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
Motorcycle crash, noisy respirations, apneic, hematoma in pharynx, airway management?
A. "Inserting an oropharyngeal airway"
B. "Inserting a nasopharyngeal airway"
C. "Performing a surgical cricothyroidotomy"
D. "Performing fiberoptic-guided nasotracheal intubation"
Show answer and rationale
Correct answer: A — "Inserting an oropharyngeal airway"
The correct answer is A: "Inserting an oropharyngeal airway." In this scenario of a motorcycle crash with noisy respirations, apnea, and a hematoma in the pharynx, the patient is likely experiencing airway obstruction. An oropharyngeal airway helps maintain a patent airway by preventing the collapse of the tongue and soft tissues in the oropharynx. It does not require visualization or manipulation of the upper airway structures, making it the most suitable initial intervention in this emergent situation.
Summary of why the other choices are incorrect:
B: "Inserting a nasopharyngeal airway" - Nasopharyngeal airways are not recommended in the presence of facial trauma or suspected basilar skull fracture due to the risk of exacerbating the injury.
C: "Performing a surgical cricothyroidotomy" - This is an invasive procedure reserved for extreme cases of airway obstruction when other methods fail.
D
Question 2
A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which response by the nurse reflects accurate knowledge about the medication and the patient’s illness?
A. Ask the patient about any visual changes in red-green color discrimination.
B. Question the patient about experiencing shortness of breath, hives, or itching.
C. Explain that orange discolored urine and tears are normal while taking this medication.
D. Advise the patient to stop the drug and report the symptoms to the health care provider.
Show answer and rationale
Correct answer: C — Explain that orange discolored urine and tears are normal while taking this medication.
The correct answer is C because orange discoloration of urine and tears is a known side effect of rifampin. This is due to the drug's ability to color bodily fluids. It is important for the nurse to reassure the patient that this is a normal and expected reaction to the medication.
Option A is incorrect as it pertains to visual changes in red-green color discrimination, which is not a common side effect of rifampin. Option B is also incorrect as it relates to symptoms such as shortness of breath, hives, or itching, which are not typically associated with rifampin use.
Option D is incorrect because stopping the medication without consulting the healthcare provider can lead to treatment failure and potential drug resistance. It is important for the patient to continue taking the medication as prescribed and to report any concerns or side effects to the healthcare provider for proper management.
Question 3
The nurse is attempting to assess the femoral pulse in a patient who is obese. Which of these actions would be most appropriate?
A. The patient is asked to assume a prone position.
B. The patient is asked to bend his or her knees to the side in a froglike position.
C. The nurse firmly presses against the bone with the patient in a semi-Fowler position.
D. The nurse listens with a stethoscope for pulsations; palpating the pulse in an obese person is extremely difficult.
Show answer and rationale
Correct answer: B — The patient is asked to bend his or her knees to the side in a froglike position.
The correct answer is B because asking the patient to bend their knees to the side in a froglike position helps to expose the femoral pulse in an obese patient. This position allows better access to the femoral artery, making it easier to palpate the pulse accurately. By bending the knees to the side, the nurse can avoid excess tissue and adipose obstruction, facilitating a more accurate assessment.
Choices A, C, and D are incorrect:
A: Asking the patient to assume a prone position would not be helpful in locating the femoral pulse as it does not provide better access to the artery.
C: Firmly pressing against the bone in a semi-Fowler position may not improve the assessment of the femoral pulse in an obese patient.
D: Listening with a stethoscope for pulsations is not the preferred method for assessing the femoral pulse; palpating the pulse is the standard practice, even in obese individuals.
Question 4
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 5
When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?
A. Determine if the expected outcomes were realistic
B. Obtain current client data to compare with expected outcomes
C. Modify the nursing interventions to achieve the client's goals
D. Review related professional standards of care
Show answer and rationale
Correct answer: A — Determine if the expected outcomes were realistic
After reviewing the expected outcomes identified in the plan of care, the nurse's next step should be to determine if these outcomes were realistic. This assessment helps in understanding if the goals set were achievable and appropriate for the client's condition before proceeding to compare them with current client data or modifying nursing interventions. By verifying the realism of the expected outcomes, the nurse ensures a solid foundation for further evaluation and adjustment of the care plan. Option B is incorrect because obtaining current client data comes after assessing the realism of the expected outcomes. Option C is incorrect because modifying nursing interventions should be based on the assessment of the expected outcomes' realism. Option D is incorrect as reviewing professional standards of care is important but not the immediate next step after assessing the expected outcomes' realism.
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Question 6
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.
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. 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
An asthmatic patient achieves a psychomotor outcome when the nurse:
A. Teaches him what asthma is and the signs and symptoms of an attack
B. Offers counseling on how he should accept and live with the chronic illness
C. Provides an inhaler and teaches him how to use it to relieve symptoms
D. Puts the patient in a semi-sitting position to ease breathing during an attack
Correct answer:
The correct answer is C because providing an inhaler and teaching the patient how to use it to relieve symptoms directly addresses the psychomotor outcome of managing asthma symptoms effectively. Step 1: Providing the inhaler allows the patient to have a tangible tool to use during an asthma attack. Step 2: Teaching the patient how to use the inhaler ensures proper technique and empowers the patient to take control of their symptoms. This approach promotes active learning and skill development, aligning with psychomotor learning.
Choices A, B, and D are incorrect because they do not directly address the psychomotor outcome of managing asthma symptoms through hands-on skill development. Choice A focuses on cognitive learning, while choice B focuses on emotional support. Choice D addresses a physical intervention during an attack but does not empower the patient to actively manage their symptoms.
A burn that affects the epidermis and causes redness and pain is a
A. First-degree (superficial) burn
B. Second-degree (partial-thickness) burn
C. Third-degree (full-thickness) burn
D. Scald
Correct answer:
The correct answer is A: First-degree (superficial) burn. This type of burn only affects the epidermis, causing redness and pain. The epidermis is the top layer of the skin, and a first-degree burn is characterized by mild symptoms such as redness and pain without blistering or skin damage.
Choice B: Second-degree (partial-thickness) burn involves damage to both the epidermis and the dermis, leading to blistering and more severe pain.
Choice C: Third-degree (full-thickness) burn affects all layers of the skin, causing white or charred skin and potentially no pain due to nerve damage.
Choice D: Scald is a type of injury caused by hot liquids or steam, not a specific classification of burn.
In summary, the other choices are incorrect because they describe burns that involve deeper layers of the skin and more severe symptoms compared to a first-degree burn, which only affects the epidermis.
The nurse is assessing a patient's lungs and hears wheezing during exhalation. What is the most likely cause of this finding?
A. Asthma.
B. Pulmonary fibrosis.
C. Pneumonia.
D. Pulmonary embolism.
Correct answer:
The correct answer is A: Asthma. Wheezing during exhalation is a common characteristic of asthma due to airway constriction. In asthma, the airways become inflamed and narrowed, leading to difficulty in breathing and wheezing sounds during exhalation. Asthma is a chronic condition that can be triggered by various factors such as allergens or exercise.
Summary of Incorrect Choices:
B: Pulmonary fibrosis - Pulmonary fibrosis is characterized by scarring of lung tissue, leading to stiff and less flexible lungs. It typically presents with crackles on auscultation, not wheezing.
C: Pneumonia - Pneumonia is an infection of the lung tissue, usually presenting with crackles or decreased breath sounds, not typically wheezing.
D: Pulmonary embolism - Pulmonary embolism is a blockage in the pulmonary artery, often causing sudden shortness of breath and chest pain, but not typically associated with whe
During a cardiac assessment, the nurse notes a pulse deficit. How is this finding assessed?
A. By comparing the apical and radial pulse rates.
B. By measuring the pulse strength in both radial arteries.
C. By auscultating the heart sounds for murmurs.
D. By palpating the carotid and femoral pulses simultaneously.
Correct answer:
To assess a pulse deficit, the nurse should first measure the apical pulse (using a stethoscope at the apex of the heart) and the radial pulse (at the wrist) simultaneously for a full minute. This is because the apical pulse represents the heart's contraction and the radial pulse represents the pulse felt at the periphery. The difference between the two rates indicates a pulse deficit, which suggests that not all heartbeats are reaching the periphery. This method allows for a direct comparison between the heart rate and the peripheral pulse rate. The other choices are incorrect because measuring the pulse strength in both radial arteries (B) does not assess for a pulse deficit, auscultating for murmurs (C) is not directly related to assessing a pulse deficit, and palpating carotid and femoral pulses simultaneously (D) does not provide a comparison between the heart rate and peripheral pulse rate.
A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which response by the nurse reflects accurate knowledge about the medication and the patient’s illness?
A. Ask the patient about any visual changes in red-green color discrimination.
B. Question the patient about experiencing shortness of breath, hives, or itching.
C. Explain that orange discolored urine and tears are normal while taking this medication.
D. Advise the patient to stop the drug and report the symptoms to the health care provider.
Correct answer:
The correct answer is C because orange discoloration of urine and tears is a known side effect of rifampin. This is due to the drug's ability to color bodily fluids. It is important for the nurse to reassure the patient that this is a normal and expected reaction to the medication.
Option A is incorrect as it pertains to visual changes in red-green color discrimination, which is not a common side effect of rifampin. Option B is also incorrect as it relates to symptoms such as shortness of breath, hives, or itching, which are not typically associated with rifampin use.
Option D is incorrect because stopping the medication without consulting the healthcare provider can lead to treatment failure and potential drug resistance. It is important for the patient to continue taking the medication as prescribed and to report any concerns or side effects to the healthcare provider for proper management.
During a cardiac assessment, the nurse notes a pulse deficit. How is this finding assessed?
A. By comparing the apical and radial pulse rates.
B. By measuring the pulse strength in both radial arteries.
C. By auscultating the heart sounds for murmurs.
D. By palpating the carotid and femoral pulses simultaneously.
Correct answer:
To assess a pulse deficit, the nurse should first measure the apical pulse (using a stethoscope at the apex of the heart) and the radial pulse (at the wrist) simultaneously for a full minute. This is because the apical pulse represents the heart's contraction and the radial pulse represents the pulse felt at the periphery. The difference between the two rates indicates a pulse deficit, which suggests that not all heartbeats are reaching the periphery. This method allows for a direct comparison between the heart rate and the peripheral pulse rate. The other choices are incorrect because measuring the pulse strength in both radial arteries (B) does not assess for a pulse deficit, auscultating for murmurs (C) is not directly related to assessing a pulse deficit, and palpating carotid and femoral pulses simultaneously (D) does not provide a comparison between the heart rate and peripheral pulse rate.
Motorcycle crash, noisy respirations, apneic, hematoma in pharynx, airway management?
A. "Inserting an oropharyngeal airway"
B. "Inserting a nasopharyngeal airway"
C. "Performing a surgical cricothyroidotomy"
D. "Performing fiberoptic-guided nasotracheal intubation"
Correct answer:
The correct answer is A: "Inserting an oropharyngeal airway." In this scenario of a motorcycle crash with noisy respirations, apnea, and a hematoma in the pharynx, the patient is likely experiencing airway obstruction. An oropharyngeal airway helps maintain a patent airway by preventing the collapse of the tongue and soft tissues in the oropharynx. It does not require visualization or manipulation of the upper airway structures, making it the most suitable initial intervention in this emergent situation.
Summary of why the other choices are incorrect:
B: "Inserting a nasopharyngeal airway" - Nasopharyngeal airways are not recommended in the presence of facial trauma or suspected basilar skull fracture due to the risk of exacerbating the injury.
C: "Performing a surgical cricothyroidotomy" - This is an invasive procedure reserved for extreme cases of airway obstruction when other methods fail.
D
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.
RN exams fundamentals practice questions, set 25 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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The first five questions already include the rationale. Start full practice to unlock the remaining keys, missed-question review, and the rest of the bank.
Keep going past these 15 questions
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