorrect - Prevention is not solely reliant on treatment provided by primary health care practitioners; it involves a combination of individual behaviors, public health initiatives, and healthcare interventions.
You are the first ambulance to arrive on the scene of a single-car accident. As you approach the scene, you see four patients, two have been ejected from their vehicle, and two are still in the vehicle. What should be your next course of action?
A. Call medical control, and advise them of the situation
B. Request additional resources, such as fire rescue, and additional ambulances to respond to the scene
C. Begin immediate triage and treatment of the two patients ejected first while awaiting fire department response
D. Notify the local trauma center so they can prepare for the patients
Correct answer:
The correct answer is B: Request additional resources, such as fire rescue, and additional ambulances to respond to the scene. This is the best course of action because in a single-car accident with four patients, the situation is likely to be complex and require multiple resources. Requesting additional help ensures that there are enough personnel and equipment on scene to effectively manage the situation and provide prompt care to all patients. This step is crucial for the safety and well-being of the patients and the responders.
Summary of other choices:
A: Calling medical control is important, but in this scenario, immediate action on scene is necessary before informing medical control.
C: Starting immediate triage and treatment is important, but given the severity of the situation, additional resources are needed before focusing solely on the two ejected patients.
D: Notifying the local trauma center is important, but the immediate priority is to ensure that all patients receive timely and appropriate care on scene before transferring them to a higher level of care.
You are the first ambulance to arrive on the scene of a single-car accident. As you approach the scene, you see four patients, two have been ejected from their vehicle, and two are still in the vehicle. What should be your next course of action?
A. Call medical control, and advise them of the situation
B. Request additional resources, such as fire rescue, and additional ambulances to respond to the scene
C. Begin immediate triage and treatment of the two patients ejected first while awaiting fire department response
D. Notify the local trauma center so they can prepare for the patients
Correct answer:
The correct answer is B: Request additional resources, such as fire rescue, and additional ambulances to respond to the scene. This is the best course of action because in a single-car accident with four patients, the situation is likely to be complex and require multiple resources. Requesting additional help ensures that there are enough personnel and equipment on scene to effectively manage the situation and provide prompt care to all patients. This step is crucial for the safety and well-being of the patients and the responders.
Summary of other choices:
A: Calling medical control is important, but in this scenario, immediate action on scene is necessary before informing medical control.
C: Starting immediate triage and treatment is important, but given the severity of the situation, additional resources are needed before focusing solely on the two ejected patients.
D: Notifying the local trauma center is important, but the immediate priority is to ensure that all patients receive timely and appropriate care on scene before transferring them to a higher level of care.
One way for a nursing assistant to determine whether to perform a procedure or not is to
A. Perform all procedures even if he has no training in the procedures
B. Perform a procedure if he has forgotten how to do it because he will know the steps once he starts
C. Perform a procedure if it is not in his job description but he knows how to do it
D. Perform a procedure if it is within his scope of practice
Correct answer:
Rationale for Correct Answer (D): A nursing assistant should only perform procedures that are within their scope of practice to ensure patient safety and quality care. Scope of practice defines the tasks and responsibilities that a healthcare provider is trained and authorized to perform, ensuring competence and expertise in those specific areas. By following their scope of practice, nursing assistants can prevent potential harm to patients and maintain professional standards.
Summary of Incorrect Choices:
A (Perform all procedures even if he has no training): This choice is incorrect as performing procedures without proper training can pose significant risks to patients and is unethical.
B (Perform a procedure if he has forgotten how to do it): This choice is incorrect as relying on memory alone may lead to errors and jeopardize patient safety.
C (Perform a procedure not in job description but knows how to do it): This choice is incorrect as job descriptions are based on scope of practice, and performing tasks outside of it can result in legal and ethical issues.
A senior staff nurse observes a new graduate nurse prepare and administer medication for a client in their unit. The senior nurse notes that the graduate nurse bypassed the electronic medical record (EMR) medication scanning system and administered the medication directly to the client. Which action by the senior staff nurse is most appropriate?
A. Instruct the new graduate nurse on the importance of compliance with the EMR scanning system.
B. Continue observing the new graduate nurse; no injury resulted from the medication administration.
C. Report the new graduate nurse to upper management.
D. Chart that the medication was given in the electronic medical record.
Correct answer:
Step-by-step rationale for the correct answer (A):
1. Instructing the new graduate nurse on the importance of compliance with the EMR scanning system is essential to ensure patient safety.
2. The EMR scanning system helps prevent medication errors by verifying the right patient, right medication, right dose, right route, and right time.
3. By bypassing the system, the new graduate nurse put the patient at risk of receiving the wrong medication or dose.
4. Education and reinforcement of protocols are crucial for the nurse to understand the significance of following proper procedures.
5. This approach focuses on correcting the behavior and preventing future errors, promoting a culture of safety.
Summary of why other choices are incorrect:
B. Continuing to observe without addressing the error may lead to potential harm to patients in the future.
C. Reporting the nurse to upper management may be premature without first addressing the issue directly with the nurse.
D. Charting that the medication was given without following the correct procedure does not address
RN exams fundamentals practice questions, set 2 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
No. Nursier is independent practice. Register through the official path named on the RN exams exam guide.
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