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
Several minutes after sealing your adult trauma patient's sucking chest wound with an occlusive dressing secured on three sides, he begins to experience increasing shortness of breath, jugular vein distension, decreasing unilateral breath sounds on the affected side, and his blood pressure is less than 90 systolic and falling. Repeated attempts to relieve the pressure at the occlusive dressing have proven ineffective. At this point, which of the following should be initiated?
A. Remove the occlusive dressing and pull sucking chest wound open gently to allow air to escape the chest
B. Translaryngeal Jet Ventilation using a 10- or 14-gauge catheter that is an inch to an inch-and-a-half long
C. Endotracheal intubation and positive pressure ventilations via forced air ventilator
D. Immediate needle decompression using a 10- or 14-gauge catheter that is at least 2 or 2.5 inches long
Show answer and rationale
Correct answer: D — Immediate needle decompression using a 10- or 14-gauge catheter that is at least 2 or 2.5 inches long
The correct answer is D: Immediate needle decompression using a 10- or 14-gauge catheter that is at least 2 or 2.5 inches long.
Rationale:
1. Symptoms indicate tension pneumothorax, a life-threatening condition where air accumulates in the pleural space, causing pressure on the heart and lungs.
2. Needle decompression is the immediate intervention for tension pneumothorax to release trapped air and relieve pressure.
3. A longer catheter is needed to ensure successful decompression.
4. Translaryngeal Jet Ventilation (Choice B) is not recommended as it does not address the underlying issue of trapped air.
5. Endotracheal intubation (Choice C) may delay definitive treatment and worsen the patient's condition.
6. Removing the occlusive dressing (Choice A) without proper decompression can further exacerbate tension pneumothorax.
Summary:
Immediate needle decompression is crucial to treat tension pneumoth
Question 2
One way for an NA to have a positive relationship with a resident's family and friends is to
A. Avoid talking to the resident when he has visitors
B. Let the family take care of the resident's needs themselves
C. Tell the resident's friends stories about the resident that will make them laugh
D. Respond immediately when the resident calls for help
Show answer and rationale
Correct answer: D — Respond immediately when the resident calls for help
The correct answer is D because responding immediately when the resident calls for help shows attentiveness and care, building trust with the resident's family and friends. This action demonstrates the NA's dedication to the resident's well-being and emphasizes their commitment to providing timely assistance.
A is incorrect as avoiding talking to the resident when he has visitors can signal indifference and lack of engagement. B is incorrect because letting the family take care of the resident's needs themselves may suggest neglect of the NA's responsibilities. C is incorrect as telling stories about the resident without their consent may invade their privacy and potentially create uncomfortable situations.
In summary, choice D is the most effective way for an NA to establish a positive relationship with a resident's family and friends by prioritizing the resident's needs and ensuring prompt assistance.
Question 3
A patient who has been placed on Contact Precautions for Clostridium difficile (C. difficile) asks you to explain what he should know about this organism. Which statements made by the patient show an understanding of the patient teaching? (Select all that apply.)
A. “The organism is usually transmitted through the fecal-oral route.”
B. “Hands should always be cleaned with soap and water rather than the alcohol-based hand sanitizer.”
C. “Everyone coming into the room must wear a gown and gloves.”
D. “While I am in Contact Precautions, I cannot leave the room.”
Show answer and rationale
Correct answer: B — “Hands should always be cleaned with soap and water rather than the alcohol-based hand sanitizer.”
The correct answer is B: "Hands should always be cleaned with soap and water rather than the alcohol-based hand sanitizer."
Rationale:
1. C. difficile spores are not effectively killed by alcohol-based hand sanitizers.
2. Washing hands with soap and water is essential for removing spores.
3. Proper hand hygiene is crucial to prevent the spread of C. difficile.
4. This statement reflects understanding of the importance of hand hygiene in preventing transmission of C. difficile.
Incorrect Choices:
A: Incorrect. While C. difficile is transmitted through the fecal-oral route, this statement does not directly address patient teaching on prevention.
C: Incorrect. While gowns and gloves are necessary in Contact Precautions, this statement does not emphasize the importance of hand hygiene.
D: Incorrect. Patients on Contact Precautions may leave the room but should practice proper hand hygiene to prevent transmission.
Question 4
Infection prevention for the portal of exit link in the chain of infection could include
A. Covering the mouth when sneezing
B. Keeping surfaces clean and dry
C. Getting a vaccine for a particular disease
D. Handwashing
Show answer and rationale
Correct answer: A — Covering the mouth when sneezing
Step-by-step rationale for why choice A is correct:
1. The portal of exit is where the infectious agent leaves the reservoir host.
2. Covering the mouth when sneezing helps prevent the spread of respiratory infections through droplets.
3. By covering the mouth, the risk of releasing infectious droplets into the environment decreases, thus reducing transmission.
4. This practice is a direct way to prevent the exit of infectious agents from the reservoir host.
Summary of why other choices are incorrect:
- B: Keeping surfaces clean and dry is related to the mode of transmission or reservoir, not specifically to the portal of exit.
- C: Getting a vaccine for a particular disease is a preventive measure but not directly related to the portal of exit.
- D: Handwashing is important for infection prevention but is more related to breaking the chain at the mode of transmission stage, not at the portal of exit.
Question 5
A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he has had 'a runny nose for a week.' When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions. The nurse's next action should be to:
A. Assure the mother that these signs are normal symptoms of a cold.
B. Recognize that these are serious signs, and contact the physician.
C. Ask the mother if the infant has had trouble with feedings.
D. Perform a complete cardiac assessment because these signs are probably indicative of early heart failure.
Show answer and rationale
Correct answer: B — Recognize that these are serious signs, and contact the physician.
The correct answer is B: Recognize that these are serious signs, and contact the physician. Nasal flaring and sternal and intercostal retractions are signs of respiratory distress in infants. These indicate increased work of breathing and potential respiratory compromise. Therefore, it is crucial to recognize these serious signs and promptly involve the physician for further evaluation and management.
Incorrect choices:
A: Assuring the mother that these signs are normal symptoms of a cold is incorrect because these signs indicate respiratory distress, not just a common cold.
C: Asking about feeding issues is not the immediate priority when the infant is showing signs of respiratory distress. Contacting the physician is more urgent.
D: Performing a complete cardiac assessment is not indicated based on the presented signs, as they are more suggestive of respiratory distress rather than early heart failure.
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Question 6
A patient referred to physical therapy with chronic low back pain has failed to make any progress toward meeting established goals in over three weeks of treatment. The physical therapist has employed a variety of treatment techniques but has yet to observe improvement. What is the most appropriate next step?
A. Transfer the patient to another therapist's schedule.
B. Re-examine the patient and establish new goals.
C. Continue to modify the patient's treatment plan.
D. Alert the referring physician to the patient's status.
Correct answer:
The correct answer is B: Re-examine the patient and establish new goals. This is the most appropriate next step because if the patient has not shown progress in over three weeks, it indicates a need to reassess the current treatment plan and goals. By re-examining the patient, the therapist can identify any factors hindering progress and adjust the treatment plan accordingly. This proactive approach ensures the patient receives the most effective care.
Choice A: Transferring the patient to another therapist does not address the root cause of the lack of progress and may disrupt continuity of care.
Choice C: Simply continuing to modify the treatment plan without re-evaluating the patient may not lead to improved outcomes.
Choice D: Alerting the referring physician should be done after reassessment and establishing new goals, as the physician may require updated information but is not the immediate next step.
Mrs. Sales also tells the nurse that she is often constipated. Because she is aging, what physical changes predispose her to constipation?
A. Inhibition of the parasympathetic reflex
B. Esophageal emptying hastens
C. Loss of tone of the smooth muscles of the colon
D. Decreased ability to absorb fluids in the lower intestines
Correct answer:
The correct answer is C: Loss of tone of the smooth muscles of the colon. As individuals age, the smooth muscles of the colon can lose their tone, resulting in slower peristalsis and decreased bowel movements, leading to constipation. This physical change is a common factor contributing to constipation in older adults.
A: Inhibition of the parasympathetic reflex is not directly related to constipation in aging individuals. Parasympathetic stimulation usually promotes bowel movements.
B: Esophageal emptying hastening is not relevant to constipation. Esophageal emptying refers to the movement of food from the esophagus into the stomach, not the colon.
D: Decreased ability to absorb fluids in the lower intestines is not a typical physical change associated with aging that predisposes individuals to constipation. Constipation is more commonly linked to issues with colonic motility rather than fluid absorption.
During chemotherapy, an oncology client has a nursing diagnosis of impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis?
A. Recommending that the client discontinue chemotherapy
B. Providing a solution of hydrogen peroxide and water for use as a mouth rinse
C. monitoring the client’s platelet and leukocyte counts
D. Checking regularly for signs and symptoms of stomatitis
Correct answer:
Step 1: Providing a solution of hydrogen peroxide and water as a mouth rinse helps in reducing the pain of stomatitis by promoting oral hygiene and preventing infections.
Step 2: Hydrogen peroxide has antimicrobial properties that can help in reducing bacteria in the mouth, which can worsen stomatitis.
Step 3: Rinsing with this solution can also help in cleansing the oral mucosa and reducing inflammation, thereby decreasing pain.
Step 4: This intervention directly addresses the nursing diagnosis of impaired oral mucous membrane and is focused on symptom management.
Summary:
A: Recommending the client to discontinue chemotherapy is not a feasible option as it is essential for treating cancer.
C: Monitoring platelet and leukocyte counts is important but does not directly address the pain of stomatitis.
D: Checking for signs and symptoms is necessary but does not provide direct relief for the pain of stomatitis.
When a patient's intracranial pressure (ICP) is being monitored with an intraventricular catheter, which information obtained by the nurse is most important to communicate to the health care provider?
A. Oral temperature 102° F
B. Apical pulse 102 beats/min
C. Intracranial pressure 18 mm Hg
D. Mean arterial pressure 90 mm Hg
Correct answer:
The correct answer is C: Intracranial pressure 18 mm Hg. This is the most important information to communicate because changes in ICP can indicate increasing intracranial pressure, which can lead to serious complications such as brain herniation. Monitoring and promptly communicating any changes in ICP to the healthcare provider is crucial for timely intervention and prevention of further damage.
Choice A: Oral temperature 102°F is important for assessing for signs of infection or inflammation, but it is not directly related to the intracranial pressure monitoring.
Choice B: Apical pulse 102 beats/min is important for assessing cardiac function, but it is not directly related to intracranial pressure monitoring.
Choice D: Mean arterial pressure 90 mm Hg is important for assessing perfusion to the brain, but it is not as directly relevant to intracranial pressure monitoring as the actual ICP reading itself.
A patient has had a 'terrible itch' for several months that he has been continuously scratching. On examination, the nurse might expect to find:
A. A keloid.
B. A fissure.
C. Keratosis.
D. Lichenification.
Correct answer:
The correct answer is D: Lichenification. Lichenification is a skin condition characterized by thickening and hardening of the skin due to chronic irritation or scratching. In this case, the patient's continuous scratching of the itch has led to lichenification. This is evident by the rough and leathery texture of the skin upon examination.
A: A keloid is an overgrowth of scar tissue that can occur after a wound heals, not typically associated with chronic scratching.
B: A fissure is a small, painful crack in the skin that can occur due to dryness or trauma, not a result of continuous scratching.
C: Keratosis refers to various skin conditions characterized by thickening of the skin, but it is not specifically associated with chronic scratching like lichenification.
In summary, lichenification is the most likely finding in this scenario due to the chronic scratching leading to skin thickening and hardening.
A patient with hearing loss by whisper test is further examined with a tuning fork, using the Weber and Rinne maneuvers. The abnormal results are as follows: bone conduction is greater than air on the left, and the patient hears the sound of the tuning fork better on the left. Which of the following is most likely?
A. Otosclerosis of the left ear
B. Exposure to chronic loud noise of the right ear
C. Otitis media of the right ear
D. Perforation of the right eardrum
Correct answer:
The correct answer is A: Otosclerosis of the left ear. In otosclerosis, there is abnormal bone growth in the middle ear that affects sound conduction. In this case, bone conduction being greater than air on the left indicates a conductive hearing loss, which is consistent with otosclerosis. The Weber test showing the sound better on the left ear suggests a lateralization towards the affected ear, supporting the diagnosis.
Incorrect choices:
B: Exposure to chronic loud noise of the right ear would likely result in sensorineural hearing loss, not a conductive hearing loss as seen in this case.
C: Otitis media of the right ear would also lead to conductive hearing loss, but the abnormal findings are consistent with left ear involvement, making this choice incorrect.
D: Perforation of the right eardrum would result in a conductive hearing loss in the right ear, not the left ear as observed in this patient.
The new graduate RN needs to have a preceptor assigned to him as he begins working in the pediatric clinic. The BEST person for this assignment would be
A. The charge RN who is a natural leader and knows all of the policies.
B. The staff RN who has 3 years of experience and enjoys orienting new employees.
C. The LPN with 15 years of experience who knows all of the doctors9 preferences.
D. The staff RN with 10 years of experience who refuses to work with students.
Correct answer:
The correct answer is B: The staff RN who has 3 years of experience and enjoys orienting new employees. This choice is the best because the staff RN has a moderate level of experience which makes them knowledgeable but not overly set in their ways. Additionally, their willingness to orient new employees shows they have a positive attitude towards teaching and mentoring. This combination of experience and willingness to teach makes them an ideal preceptor for a new graduate RN.
A: The charge RN may be a natural leader and know the policies, but may not have the time or interest in orienting a new graduate.
C: The LPN with 15 years of experience may know the doctor's preferences, but their scope of practice may not align with the RN's learning needs.
D: The staff RN with 10 years of experience who refuses to work with students is not suitable as a preceptor due to their negative attitude towards teaching.
The natural cycle relating to body functions that occurs due to daily, monthly or yearly changes is called
A. Biofuel
B. Biology
C. Biodiversity
D. Biorhythm
Correct answer:
The correct answer is D: Biorhythm. Biorhythm refers to the natural cycle of body functions that occur due to daily, monthly, or yearly changes. This term is specific to the biological rhythms that regulate various physiological processes in living organisms.
A: Biofuel - Biofuel is not related to the natural cycle of body functions. It refers to renewable energy sources derived from living organisms.
B: Biology - While biology is the study of living organisms and their interactions, it does not specifically refer to the natural cycles of body functions.
C: Biodiversity - Biodiversity refers to the variety of life forms in a particular ecosystem and is not directly related to the natural cycles of body functions.
In summary, biorhythm is the correct answer as it directly pertains to the natural cycles of body functions, while the other choices are unrelated terms in the context of this question.
Which test is the most specific test to diagnose an ACL tear?
A. Pivot shift
B. Lachman test
C. Anterior drawer sign
D. Ege's test
Correct answer:
The correct answer is A: Pivot shift. This test is the most specific for diagnosing an ACL tear because it assesses the rotational instability of the knee joint, which is a key characteristic of an ACL injury. During the test, the examiner applies a valgus force and internal rotation to the knee while extending it, causing the tibia to subluxate anteriorly. If there is an ACL tear, the tibia will suddenly reduce back into place, producing a characteristic "pivot shift" movement.
Summary of other choices:
B: Lachman test - While also used to assess ACL integrity, it primarily evaluates anterior translation of the tibia and is not as specific for rotational instability.
C: Anterior drawer sign - This test is primarily used to assess anterior translation of the tibia and is not specific to diagnosing an ACL tear.
D: Ege's test - This test is not commonly used in clinical practice for diagnosing ACL tears.
During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation?
A. When the bronchial tree is obstructed.
B. When adventitious sounds are present.
C. In conjunction with whispered pectoriloquy.
D. In conditions of consolidation, such as pneumonia.
Correct answer:
The correct answer is A: When the bronchial tree is obstructed. Decreased breath sounds are expected in situations where airflow is obstructed, leading to diminished sound transmission. When there is an obstruction in the bronchial tree, such as in asthma or bronchitis, breath sounds become decreased due to the restricted airflow.
The other choices are incorrect because:
B: When adventitious sounds are present - Adventitious sounds like crackles or wheezes indicate abnormal lung sounds but do not necessarily result in decreased breath sounds.
C: In conjunction with whispered pectoriloquy - Whispered pectoriloquy is a finding where whispering is heard clearly through the stethoscope, indicating lung consolidation rather than decreased breath sounds.
D: In conditions of consolidation, such as pneumonia - Consolidation leads to increased breath sounds due to the denser lung tissue, not decreased breath sounds.
RN exams fundamentals practice questions, set 22 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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