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 planning care for a client with a pulmonary embolism. Which nursing action would assist with the client's decrease in cardiac output?
A. Provide oxygen
B. Keep protamine sulfate at the bedside
C. Monitor pulmonary arterial pressures
D. Assess for bleeding
Show answer and rationale
Correct answer: A — Provide oxygen
Providing oxygen will help increase the oxygen supply to the tissues, thus supporting the heart in maintaining cardiac output. A decrease in cardiac output is a concern with pulmonary embolism as it can lead to inadequate tissue perfusion and possible complications. Oxygen therapy can improve oxygenation and support the heart in meeting the body's demands, helping to stabilize cardiac output. Monitoring and assessing pulmonary arterial pressures would be important in managing a pulmonary embolism but would not directly assist in increasing cardiac output. Keeping protamine sulfate at the bedside is more relevant for managing heparin overdose, not specifically for addressing a decrease in cardiac output. Assessing for bleeding is important in monitoring for potential complications of anticoagulant therapy but does not directly address the decrease in cardiac output seen in pulmonary embolism.
Question 2
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.
Show answer and rationale
Correct answer: D — Palpate for the presence of dorsalis pedis and posterior tibial pulses.
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.
Question 3
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
Show answer and rationale
Correct answer: A — First-degree (superficial) burn
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.
Question 4
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.
Show answer and rationale
Correct answer: 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.
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.
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
The most appropriate definition of Vital Signs:
A. Signs and symptoms of a disease
B. An indication of basic body functioning
C. A part of human composition
D. Physiology and anatomy
Correct answer:
Vital signs are fundamental indicators used by healthcare professionals to assess the basic physiological functions of the body, such as temperature, pulse, respiration, and blood pressure. An indication of basic body functioning, accurately captures this concept because vital signs reflect how well the body is maintaining homeostasis and performing essential tasks like circulation and oxygenation. Signs and symptoms of a disease, is incorrect because vital signs are not exclusively tied to illness; they are monitored in healthy individuals too. A part of human composition, is vague and does not specify function, while Physiology and anatomy, refers to broader scientific fields rather than the specific measurements vital signs represent. Thus, B is the most precise and appropriate definition, aligning with clinical practice where vital signs serve as a baseline for evaluating health status.
You are transporting a 20-year-old pregnant female from a local hospital to a medical facility that specializes in high-risk pregnancies when you note the patient is experiencing unexplained hypotension and bradycardia. The patient has a patent IV and is being administered magnesium that was initiated by hospital staff. On the cardiac monitor, the patient presents with a lengthening PR interval and signs of an impending high-degree nodal block. Which of the following interventions would be most appropriate in this case?
A. Increase the magnesium sulfate infusion rate, and administer a 1,000 mL normal saline bolus to support the patient's blood pressure
B. Stop the magnesium sulfate infusion immediately, and administer the appropriate dose of calcium chloride to correct the adverse effects of magnesium toxicity
C. Continue the infusion, but administer potassium chloride to counteract the adverse effects of the magnesium chloride administration
D. Reduce the infusion by half, and administer dextrose 50% to counteract the adverse cardiac effects caused by the magnesium chloride infusion
Correct answer:
The correct answer is B: Stop the magnesium sulfate infusion immediately, and administer the appropriate dose of calcium chloride to correct the adverse effects of magnesium toxicity.
Rationale:
1. **Stop magnesium infusion**: Magnesium toxicity can cause hypotension, bradycardia, and high-degree nodal block, hence stopping the infusion is crucial.
2. **Administer calcium chloride**: Calcium is the antidote for magnesium toxicity as it competes with magnesium for binding sites, reversing its effects.
3. **Corrects adverse effects**: Calcium chloride helps in counteracting the negative effects of magnesium on the cardiovascular system.
Summary:
- **Option A**: Increasing magnesium and giving saline won't address magnesium toxicity.
- **Option C**: Potassium won't counteract magnesium toxicity.
- **Option D**: Reducing infusion and giving dextrose won't correct magnesium toxicity.
Vital signs are fundamental indicators used by healthcare professionals to assess the basic physiological functions of the body, such as temperature, pulse, respiration, and blood pressure. An indication of basic body functioning, accurately captures this concept because vital signs reflect how well the body is maintaining homeostasis and performing essential tasks like circulation and oxygenation. Signs and symptoms of a disease, is incorrect because vital signs are not exclusively tied to illness; they are monitored in healthy individuals too. A part of human composition, is vague and does not specify function, while Physiology and anatomy, refers to broader scientific fields rather than the specific measurements vital signs represent. Thus, B is the most precise and appropriate definition, aligning with clinical practice where vital signs serve as a baseline for evaluating health status.
The nurse is caring for a patient who will undergo a removal of a lung lobe. Which level of care will the patient require immediately post procedure?
A. Acute care"â€medical-surgical unit
B. Acute care"â€intensive care unit
C. Ambulatory surgery
D. Ambulatory surgery"â€extended stay
Correct answer:
The correct answer is B: Acute care - intensive care unit. Post lung lobe removal, the patient may require close monitoring of vital signs, respiratory status, pain management, and potential complications like bleeding or respiratory distress. The intensive care unit provides specialized care and continuous monitoring by healthcare professionals to manage any postoperative complications promptly.
Choice A (Acute care - medical-surgical unit) may not provide the level of monitoring and specialized care that an intensive care unit offers for a patient undergoing major surgery like lung lobe removal.
Choices C (Ambulatory surgery) and D (Ambulatory surgery - extended stay) are not appropriate postoperative care settings for a patient undergoing lung lobe removal, as this surgery is major and requires more intensive monitoring and care than what ambulatory surgery settings can provide.
When assessing a child who complains of abdominal pain, what is the most appropriate nursing action?
A. Palpate the most painful area first.
B. Palpate for rebound tenderness.
C. Avoid painful areas until the end of the assessment.
D. Use deep palpation for abdominal tenderness.
Correct answer:
The most appropriate nursing action when assessing a child complaining of abdominal pain is to avoid painful areas until the end of the assessment (Choice C). This approach helps prevent causing unnecessary discomfort or distress to the child. By starting with non-painful areas, the nurse can establish rapport, gather important information, and assess the child's overall condition before addressing the painful areas. This ensures a thorough and sensitive assessment process.
Choice A is incorrect because palpating the most painful area first can cause distress and may not provide a comprehensive assessment. Choice B, palpating for rebound tenderness, is not appropriate as it is more specific to assessing for peritonitis in adults. Choice D, using deep palpation for abdominal tenderness, can be uncomfortable for the child and should be avoided until other assessments have been completed.
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.
When observing a patient's verbal and nonverbal communication, the nurse notices a discrepancy. Which statement is true regarding this situation? The nurse should:
A. Ask someone who knows the patient well to help interpret this discrepancy.
B. Focus on the patient's verbal message, and try to ignore the nonverbal behaviors.
C. Try to integrate the verbal and nonverbal messages and then interpret them as an average.
D. Focus on the patient's nonverbal behaviors, because these are often more reflective of a patient's true feelings.
Correct answer:
The correct answer is D. When observing a discrepancy between a patient's verbal and nonverbal communication, focusing on the patient's nonverbal behaviors is crucial because nonverbal cues often provide more accurate insights into a person's true feelings. Nonverbal communication, such as body language and facial expressions, can convey emotions and thoughts that may not be expressed verbally. By paying attention to these cues, the nurse can better understand the patient's underlying emotions and concerns. In contrast, focusing solely on the verbal message (Choice B) may lead to missing important cues, and integrating verbal and nonverbal messages as an average (Choice C) may dilute the significance of nonverbal cues. Asking someone who knows the patient well (Choice A) could be helpful but may not provide as direct and immediate insights as focusing on the patient's nonverbal behaviors.
When observing a patient's verbal and nonverbal communication, the nurse notices a discrepancy. Which statement is true regarding this situation? The nurse should:
A. Ask someone who knows the patient well to help interpret this discrepancy.
B. Focus on the patient's verbal message, and try to ignore the nonverbal behaviors.
C. Try to integrate the verbal and nonverbal messages and then interpret them as an average.
D. Focus on the patient's nonverbal behaviors, because these are often more reflective of a patient's true feelings.
Correct answer:
The correct answer is D. When observing a discrepancy between a patient's verbal and nonverbal communication, focusing on the patient's nonverbal behaviors is crucial because nonverbal cues often provide more accurate insights into a person's true feelings. Nonverbal communication, such as body language and facial expressions, can convey emotions and thoughts that may not be expressed verbally. By paying attention to these cues, the nurse can better understand the patient's underlying emotions and concerns. In contrast, focusing solely on the verbal message (Choice B) may lead to missing important cues, and integrating verbal and nonverbal messages as an average (Choice C) may dilute the significance of nonverbal cues. Asking someone who knows the patient well (Choice A) could be helpful but may not provide as direct and immediate insights as focusing on the patient's nonverbal behaviors.
The nurse is assessing cranial nerve XI (spinal accessory nerve). Which action is most appropriate?
A. Ask the patient to shrug their shoulders against resistance.
B. Have the patient stick out their tongue.
C. Test the patient's ability to chew.
D. Evaluate the patient's sense of smell.
Correct answer:
The correct answer is A: Ask the patient to shrug their shoulders against resistance. This is the most appropriate action for assessing cranial nerve XI (spinal accessory nerve) because this nerve innervates the trapezius and sternocleidomastoid muscles, which are responsible for shoulder shrugging and head rotation, respectively. By asking the patient to shrug their shoulders against resistance, the nurse can assess the strength and function of the trapezius muscle, which is controlled by the spinal accessory nerve.
Choices B, C, and D are incorrect:
B: Having the patient stick out their tongue is used to assess cranial nerve XII (hypoglossal nerve), not cranial nerve XI.
C: Testing the patient's ability to chew is used to assess cranial nerve V (trigeminal nerve), not cranial nerve XI.
D: Evaluating the patient's sense of smell is used to assess cranial nerve I (olfactory nerve),
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.
RN exams fundamentals practice questions, set 28 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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