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 patient who has just undergone a colon resection complains to a nurse that he felt something pop under his dressing while trying to get out of bed.the nurse removes the dressing and finds that dehiscence of the wound has occurred.what nursing action should be implemented first?
A. Cover the wound with sterile dressings saturated with normal saline
B. Notify the surgeon immediately
C. Apply pressure to the wound
D. Place the patient in Trendelenburg position
Show answer and rationale
Correct answer: A — Cover the wound with sterile dressings saturated with normal saline
The correct answer is A: Cover the wound with sterile dressings saturated with normal saline. This action helps to maintain a moist environment for wound healing and prevent further contamination. The step-by-step rationale is: 1) Covering the wound with sterile dressings helps protect the wound from infection and further trauma. 2) Saturating the dressings with normal saline helps keep the wound moist, promoting healing. 3) This immediate action is crucial in preventing complications such as infection and further wound dehiscence.
Summary of other choices:
B: Notifying the surgeon immediately is important, but covering the wound to protect it should be done first.
C: Applying pressure to the wound can further damage the tissue and should not be done.
D: Placing the patient in Trendelenburg position is not necessary for wound dehiscence and does not address the immediate need to protect the wound.
Question 2
A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse include in this client’s teaching?
A. “Have you spouse watch you for irritability and anxiety.”
B. “Notify the clinic if you notice muscle twitching.”
C. “Call your primary health care provider for diarrhea.”
D. “Bake or grill your meat rather than frying it.”
Show answer and rationale
Correct answer: B — “Notify the clinic if you notice muscle twitching.”
The correct answer is B: “Notify the clinic if you notice muscle twitching.” Muscle twitching can be a symptom of hyponatremia, which is a condition characterized by low sodium levels in the blood. The nurse should include this statement in the client’s teaching because it is important for the client to recognize and report this symptom promptly to prevent potential complications. Muscle twitching can indicate worsening hyponatremia and requires medical attention.
Incorrect choices:
A: “Have your spouse watch you for irritability and anxiety.” This choice focuses on emotional symptoms rather than physical symptoms of hyponatremia.
C: “Call your primary health care provider for diarrhea.” Diarrhea is not a common symptom of hyponatremia; this choice is unrelated to the condition.
D: “Bake or grill your meat rather than frying it.” This choice is unrelated to the prevention or management of hyponatremia.
Question 3
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
Show answer and rationale
Correct answer: A — Pivot shift
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.
Question 4
The electrical stimulus of the cardiac cycle follows which sequence?
A. AV node → SA node → bundle of His
B. Bundle of His → AV node → SA node
C. SA node → AV node → bundle of His → bundle branches
D. AV node → SA node → bundle of His → bundle branches
Show answer and rationale
Correct answer: C — SA node → AV node → bundle of His → bundle branches
The correct sequence of the electrical stimulus in the cardiac cycle is SA node ? AV node ? bundle of His ? bundle branches. The rationale is as follows:
1. The SA node initiates the electrical impulse in the heart.
2. The impulse travels to the AV node, which serves as a delay mechanism to ensure proper coordination of atrial and ventricular contractions.
3. From the AV node, the impulse then travels to the bundle of His, which conducts the impulse to the bundle branches.
4. Finally, the impulse is transmitted through the bundle branches to the Purkinje fibers, which then distribute the impulse throughout the ventricles for coordinated contraction.
Therefore, choice C is correct as it accurately represents the sequential pathway of the electrical stimulus in the cardiac cycle. Choices A, B, and D are incorrect as they do not follow the physiologically accurate sequence of the cardiac conduction system.
Question 5
The postanesthesia care unit (PACU) nurse transports the inpatient surgical patient to the medical-surgical floor. Before leaving the floor, the medical-surgical nurse obtains a complete set of vital signs. What is the rationale for this nursing action?
A. This is done to complete the first action in a head-to-toe assessment.
B. This is done to compare and monitor for vital sign variation during transport.
C. This is done to ensure that the medical-surgical nurse checks on the postoperative patient.
D. This is done to follow hospital policy and procedure for care of the surgical patient.
Show answer and rationale
Correct answer: B — This is done to compare and monitor for vital sign variation during transport.
The correct answer is B: This is done to compare and monitor for vital sign variation during transport.
1. Monitoring vital signs during transport is crucial to detect any changes or complications post-surgery.
2. Comparing pre-transport and post-transport vital signs helps in assessing the patient's stability.
3. Any significant variations in vital signs can indicate potential issues that need immediate attention.
4. This practice ensures continuity of care and promotes patient safety during transitions.
Incorrect Choices:
A: Completing a head-to-toe assessment is not the primary purpose of obtaining vital signs before transport.
C: The medical-surgical nurse obtaining vital signs does not necessarily imply checking on the postoperative patient.
D: Following hospital policy and procedure is important but does not specifically address the rationale for checking vital signs during transport.
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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.
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.
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
Correct answer:
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.
A 27-year-old policewoman comes to your clinic, complaining of severe left-sided back pain radiating down into her groin. It began in the middle of the night and woke her up suddenly. It hurts in her bladder to urinate but she has no burning on the outside. She has had no frequency or urgency with urination but she has seen blood in her urine. She has had nausea with the pain but no vomiting or fever. She denies any other recent illness or injuries. Her past medical history is unremarkable. She denies tobacco or drug use and drinks alcohol rarely. Her mother has high blood pressure and her father is healthy. On examination she looks her stated age and is in obvious pain. She is lying on her left side trying to remain very still. Her cardiac, pulmonary, and abdominal examinations are unremarkable. She has tenderness just inferior to the left costovertebral angle. Her urine pregnancy test is negative and her urine analysis shows red blood cells. What type of urinary tract pain is she most likely to have?
A. Kidney pain (from pyelonephritis)
B. Ureteral pain (from a kidney stone)
C. Musculoskeletal pain
D. Ischemic bowel pain
Correct answer:
The policewoman's presentation of severe left-sided back pain radiating down into her groin, associated with nausea, blood in urine, and tenderness just inferior to the left costovertebral angle is highly suggestive of a kidney stone causing ureteral colic. Kidney stones are solid masses made of crystals that form in the kidneys and can cause sudden severe pain as they move through the urinary tract, leading to blockage and subsequent stretching of the ureter (the tube connecting the kidney to the bladder), resulting in pain that radiates from the flank down to the groin region. The presence of blood in the urine (hematuria) is a common finding with kidney stones due to irritation and damage to the ureteral lining as the stone passes. The negative urine pregnancy test rules out pregnancy-related causes of urinary symptoms. Musculoskeletal pain is less likely given the location and character of the pain
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.
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
While discussing the history of a 6-month-old infant, the mother tells the nurse that she took a significant amount of aspirin while she was pregnant. What question would the nurse want to include in the history?
A. Does your baby seem to startle with loud noises?'
B. Has your baby had any surgeries on her ears?'
C. Have you noticed any drainage from her ears?'
D. How many ear infections has your baby had since birth?'
Correct answer:
The correct answer is A: "Does your baby seem to startle with loud noises?" This question is relevant because exposure to aspirin during pregnancy can potentially lead to hearing loss in the infant. Aspirin is known to cause ototoxicity, affecting the auditory nerve and leading to hearing problems. Therefore, asking about the baby's response to loud noises can help identify any potential hearing issues related to the aspirin exposure during pregnancy.
Choices B, C, and D are incorrect because they focus on ear-related issues, such as surgeries, drainage, and infections. While these are valid concerns, they are not directly related to the potential hearing loss caused by aspirin exposure during pregnancy. Hence, these options are less relevant in this context compared to the correct answer, which directly addresses the possible consequence of aspirin intake during pregnancy on the infant's hearing.
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.
You are monitoring the cardiac rhythm of your 60-year-old female patient with shortness of breath when you note the presence of a possible first-degree atrioventricular block in lead II on the EKG. Which of the following electrocardiogram abnormalities makes you think there is a first-degree AV block present?
A. There are more than one P wave for each QRS complex
B. A P-R interval greater than five small boxes (0.20 seconds) wide on the electrocardiogram tracing
C. The P-R intervals become progressively longer until a QRS complex is dropped altogether
D. The P waves are present but bear no relationship to the QRS complexes
Correct answer:
The correct answer is B: A P-R interval greater than five small boxes (0.20 seconds) wide on the electrocardiogram tracing. In first-degree AV block, there is a delay in conduction from the atria to the ventricles, resulting in a prolonged P-R interval on the EKG. This delay is represented by a P-R interval greater than 0.20 seconds. This finding is characteristic of first-degree AV block.
Now, let's analyze why the other choices are incorrect:
A: There are more than one P wave for each QRS complex - This describes a condition called atrial fibrillation, where multiple P waves are present but not associated with QRS complexes.
C: The P-R intervals become progressively longer until a QRS complex is dropped altogether - This describes a Mobitz Type II second-degree AV block, where there is a sudden block of conduction without a progressive increase in P-R intervals.
D: The P waves are present but
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
Correct answer:
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
RN exams fundamentals practice questions, set 24 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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