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
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
Show answer and rationale
Correct answer: C — Provides an inhaler and teaches him how to use it to relieve symptoms
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.
Question 2
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
Show answer and rationale
Correct answer: B — A P-R interval greater than five small boxes (0.20 seconds) wide on the electrocardiogram tracing
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
Question 3
A client who is NPO, comatose, and receiving oxygen has cracked lips, dry mucus membranes, swollen gums, and caked mucus on the tongue and teeth. The best intervention is to:
A. Swab the oral cavity with a normal saline solution as needed.
B. Swab the mouth every half-hour with lemon-glycerin swabs.
C. Swab lips and mucus membranes with mineral oil
D. Swab the oral cavity with hydrogen peroxide followed with water
Show answer and rationale
Correct answer: A — Swab the oral cavity with a normal saline solution as needed.
The correct answer is A: Swab the oral cavity with a normal saline solution as needed. This intervention is the best choice as it helps to keep the oral cavity moist, clean, and free from infection. Normal saline is gentle, non-irritating, and helps to maintain hydration. Cracked lips, dry mucus membranes, and caked mucus can lead to discomfort and potential infection in a comatose client.
Summary:
- Choice B (Swab the mouth every half-hour with lemon-glycerin swabs) is incorrect as lemon-glycerin swabs may irritate the oral mucosa and are not suitable for continuous use.
- Choice C (Swab lips and mucus membranes with mineral oil) is incorrect as mineral oil can be harmful if aspirated and does not provide hydration.
- Choice D (Swab the oral cavity with hydrogen peroxide followed with water) is incorrect as hydrogen peroxide can be harsh on delicate oral tissues and is not recommended for
Question 4
Which action indicates a nurse is using critical thinking for implementation of nursing care to patients?
A. Determines whether an intervention is correct and appropriate for the given situation
B. Reads over the steps and performs a procedure despite lack of clinical competency
C. Establishes goals for a particular patient without assessment
D. Evaluates the effectiveness of interventions
Show answer and rationale
Correct answer: A — Determines whether an intervention is correct and appropriate for the given situation
The correct answer is A because determining whether an intervention is correct and appropriate for the given situation indicates critical thinking in nursing care implementation. This involves assessing the patient's needs, analyzing the situation, and using evidence-based practice to make informed decisions. This process ensures that interventions are tailored to individual patient needs and promotes safe and effective care delivery.
Option B is incorrect because performing a procedure without clinical competency can jeopardize patient safety and is not an example of critical thinking. Option C is incorrect as establishing goals without assessment lacks a foundation in data and may lead to inappropriate care planning. Option D is incorrect as evaluating the effectiveness of interventions is a part of the nursing process but does not specifically demonstrate critical thinking in implementation.
Question 5
The nurse is preparing to insert a urinary catheter. The nurse is using open gloving to apply the sterile gloves. Which steps will the nurse take? (Select all that apply.)
A. While putting on the first glove, touch only the outside surface of the glove.
B. With gloved dominant hand, slip fingers underneath second glove cuff.
C. Remove outer glove package by tearing the package open.
D. Lay glove package on clean flat surface above waistline.
Show answer and rationale
Correct answer: D — Lay glove package on clean flat surface above waistline.
The correct answer is D because laying the glove package on a clean flat surface above the waistline helps maintain sterility. Placing the package above waistline prevents contamination from any potential contact with the clothing. This step ensures that the gloves remain sterile and ready for use during the catheter insertion procedure.
Explanation for why the other choices are incorrect:
A: While putting on the first glove, touching only the outside surface of the glove is correct, but this step alone does not address maintaining sterility during the open gloving process.
B: Slipping fingers underneath the second glove cuff with the gloved dominant hand is incorrect in the context of open gloving as it introduces the risk of contamination.
C: Removing the outer glove package by tearing the package open is not recommended for open gloving as it can compromise the sterility of the gloves.
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Question 6
Which of these clinical situations would the nurse consider to be outside normal limits?
A. A patient has had one pregnancy and states that she believes she may be entering menopause. Her breast examination reveals breasts that are soft and slightly sagging.
B. A patient has never been pregnant. Her breast examination reveals large pendulous breasts that have a firm, transverse ridge along the lower quadrant in both breasts.
C. A patient has never been pregnant and reports that she should begin her period tomorrow. Her breast examination reveals breast tissue that is nodular and somewhat engorged. She states that the examination was slightly painful.
D. A patient has had two pregnancies, and she breastfed both of her children. Her youngest child is now 10 years old. Her breast examination reveals breast tissue that is somewhat soft, and she has a small amount of thick yellow discharge from both nipples.
Correct answer:
The correct answer is D because the presence of thick yellow discharge from both nipples in a patient who has had two pregnancies and breastfed her children is outside the normal limits. This could indicate a condition such as galactorrhea, which is abnormal lactation unrelated to breastfeeding. The discharge may be due to hormonal imbalances or other underlying issues that require further investigation.
Explanation for other choices:
A: Soft and slightly sagging breasts in a patient entering menopause can be considered within normal limits due to hormonal changes.
B: Firm, transverse ridges along the lower quadrant of breasts in a patient who has never been pregnant may indicate fibrocystic changes, which are common and typically not concerning.
C: Nodular and engorged breast tissue with slight pain before menstruation is a common premenstrual symptom and is usually within normal limits.
What is the primary reason for performing light palpation before deep palpation during an abdominal examination?
A. To assess for organ size.
B. To accustom the patient to being touched.
C. To detect deep masses.
D. To check for rebound tenderness.
Correct answer:
The correct answer is B: To accustom the patient to being touched. This is because starting with light palpation helps the patient to relax and become accustomed to the examiner's touch, reducing discomfort and anxiety. This approach also allows the examiner to gradually assess for tenderness, muscle tone, and superficial masses before moving on to deep palpation to evaluate deeper structures.
Incorrect answers:
A: To assess for organ size - This is incorrect because assessing organ size is typically done through techniques such as percussion or imaging studies, not palpation.
C: To detect deep masses - This is incorrect because deep masses are typically assessed during deep palpation, not light palpation.
D: To check for rebound tenderness - This is incorrect because rebound tenderness is a specific test for peritoneal irritation, which is typically assessed after palpation, not before.
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.
Correct answer:
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.
You are caring for a patient who was recently diagnosed with type 1 diabetes. She is learning to manage her diabetes and will need support after discharge. Her knowledge deficit is considered a _____ priority problem & will require a collaborative effort with health care professionals.
A. First-level
B. Second-level
C. Third-level
Correct answer:
The correct answer is B: Second-level. In the nursing process, addressing a knowledge deficit for a patient with a new diagnosis like type 1 diabetes falls under second-level priority. This is because it is essential for the patient's immediate well-being and safety, but it does not pose a direct threat to their life or physiological stability. Collaborative effort with healthcare professionals is crucial to ensure the patient receives comprehensive education and support.
Choice A: First-level priorities are for life-threatening issues requiring immediate attention, such as airway obstruction or cardiac arrest, which do not apply in this scenario.
Choice C: Third-level priorities are important for long-term health outcomes but not immediate concerns like knowledge deficit in a newly diagnosed patient.
Choice D: This option is likely incomplete and cannot be considered a valid choice.
The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea over the past 3 days. Which finding is important for the nurse to report to the health care provider?
A. Respirations are 36 breaths/min.
B. Anterior-posterior chest ratio is 1:1.
C. Lung expansion is decreased bilaterally.
D. Hyperresonance to percussion is present.
Correct answer:
The correct answer is A because an increased respiratory rate of 36 breaths/min in a patient with COPD and worsening dyspnea can indicate respiratory distress or impending respiratory failure. This finding is crucial to report promptly to the healthcare provider for further evaluation and intervention.
Choice B is incorrect because an anterior-posterior chest ratio of 1:1 is within normal limits and not directly related to the patient's current respiratory distress.
Choice C is incorrect as decreased lung expansion bilaterally can be expected in a patient with COPD and may not necessarily warrant immediate concern unless it is significantly asymmetric or accompanied by other concerning signs.
Choice D is incorrect as hyperresonance to percussion may be a typical finding in COPD due to increased lung volumes and is not an immediate priority compared to the elevated respiratory rate.
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.
Correct answer:
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.
A patient at the clinic says, “I always walk after dinner, but lately my leg cramps and hurts after just a few minutes. The pain goes away after I stop walking, though.†What focused assessment should the nurse make?
A. Look for the presence of tortuous veins bilaterally on the legs.
B. Ask about any skin color changes that occur in response to cold.
C. Assess for unilateral swelling, redness, and tenderness of either leg.
D. Palpate for the presence of dorsalis pedis and posterior tibial pulses.
Correct answer:
The correct answer is D because the patient's symptoms suggest a possible vascular issue, such as peripheral arterial disease (PAD). Palpating for the dorsalis pedis and posterior tibial pulses can help assess the adequacy of blood flow in the lower extremities. A decrease or absence of these pulses may indicate compromised blood flow, leading to symptoms like leg cramps and pain with activity.
Choices A, B, and C are incorrect because they do not directly address the patient's symptoms of leg cramps and pain with walking, which are suggestive of a vascular etiology. Looking for tortuous veins, skin color changes in response to cold, or unilateral swelling, redness, and tenderness may be indicative of other conditions like varicose veins, Raynaud's phenomenon, or deep vein thrombosis, respectively. However, these symptoms are not consistent with the patient's presentation in this scenario.
A 25-year-old woman presents with a complaint of fatigue and muscle weakness. On examination, she has ptosis and weakness of the proximal muscles of the upper limbs. Her vital signs are stable, and laboratory tests reveal a positive anti-acetylcholine receptor antibody test. Which of the following is the most likely diagnosis?
The nurse is teaching a pregnant woman about breast milk. Which statement by the nurse is correct?
A. "Your breast milk is immediately present after the delivery of your baby."
B. "Breast milk is rich in protein and sugars (lactose) but has very little fat."
C. "The colostrum, which is present right after birth, does not contain the same nutrients as breast milk."
D. "You may notice a thick, yellow fluid expressed from your breasts as early as the fourth month of pregnancy."
Correct answer:
The correct answer is D because the statement accurately describes colostrum, the first milk produced during pregnancy. Colostrum is a thick, yellow fluid that can be expressed from the breasts as early as the fourth month of pregnancy. It is rich in antibodies and nutrients essential for the newborn.
A: Incorrect. Breast milk does not immediately appear after delivery; it takes a few days for mature milk to come in.
B: Incorrect. Breast milk is rich in fat, not just protein and sugars. Fat is crucial for a baby's growth and development.
C: Incorrect. Colostrum is a nutrient-rich fluid that provides essential nutrients to the newborn, even though it may not have the same composition as mature breast milk.
In summary, choice D is correct because it accurately describes the early milk production during pregnancy, while the other choices provide inaccurate information about breast milk.
You are seeing patients in clinic when two men in dark suits and dark glasses come in and show you badges marking them as members of a federal law enforcement agency. The identification is legitimate. These 'men in black' inform you that they are making a 'minor investigation' of one of your patients. They ask to look at the patient's chart for a few minutes, saying, 'You wouldn't want to interfere with a federal investigation, would you?' What should you do?
A. Give them the chart.
B. Ask them to sign a release for the chart so you are absolved of responsibility.
C. Tell them you cannot show them the chart unless there is a signed release from the patient.
D. Tell them that you can give copies but not the original record.
Correct answer:
You cannot release a patient's medical records unless there is a clear, signed release from the patient or there is a court order. This is true no matter who is asking. If the federal agents have a court order for the records then they have a right to the information. A court order, warrant, or subpoena can be used by the judicial system to violate confidentiality if the judicial system sanctions the violation. Although the medical record as a physical object is the property of the physician or health-care facility, the information is the property of the patient. In a sense, the information is like a person's house. No one has the right to enter your home without either your permission or a court order allowing the investigation. This is also true even if the people requesting it are law enforcement agents. We all have a constitutional right against illegal search and seizure of our property.
RN exams fundamentals practice questions, set 26 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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Keep going past these 15 questions
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