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. Needle decompression is the standard treatment for tension pneumothorax, a life-threatening condition causing respiratory distress.
2. The patient's symptoms (shortness of breath, jugular vein distension, decreased breath sounds, falling blood pressure) are indicative of tension pneumothorax.
3. Repeated attempts to relieve pressure at the occlusive dressing have failed, suggesting a need for more definitive intervention.
4. A longer catheter (2-2.5 inches) is recommended to ensure proper decompression.
Summary:
A: Removing the occlusive dressing and pulling the wound open could worsen the tension pneumothorax by allowing more air into the chest.
B: Translaryngeal Jet Ventilation is not indicated for tension pneumothorax and may delay appropriate treatment
Question 2
A woman is leaving on a trip to Hawaii and has come in for a checkup. During the examination the nurse learns that she has diabetes and takes oral hypoglycemic agents. The patient needs to be concerned about which possible effect of her medications?
A. Increased possibility of bruising
B. Skin sensitivity as a result of exposure to salt water
C. Lack of availability of glucose-monitoring supplies
D. Importance of sunscreen and avoiding direct sunlight
Show answer and rationale
Correct answer: D — Importance of sunscreen and avoiding direct sunlight
The correct answer is D: Importance of sunscreen and avoiding direct sunlight.
Rationale:
1. Oral hypoglycemic agents can increase sensitivity to sunlight, leading to sunburn or skin damage.
2. Diabetic patients are at higher risk of skin complications, so protecting the skin from sunlight is crucial.
3. Sun exposure can also affect blood sugar levels, potentially causing fluctuations in glucose levels.
4. Use of sunscreen and avoiding direct sunlight can help prevent skin issues and maintain overall health for a diabetic patient.
Summary:
A: Increased possibility of bruising - Not directly related to diabetes or oral hypoglycemic agents.
B: Skin sensitivity as a result of exposure to salt water - Not a common concern for diabetic patients on oral hypoglycemic agents.
C: Lack of availability of glucose-monitoring supplies - Important but not directly related to the side effects of oral hypoglycemic agents.
Question 3
You are serving as the supervisory nurse for a home healthcare agency in the community. You are doing an admission assessment for a 76 year old male client who resides with his elderly wife. Which of the following assessments would indicate that the couple needs some education relating to home safety?
A. The client has refrigerated foods labelled with an expiration date.
B. You assess that the home is free of scatter rugs that many use to protect the feet against hard floors.
C. The client uses the FIFO method for insuring food safety.
D. The client assures you that the smoke alarm batteries are replaced annually to insure that they work.
Show answer and rationale
Correct answer: D — The client assures you that the smoke alarm batteries are replaced annually to insure that they work.
Step 1: The correct answer is D because ensuring that smoke alarm batteries are replaced annually is crucial for home safety, especially for elderly individuals who may have decreased mobility or sensory perception.
Step 2: Smoke alarms are essential for early detection of fires, which is crucial for elderly individuals who may have difficulty escaping quickly.
Step 3: By replacing the batteries annually, the client demonstrates proactive measures to protect themselves and their spouse from potential fire hazards.
Step 4: Choices A, B, and C are not indicators of needing education on home safety as they all reflect positive practices related to food storage, fall prevention, and food safety.
Summary: Option D is the correct answer as it directly relates to fire safety, a critical aspect of home safety for elderly individuals. Options A, B, and C are not relevant to home safety education in this context.
Question 4
During the cardiac auscultation, the nurse hears a sound immediately occurring after the S2 at the second left intercostal space. To further assess this sound, what should the nurse do?
A. Have the patient turn to the left side while the nurse listens with the bell of the stethoscope.
B. Ask the patient to hold his or her breath while the nurse listens again.
C. No further assessment is needed because the nurse knows this sound is an S3.
D. Watch the patient's respirations while listening for the effect on the sound.
Show answer and rationale
Correct answer: D — Watch the patient's respirations while listening for the effect on the sound.
The correct answer is D because watching the patient's respirations while listening for the effect on the sound can help differentiate between an S3 and an opening snap or ejection sound. Observing how the sound changes with the respiratory cycle can provide valuable information about the origin and nature of the sound.
Choice A is incorrect because having the patient turn to the left side with the bell of the stethoscope is typically done to enhance the detection of a mitral murmur, not to assess a sound immediately after S2.
Choice B is incorrect because asking the patient to hold their breath is more relevant in assessing for a pericardial friction rub, not in differentiating between heart sounds.
Choice C is incorrect because assuming the sound is an S3 without further assessment can lead to a misdiagnosis. It is essential to confirm the nature of the sound through appropriate assessment techniques.
Question 5
Why must a nurse measure the intake and output and recommend a daily fluid intake of approximately 3000 to 4000 mL for a client with pyelonephritis?
A. To determine the clients response to the therapy
B. To flush out the infectious microorganisms from the urinary tract
C. To determine the location of discomfort
D. To detect any evidence of changes
Show answer and rationale
Correct answer: B — To flush out the infectious microorganisms from the urinary tract
Correct Answer: B
Rationale: Measuring intake and output and recommending increased fluid intake for a client with pyelonephritis is crucial to help flush out infectious microorganisms from the urinary tract. By increasing fluid intake, the client will urinate more frequently, aiding in the removal of bacteria causing the infection. This helps in reducing the bacterial load in the urinary tract and promoting faster recovery. Monitoring intake and output also helps ensure the client is adequately hydrated.
Summary of Other Choices:
A: Monitoring intake and output is more about assessing hydration status and kidney function rather than the response to therapy.
C: Intake and output measurement does not directly determine the location of discomfort in pyelonephritis.
D: Monitoring intake and output is not primarily for detecting changes but for ensuring proper fluid balance and aiding in infection clearance.
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Question 6
When assessing a 75-year-old patient who has asthma, the nurse notes that he assumes a tripod position, leaning forward with arms braced on the chair. On the basis of this observation, the nurse should:
A. Assume that the patient is eager and interested in participating in the interview.
B. Evaluate the patient for abdominal pain, which may be exacerbated in the sitting position.
C. Assume that the patient is having difficulty breathing and assist him to a supine position.
D. Recognize that a tripod position is often used when a patient is having respiratory difficulties.
Correct answer:
The correct answer is D. A tripod position, where a patient leans forward with arms braced on a chair, is often used when a patient is having respiratory difficulties, such as in asthma exacerbation. This position helps improve airflow by allowing better expansion of the chest. The patient is likely trying to relieve breathing difficulty by maximizing lung expansion. Choosing option D is appropriate as it acknowledges the significance of the tripod position in respiratory distress.
A: This choice is incorrect because assuming the patient is eager and interested in participating in the interview does not relate to the observation of the tripod position in a patient with asthma.
B: Evaluating the patient for abdominal pain is not the priority in this scenario where respiratory distress is suspected.
C: This option is incorrect as moving the patient to a supine position may worsen breathing difficulties.
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
Correct answer:
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.
The health care provider has prescribed bed rest with the feet elevated for a patient admitted to the hospital with venous thromboembolism of the left lower leg. Which action by the nurse is best?
A. The patient’s bed is placed in the Trendelenburg position.
B. Two pillows are positioned under the calf of the affected leg.
C. The bed is elevated at the knee and pillows are placed under both feet.
D. One pillow is placed under the thighs and 2 pillows are under the lower legs.
Correct answer:
The correct answer is D because elevating the thighs and lower legs above the heart level promotes venous return and reduces swelling in the affected leg, aiding in the prevention of complications related to venous thromboembolism. Placing one pillow under the thighs and two pillows under the lower legs ensures proper elevation and support.
A: Placing the bed in Trendelenburg position isn't appropriate as it involves the head being lower than the feet, which could increase pressure on the lower extremities and potentially worsen the condition.
B: Placing two pillows under the calf of the affected leg doesn't provide sufficient elevation for optimal venous return and may not effectively reduce swelling.
C: Elevating only at the knee and placing pillows under both feet may not adequately elevate the lower extremities above heart level, limiting the effectiveness of venous return and swelling reduction.
The nurse is assessing a patient in the hospital who has received numerous antibiotics and notices that his tongue appears to be black and hairy. In response to his concern, what would the nurse say?
A. "We will need to get a biopsy to determine the cause."
B. "This is an overgrowth of hair and will go away in a few days."
C. "Black, hairy tongue is a fungal infection caused by all the antibiotics you have received."
D. "This is probably caused by the same bacteria you had in your lungs."
Correct answer:
The correct answer is C: "Black, hairy tongue is a fungal infection caused by all the antibiotics you have received."
Rationale:
1. Black, hairy tongue is a known side effect of prolonged antibiotic use, leading to fungal overgrowth.
2. Antibiotics can disrupt the natural balance of bacteria in the mouth, allowing fungi to overgrow.
3. Fungal infections can manifest as a black, hairy appearance on the tongue.
4. Biopsy is not typically needed for the diagnosis of black, hairy tongue.
5. Overgrowth of hair is not a plausible explanation for this condition.
6. The black, hairy tongue is not caused by the same bacteria the patient had in his lungs.
Summary:
Choice C is correct as it accurately links the patient's antibiotic use to the fungal infection causing black, hairy tongue. Choices A, B, and D are incorrect as they do not address the specific cause of this condition and provide inaccurate information.
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.
Correct answer:
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.
You are preparing to perform synchronized electrical cardioversion with a biphasic defibrillator on your unstable adult patient who is experiencing supraventricular tachycardia at 160 beats per minute on the monitor. Which of the following initial energy settings would be recommended if he was exhibiting a narrow complex, regular supraventricular tachycardia, in which his palpable carotid pulse matches the rhythm on the monitor?
A. Synchronized cardioversion at 50-100 joules
B. Defibrillation at 100 joules
C. Synchronized cardioversion at 360 joules
D. Defibrillation at 360 joules
Correct answer:
The correct initial energy setting for synchronized electrical cardioversion in this scenario is option A: Synchronized cardioversion at 50-100 joules. This is because the patient is stable with a narrow complex, regular supraventricular tachycardia, and synchronized cardioversion is indicated for this condition. The recommended starting energy range for synchronized cardioversion in this case is typically 50-100 joules. This energy setting is appropriate for converting supraventricular tachycardia back to sinus rhythm without causing unnecessary harm to the patient.
Summary of other choices:
- B: Defibrillation at 100 joules: Defibrillation is not indicated for stable supraventricular tachycardia; it is used for ventricular fibrillation or pulseless ventricular tachycardia.
- C: Synchronized cardioversion at 360 joules: This energy setting is too high for a stable patient with supraventricular tach
A woman in her 26th week of pregnancy states that she is 'not really short of breath' but feels that she is aware of her breathing and the need to breathe. What is the nurse's best reply?
A. The diaphragm becomes fixed during pregnancy, making it difficult to take in a deep breath.'
B. The increase in estrogen levels during pregnancy often causes a decrease in the diameter of the rib cage and makes it difficult to breathe.'
C. What you are experiencing is normal. Some women may interpret this as shortness of breath, but it is a normal finding and nothing is wrong.'
D. This increased awareness of the need to breathe is normal as the fetus grows because of the increased oxygen demand on the mother's body, which results in an increased respiratory rate.'
Correct answer:
The correct answer is C because in the 26th week of pregnancy, it is normal for women to experience an increased awareness of their breathing without actual shortness of breath. This is due to the growing fetus putting pressure on the diaphragm, leading to a sensation of needing to breathe more frequently. The nurse's response should reassure the woman that her experience is normal and not a cause for concern.
Choice A is incorrect because the diaphragm does not become fixed during pregnancy, rather it is pushed upward by the growing uterus. Choice B is incorrect because although estrogen levels increase during pregnancy, causing changes in the rib cage, this does not directly lead to difficulty in breathing. Choice D is incorrect because the increased awareness of breathing is not solely due to the increased oxygen demand from the fetus but also from the physical changes in the body due to pregnancy.
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.
A specific aspect of the treatment of thermal injury is:
A. Chemical burn require the immediate removal of clothing
B. Patients who sustain thermal injury are at lower risk for hypothermia
C. Patients with circumferential truncal burns need prompt fasciotomies
D. Electrical burns are associated with extensive skin necrosis (from entry point to exit)
Correct answer:
Step-by-step rationale for why choice A is correct:
1. In cases of thermal injury, immediate removal of clothing is crucial to stop the burning process and prevent further damage.
2. Clothing can retain heat and continue to burn the skin, exacerbating the injury.
3. Removing clothing also allows for a thorough assessment of the extent of the burn and enables proper treatment.
4. Prompt removal of clothing is a standard protocol in the initial management of thermal injuries.
Summary of why other choices are incorrect:
B. Patients with thermal injuries are at higher risk for hypothermia due to loss of skin integrity and body heat, not lower risk.
C. Fasciotomies are typically needed for patients with compartment syndrome, not circumferential truncal burns.
D. Electrical burns can cause tissue necrosis along the path of the current, not necessarily extensive skin necrosis from entry to exit points.
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.
RN exams fundamentals practice questions, set 23 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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