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
The nurse is caring for a client with type I diabetes mellitus who exhibits confusion, light-headedness, and aberrant behavior. The client is still conscious. The nurse should first administer:
A. I.M. or subcutaneous glucagon.
B. I.V. bolus of dextrose 50%.
C. 15 to 20 g of a fast-acting carbohydrate such as orange juice.
D. 10 U of fast-acting insulin.
Show answer and rationale
Correct answer: C — 15 to 20 g of a fast-acting carbohydrate such as orange juice.
The correct answer is C: 15 to 20 g of a fast-acting carbohydrate such as orange juice. In this scenario, the client is experiencing hypoglycemia, which can lead to confusion and abnormal behavior. Administering fast-acting carbohydrates like orange juice will help quickly raise the blood sugar levels. This is the first-line treatment for conscious patients with hypoglycemia.
Choice A (I.M. or subcutaneous glucagon) is used for unconscious patients or when oral intake is not possible. Choice B (I.V. bolus of dextrose 50%) is too aggressive for a conscious patient and may lead to complications. Choice D (10 U of fast-acting insulin) would further lower the blood sugar levels and worsen the situation.
Administering fast-acting carbohydrates is the safest and most effective approach for conscious patients with hypoglycemia to quickly raise their blood sugar levels and resolve their symptoms.
Question 2
Which of the following would be an early sign of a possible aortic dissection?
A. A narrowing pulse pressure and tachycardia
B. A sudden rise in systolic blood pressure and fall in diastolic blood pressure
C. Blood pressure difference of 20 mmHg or more in the upper extremities
D. A reddish-blue discoloration of the skin above the shoulders
Show answer and rationale
Correct answer: C — Blood pressure difference of 20 mmHg or more in the upper extremities
Rationale for Correct Answer (C): An early sign of a possible aortic dissection is a blood pressure difference of 20 mmHg or more in the upper extremities. This is due to the unequal blood pressure distribution resulting from the dissection affecting the aorta. The pressure gradient occurs because the false lumen of the aorta created by the dissection leads to different blood pressures in the upper extremities. Monitoring blood pressure in both arms helps detect this discrepancy.
Summary of Incorrect Choices:
A: A narrowing pulse pressure and tachycardia - Not specific to aortic dissection.
B: A sudden rise in systolic blood pressure and fall in diastolic blood pressure - More commonly seen in aortic rupture than dissection.
D: A reddish-blue discoloration of the skin above the shoulders - Typically associated with different conditions and not a characteristic sign of aortic dissection.
Question 3
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.
Show answer and rationale
Correct answer: A — Asthma.
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
Question 4
The nurse is assessing a patient's gait and notes that the patient lifts their foot high and slaps it down while walking. What does this finding suggest?
A. Ataxia.
B. Steppage gait.
C. Spastic hemiparesis.
D. Cerebellar dysfunction.
Show answer and rationale
Correct answer: B — Steppage gait.
The correct answer is B: Steppage gait. This finding suggests a steppage gait pattern, which is characterized by foot drop and excessive hip and knee flexion to lift the foot higher to avoid dragging it on the ground. This gait pattern is often seen in patients with weakness or paralysis of the dorsiflexor muscles of the foot, typically due to conditions such as peripheral neuropathy or nerve compression. This results in a high-stepping gait with foot slap during the swing phase of walking. Ataxia (A) refers to incoordination and would manifest as unsteady and uncoordinated movements, not specifically as foot slap. Spastic hemiparesis (C) typically presents with increased muscle tone and stiffness on one side of the body, affecting arm and leg movements. Cerebellar dysfunction (D) would present with ataxic gait, intention tremors, and dysmetria, rather than the specific steppage gait pattern
Question 5
A nurse is caring for a patient who has had a total knee replacement. The patient is complaining of severe pain. What is the priority intervention?
A. Administer analgesics.
B. Administer antibiotics.
C. Administer insulin therapy.
D. Administer an oral anticoagulant.
Show answer and rationale
Correct answer: D — Administer an oral anticoagulant.
The correct answer is D: Administer an oral anticoagulant. The priority intervention for a patient who has had a total knee replacement and is experiencing severe pain is to administer an oral anticoagulant. This is because after surgery, there is an increased risk of blood clots forming in the legs due to immobility, which can lead to serious complications like pulmonary embolism. Administering an oral anticoagulant helps prevent the formation of blood clots and reduces the risk of these complications.
Summary:
- Option A (Administer analgesics): While controlling pain is important, in this case, preventing blood clots is the priority.
- Option B (Administer antibiotics): Antibiotics are not indicated unless there is an infection present.
- Option C (Administer insulin therapy): Insulin therapy is not relevant in this scenario unless the patient has diabetes that requires management.
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Question 6
A 22-year-old unemployed roofer presents to your clinic, complaining of pain in his testicle and penis. He states the pain began last night and has steadily become worse. He states it hurts when he urinates and he has not attempted intercourse since the pain began. He has tried Tylenol and ibuprofen without improvement. He denies any fever or night sweats. His past medical history is unremarkable. He has had four previous sexual partners and has had a new partner for the last month. She is on oral contraceptives so he has not used condoms. His parents are both in good health. On examination you see a young man lying on his side. He appears mildly ill. His temperature is 100.2 and his blood pressure, respirations, and pulse are normal. On visualization of the penis he is circumcised, with no lesions or discharge from the meatus. Visualization of the scrotal skin appears unremarkable. Palpation of the testes shows severe tenderness at the superior pole of the normal-sized left testicle. He also has tenderness when you palpate the structures superior to the testicle through the scrotal wall. The right testicle is unremarkable. An examining finger is placed through each inguinal ring without bulges being noted with bearing down. His prostate examination is unremarkable. Urine analysis shows white blood cells and bacteria. What diagnosis of the male genitalia is most likely in this case?
A. Acute orchitis
B. Acute epididymitis
C. Torsion of the spermatic cord
D. Prostatitis
Correct answer:
The correct answer is B: Acute epididymitis. Epididymitis is characterized by pain, swelling, and inflammation of the epididymis, which is located next to the testicle. In this case, the patient's symptoms of testicular pain, pain with urination, and tenderness at the superior pole of the left testicle are classic signs of epididymitis. The presence of white blood cells and bacteria in the urine analysis further supports the diagnosis of an infectious process in the genitourinary tract. Acute orchitis (choice A) involves inflammation of the testicle itself, without the characteristic tenderness of the epididymis. Torsion of the spermatic cord (choice C) typically presents with sudden severe testicular pain and swelling, with absent cremasteric reflex. Prostatitis (choice D) would present with symptoms related to the prostate gland, such as perineal or pelvic pain, not the testicle and penis.
A 22-year-old unemployed roofer presents to your clinic, complaining of pain in his testicle and penis. He states the pain began last night and has steadily become worse. He states it hurts when he urinates and he has not attempted intercourse since the pain began. He has tried Tylenol and ibuprofen without improvement. He denies any fever or night sweats. His past medical history is unremarkable. He has had four previous sexual partners and has had a new partner for the last month. She is on oral contraceptives so he has not used condoms. His parents are both in good health. On examination you see a young man lying on his side. He appears mildly ill. His temperature is 100.2 and his blood pressure, respirations, and pulse are normal. On visualization of the penis he is circumcised, with no lesions or discharge from the meatus. Visualization of the scrotal skin appears unremarkable. Palpation of the testes shows severe tenderness at the superior pole of the normal-sized left testicle. He also has tenderness when you palpate the structures superior to the testicle through the scrotal wall. The right testicle is unremarkable. An examining finger is placed through each inguinal ring without bulges being noted with bearing down. His prostate examination is unremarkable. Urine analysis shows white blood cells and bacteria. What diagnosis of the male genitalia is most likely in this case?
A. Acute orchitis
B. Acute epididymitis
C. Torsion of the spermatic cord
D. Prostatitis
Correct answer:
The correct answer is B: Acute epididymitis. Epididymitis is characterized by pain, swelling, and inflammation of the epididymis, which is located next to the testicle. In this case, the patient's symptoms of testicular pain, pain with urination, and tenderness at the superior pole of the left testicle are classic signs of epididymitis. The presence of white blood cells and bacteria in the urine analysis further supports the diagnosis of an infectious process in the genitourinary tract. Acute orchitis (choice A) involves inflammation of the testicle itself, without the characteristic tenderness of the epididymis. Torsion of the spermatic cord (choice C) typically presents with sudden severe testicular pain and swelling, with absent cremasteric reflex. Prostatitis (choice D) would present with symptoms related to the prostate gland, such as perineal or pelvic pain, not the testicle and penis.
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
Correct answer:
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
One important thing for the nursing assistant to check when a resident is being discharged is
A. Whether the resident will have enough food and drink for the trip home
B. Whether the resident or his family knows the address of his physician
C. Whether the resident has had all of his tubes and dressings removed by the nurse
D. Whether the resident or his family has paid his bill in full
Correct answer:
The correct answer is C because it is crucial for the nursing assistant to ensure that all tubes and dressings have been removed by the nurse before the resident is discharged. This is important for the resident's safety and well-being to prevent any complications or infections post-discharge. Checking for this ensures that the resident is ready to leave the healthcare facility in a stable condition.
A: Whether the resident will have enough food and drink for the trip home - While important, this is not the nursing assistant's primary responsibility at discharge.
B: Whether the resident or his family knows the address of his physician - Important for follow-up care, but not the nursing assistant's immediate concern at discharge.
D: Whether the resident or his family has paid his bill in full - Financial matters are not typically within the nursing assistant's scope of responsibilities.
How many drops per minute should a client weighing 182 pounds receive if a nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min? The drip factor is 60 gtt/ml.
A. 31 gtt/min.
B. 62 gtt/min.
C. 93 gtt/min.
D. 124 gtt/min.
Correct answer:
To determine the drops per minute for the client, first convert the client's weight from pounds to kilograms: 182/2.2 = 82.73 kg. Calculate the dosage by multiplying 5 mcg by the client's weight in kg: 5 mcg/kg/min 82.73 kg = 413.65 mcg/min. Find the concentration of the solution in mcg/ml by dividing 250 ml by 50,000 mcg (50 mg): 250 ml/50,000 mcg = 200 mcg/ml. As the client needs 413.65 mcg/min and the solution is 200 mcg/ml, the client should receive 2.07 ml per minute. Finally, using the drip factor of 60 gtt/ml, multiply the ml per minute by the drip factor: 60 gtt/ml 2.07 ml/min = 124.28 gtt/min, which rounds to 124 gtt/min. Therefore, the client should receive 124 drops per minute. Choice D is the correct answer. Choices A, B, and C are incorrect because they do not reflect the accurate calculation based on the client's weight, dosage, concentration of the solution, and drip factor.
A patient presents with ear pain. She is an avid swimmer. The history includes pain and drainage from the left ear. On examination, she has pain when the ear is manipulated, including manipulation of the tragus. The canal is narrowed and erythematous, with some white debris in the canal. The rest of the examination is normal. What diagnosis would you assign this patient?
A. Otitis media
B. External otitis
C. Perforation of the tympanum
D. Cholesteatoma
Correct answer:
The correct diagnosis for this patient is external otitis (choice B). The key findings that support this diagnosis include pain on manipulation of the ear, especially the tragus, narrowed and erythematous ear canal, drainage, and white debris in the canal. These are classic signs of external otitis, also known as swimmer's ear, which is an infection of the ear canal. Otitis media (choice A) typically presents with middle ear inflammation and fluid accumulation, but this patient's symptoms are more consistent with an external ear infection. Perforation of the tympanum (choice C) would present with different symptoms, such as hearing loss, ear discharge, and possible pain, but the examination findings described do not suggest a perforation. Cholesteatoma (choice D) is a benign growth in the middle ear and does not typically present with the external ear canal findings described in the patient.
The nurse is assessing a patient's gait and notes that the patient lifts their foot high and slaps it down while walking. What does this finding suggest?
A. Ataxia.
B. Steppage gait.
C. Spastic hemiparesis.
D. Cerebellar dysfunction.
Correct answer:
The correct answer is B: Steppage gait. This finding suggests a steppage gait pattern, which is characterized by foot drop and excessive hip and knee flexion to lift the foot higher to avoid dragging it on the ground. This gait pattern is often seen in patients with weakness or paralysis of the dorsiflexor muscles of the foot, typically due to conditions such as peripheral neuropathy or nerve compression. This results in a high-stepping gait with foot slap during the swing phase of walking. Ataxia (A) refers to incoordination and would manifest as unsteady and uncoordinated movements, not specifically as foot slap. Spastic hemiparesis (C) typically presents with increased muscle tone and stiffness on one side of the body, affecting arm and leg movements. Cerebellar dysfunction (D) would present with ataxic gait, intention tremors, and dysmetria, rather than the specific steppage gait pattern
A patient presents with ear pain. She is an avid swimmer. The history includes pain and drainage from the left ear. On examination, she has pain when the ear is manipulated, including manipulation of the tragus. The canal is narrowed and erythematous, with some white debris in the canal. The rest of the examination is normal. What diagnosis would you assign this patient?
A. Otitis media
B. External otitis
C. Perforation of the tympanum
D. Cholesteatoma
Correct answer:
The correct diagnosis for this patient is external otitis (choice B). The key findings that support this diagnosis include pain on manipulation of the ear, especially the tragus, narrowed and erythematous ear canal, drainage, and white debris in the canal. These are classic signs of external otitis, also known as swimmer's ear, which is an infection of the ear canal. Otitis media (choice A) typically presents with middle ear inflammation and fluid accumulation, but this patient's symptoms are more consistent with an external ear infection. Perforation of the tympanum (choice C) would present with different symptoms, such as hearing loss, ear discharge, and possible pain, but the examination findings described do not suggest a perforation. Cholesteatoma (choice D) is a benign growth in the middle ear and does not typically present with the external ear canal findings described in the patient.
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 correct answer is B: Myasthenia gravis. This autoimmune disorder is characterized by muscle weakness and fatigability due to antibodies attacking acetylcholine receptors at the neuromuscular junction. The presence of anti-acetylcholine receptor antibodies in this patient supports the diagnosis. Ptosis and weakness of proximal muscles are classic features.
Choice A, Multiple sclerosis, is a central nervous system disorder and typically presents with sensory and motor deficits, not ptosis or fluctuating weakness. Guillain-Barré syndrome (Choice C) is characterized by ascending weakness and is typically preceded by an infection, unlike the chronic presentation in myasthenia gravis. Lambert-Eaton syndrome (Choice D) involves antibodies against presynaptic calcium channels and presents with proximal muscle weakness but often includes autonomic symptoms, which are not evident in this patient.
You are conducting a pupillary examination on a 34-year-old man. You note that both pupils dilate slightly. Both are noted to constrict briskly when the light is placed on the right eye. What is the most likely problem?
A. Optic nerve damage on the right
B. Optic nerve damage on the left
C. Efferent nerve damage on the right
D. Efferent nerve damage on the left
Correct answer:
The correct answer is B: Optic nerve damage on the left. When both pupils dilate slightly but the right pupil constricts briskly when light is shone on it, it indicates an afferent defect in the left eye. The optic nerve carries afferent (sensory) signals from the eye to the brain. Since the left optic nerve is damaged, the afferent signal from the left eye is not transmitted properly, resulting in the dilated pupils. The brisk constriction of the right pupil in response to light indicates that the efferent (motor) pathway is intact on the right side. Therefore, the problem is likely on the afferent pathway of the left optic nerve.
Incorrect choices:
A: Optic nerve damage on the right - Incorrect because the brisk constriction of the right pupil indicates the efferent pathway on the right is intact.
C: Efferent nerve damage on the right - Incorrect because the brisk constriction of the
RN exams fundamentals practice questions, set 27 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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