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 performing a breast examination. Which of these statements best describes the correct procedure to use when screening for nipple and skin retraction during a breast examination? Have the woman:
A. Bend over and touch her toes.
B. Lie down on her left side and notice any retraction.
C. Shift from a supine position to a standing position, and note any lag or retraction.
D. Slowly lift her arms above her head, and note any retraction or lag in movement.
Show answer and rationale
Correct answer: D — Slowly lift her arms above her head, and note any retraction or lag in movement.
The correct answer is D. When a woman slowly lifts her arms above her head during a breast examination, it allows for better visualization and detection of any nipple or skin retraction. This position stretches the breast tissue and skin, making any abnormalities more apparent. Additionally, observing for any lag or retraction in movement while the arms are raised can help identify any potential issues.
Choice A is incorrect because bending over and touching her toes does not provide the necessary positioning to properly assess for nipple and skin retraction.
Choice B is incorrect because lying down on the left side may not provide the same level of stretching and visibility as lifting the arms above the head.
Choice C is incorrect because shifting from a supine position to a standing position may not provide the optimal angle for assessing nipple and skin retraction.
Question 2
A nurse assesses an oral temperature for an adult patient and records that the patient is afebrile. What would be the nurses best response to this finding?
A. Check the patient record for prescribed antipyretic medication.
B. Report the finding to the primary care provider.
C. Take the patient temperature using a different method.
D. No action is necessary; this is a normal reading.
Show answer and rationale
Correct answer: D — No action is necessary; this is a normal reading.
Afebrile means the patient has no fever, indicating a temperature within the normal range for an adult (typically 36.6°C to 38°C or 97.9°F to 100.4°F). When a nurse records a patient as afebrile, it suggests the absence of an elevated temperature that would require intervention. Choice A (checking for antipyretics) is unnecessary unless theres evidence of recent fever management, which isnt indicated here. Choice B (reporting to the provider) is not warranted for a normal finding unless other symptoms suggest a need for escalation. Choice C (using a different method) is redundant since the oral method is reliable and the result is normal. Choice D is correct because no further action is needed for a temperature within normal limits. This reflects standard nursing practice where routine findings dont prompt additional steps unless contextual factors suggest otherwise.
Question 3
You are serving as the preceptor for a newly graduated nurse. As you observe the new nurse for their application of body mechanics principles into client care, you observe that the nurse spreads her legs apart during a transfer with a client. What should you do?
A. Advise the nurse that the legs must be close together for stability during lifting and transfers.
B. Advise the nurse that the legs should be one in front of the other and not spread apart during a transfer.
C. Validate the nurse’s competency in terms of the application of body mechanics principles during a transfer.
D. Validate the nurse’s competency in terms of the application of ergonomics principles during a transfer.
Show answer and rationale
Correct answer: C — Validate the nurse’s competency in terms of the application of body mechanics principles during a transfer.
Step 1: Assess the Situation
- Evaluate the nurse's competency in the application of body mechanics principles during the transfer.
Step 2: Provide Feedback
- If the nurse demonstrates correct technique (even if different from what you expect), validate their competency.
Step 3: Encourage Open Communication
- Discuss the nurse's rationale for spreading legs apart and provide constructive feedback if needed.
Step 4: Support Learning
- Offer additional guidance on the importance of proper body mechanics and collaborate on improvement strategies.
Summary:
- Choice C is correct as it emphasizes validating competency before providing feedback.
- Choices A and B are incorrect as they immediately advise on specific techniques without assessing the nurse's current competency.
- Choice D is incorrect as it focuses on ergonomics, which may not be the immediate issue observed.
Question 4
The nurse is preparing to assess a patient's blood pressure. Which action is essential for obtaining an accurate reading?
A. Positioning the patient's arm above the level of the heart.
B. Using a cuff that covers two-thirds of the patient's upper arm.
C. Deflating the cuff at a rate of 5-10 mm Hg per second.
D. Having the patient stand during the measurement.
Show answer and rationale
Correct answer: B — Using a cuff that covers two-thirds of the patient's upper arm.
The correct answer is B: Using a cuff that covers two-thirds of the patient's upper arm. This is essential for obtaining an accurate blood pressure reading because using a cuff that is too small can result in falsely elevated readings, while using a cuff that is too large can result in falsely low readings. By covering two-thirds of the upper arm, the cuff ensures proper compression of the brachial artery, allowing for an accurate measurement.
A: Positioning the patient's arm above the level of the heart is not essential for obtaining an accurate reading and can lead to inaccurate results.
C: Deflating the cuff at a rate of 5-10 mm Hg per second is important but not as crucial as using the correct cuff size.
D: Having the patient stand during the measurement is not recommended as blood pressure should be measured with the patient in a seated or lying position for accuracy.
Question 5
A physical therapist uses an incentive spirometer with a patient post-thoracic surgery. The PRIMARY purpose of this intervention is to:
A. Promote relaxation.
B. Improve inspiratory muscle strength.
C. Reduce pain during breathing.
D. Prevent pulmonary complications.
Show answer and rationale
Correct answer: D — Prevent pulmonary complications.
The correct answer is D: Prevent pulmonary complications. Using an incentive spirometer post-thoracic surgery helps prevent atelectasis and pneumonia by promoting lung expansion, improving ventilation, and clearing secretions. This intervention aids in maintaining lung function and preventing respiratory complications.
A: Promote relaxation - While using an incentive spirometer may induce relaxation as a side effect, the primary purpose is not relaxation but rather to prevent pulmonary complications.
B: Improve inspiratory muscle strength - Although using an incentive spirometer can help improve inspiratory muscle strength, the primary purpose is to prevent pulmonary complications.
C: Reduce pain during breathing - While using an incentive spirometer may indirectly reduce pain by promoting optimal lung function, the primary purpose is to prevent pulmonary complications.
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Question 6
Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis?
A. Perform cough and deep breathing exercises hourly.
B. Turn from side to side in bed at least every 2 hours.
C. Dorsiflex and plantarflex the feet 10 times each hour.
D. Drink approximately 4 ounces of water every hour.
Correct answer:
The most crucial instruction for a client with limited mobility to prevent venous thrombosis is to perform dorsiflexion and plantarflexion of the feet 10 times each hour. These exercises help promote venous return, reducing the risk of thrombosis by preventing blood stasis in the lower extremities. While other measures like turning in bed and staying hydrated are beneficial, promoting venous return through foot exercises is the priority in preventing venous thrombosis in clients with limited mobility. Dorsiflexion and plantarflexion directly target the calf muscle pump, aiding in the circulation of blood back to the heart and preventing clot formation. The other options, such as cough and deep breathing exercises, turning in bed, and hydration, are important for overall health but do not directly address venous stasis and thrombosis prevention in the same way as foot exercises.
The best position for a client for thoracentesis is:
A. Upright leaning sideward
B. Orthopneic
C. Prone
D. Supine
Correct answer:
The correct answer is A: Upright leaning sideward. This position allows for better access to the pleural space between the ribs, minimizing the risk of injury to surrounding structures. The upright position helps to expand the lung and diaphragm, making it easier to locate the fluid pocket for thoracentesis. Leaning sideways helps to ensure gravity assists in pooling the fluid away from the needle insertion site.
Choice B: Orthopneic is not the best position for thoracentesis as the patient is sitting upright and leaning forward, which may not be as effective in accessing the fluid pocket.
Choice C: Prone position is incorrect because the patient is lying face down, making it difficult to access the pleural space in the back.
Choice D: Supine position is also incorrect as the patient is lying flat on their back, making it challenging to access the pleural space effectively.
A nurse is caring for a patient with chronic kidney disease (CKD) who is experiencing fluid retention. What is the priority action?
A. Administer diuretics.
B. Administer an opioid analgesic.
C. Administer fluids and electrolytes.
D. Administer a vasodilator.
Correct answer:
The correct answer is B: Administer an opioid analgesic. The priority action for a patient with CKD experiencing fluid retention is to manage their pain with an opioid analgesic. Pain can exacerbate fluid retention by activating the sympathetic nervous system, leading to increased sodium and water retention. Administering an opioid analgesic can help alleviate the pain, reduce sympathetic activation, and potentially decrease fluid retention.
Other choices are incorrect:
A: Administer diuretics - While diuretics are commonly used for fluid retention in CKD, managing pain should take precedence in this scenario.
C: Administer fluids and electrolytes - Administering more fluids can further worsen fluid retention in a patient with CKD.
D: Administer a vasodilator - Vasodilators are not commonly used for fluid retention in CKD and may not address the underlying issue of pain.
A 50-year-old woman presents with a complaint of severe headaches that occur in the morning and are associated with nausea and vomiting. She also reports blurred vision. Neurological examination reveals papilledema. Which of the following is the most likely diagnosis?
A. Migraine
B. Cluster headache
C. Tension-type headache
D. Intracranial hypertension
Correct answer:
The correct answer is D, Intracranial hypertension. This condition is characterized by increased pressure within the skull, leading to symptoms such as morning headaches, nausea, vomiting, blurred vision, and papilledema. The patient's presentation of severe morning headaches with associated symptoms and papilledema is classic for intracranial hypertension. Migraine (A) typically presents with pulsating headaches without neurological signs. Cluster headache (B) is characterized by severe unilateral headaches with autonomic features but not typically associated with papilledema. Tension-type headache (C) is usually bilateral, mild to moderate in intensity, and not associated with papilledema. In summary, the patient's symptoms and signs are most consistent with intracranial hypertension due to the presence of morning headaches, nausea, vomiting, blurred vision, and papilledema.
A 50-year-old woman presents with a complaint of severe headaches that occur in the morning and are associated with nausea and vomiting. She also reports blurred vision. Neurological examination reveals papilledema. Which of the following is the most likely diagnosis?
A. Migraine
B. Cluster headache
C. Tension-type headache
D. Intracranial hypertension
Correct answer:
The correct answer is D, Intracranial hypertension. This condition is characterized by increased pressure within the skull, leading to symptoms such as morning headaches, nausea, vomiting, blurred vision, and papilledema. The patient's presentation of severe morning headaches with associated symptoms and papilledema is classic for intracranial hypertension. Migraine (A) typically presents with pulsating headaches without neurological signs. Cluster headache (B) is characterized by severe unilateral headaches with autonomic features but not typically associated with papilledema. Tension-type headache (C) is usually bilateral, mild to moderate in intensity, and not associated with papilledema. In summary, the patient's symptoms and signs are most consistent with intracranial hypertension due to the presence of morning headaches, nausea, vomiting, blurred vision, and papilledema.
When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft breath sounds are heard over the posterior lower lobes, with inspiration being longer than expiration. The nurse interprets that these sounds are:
A. Normally auscultated over the trachea.
B. Bronchial breath sounds and normal in that location.
C. Vesicular breath sounds and normal in that location.
D. Bronchovesicular breath sounds and normal in that location.
Correct answer:
The correct answer is C: Vesicular breath sounds and normal in that location. Vesicular breath sounds are low-pitched, soft sounds heard over most of the lung fields. In this case, they are heard over the posterior lower lobes, which is a normal location for vesicular sounds. The longer inspiration than expiration is also characteristic of vesicular breath sounds.
A: Normally auscultated over the trachea - This is incorrect as breath sounds over the trachea are typically harsh and high-pitched.
B: Bronchial breath sounds and normal in that location - Bronchial breath sounds are harsh, loud sounds heard over the trachea and are not normal in the posterior lower lobes.
D: Bronchovesicular breath sounds and normal in that location - Bronchovesicular breath sounds are a mix of bronchial and vesicular sounds, and they are not normally auscultated in the posterior lower lobes.
Mrs. Zeno continues to become a weaker despite .treatment with neostigmine. Edrophonium HCL is ordered:
A. For its synergestic effect
B. Because of the client's resistance to
C. To rule out cholinergic crisis Neostigmine
D. To confirm the diagnosis of myasthenia
Correct answer:
The correct answer is C: To rule out cholinergic crisis Neostigmine. Edrophonium HCL is a short-acting cholinesterase inhibitor used to differentiate between myasthenic crisis and cholinergic crisis, as both conditions present similarly with muscle weakness. Administering edrophonium HCL will help determine if the patient's worsening weakness is due to excessive cholinergic stimulation from neostigmine (cholinergic crisis) or inadequate acetylcholine at the neuromuscular junction (myasthenic crisis). This step is crucial for proper management, as treating cholinergic crisis with more cholinesterase inhibitors like neostigmine can worsen symptoms.
Incorrect choices:
A: For its synergistic effect - Edrophonium HCL does not have a synergistic effect with neostigmine.
B: Because of the client's resistance to - Resistance to neostigmine is not a reason to administer edrophonium H
Which of the following patients best fits the criteria for a critical burn?
A. A 10-year-old patient with superficial burns over 60% of the body
B. A 15-year-old patient with full-thickness burns on the left upper/lower arm, non-circumferential
C. A 60-year-old patient with partial-thickness burns across 25% of the body, not involving the hands, feet, face, or genitals
D. A 20-year-old patient with partial-thickness burns on 25% of the body, not including the hands, feet, face, or genitals
Correct answer:
The correct answer is A because a critical burn is determined by the percentage of total body surface area (TBSA) affected. In this case, a 10-year-old patient with superficial burns over 60% of the body meets the criteria for a critical burn due to the extensive TBSA involvement. Superficial burns over 60% of the body can lead to significant fluid loss, infection risk, and systemic complications.
Choice B is incorrect because full-thickness burns on a specific area of the arm, even if full-thickness, are not as extensive as 60% TBSA involvement.
Choice C is incorrect as partial-thickness burns across 25% of the body, not involving critical areas, do not meet the criteria for a critical burn based on TBSA.
Choice D is also incorrect as partial-thickness burns on 25% of the body, not involving critical areas, do not meet the criteria for a critical burn based on TBSA.
The nurse is assessing a patient's cranial nerve V (trigeminal nerve). Which action is most appropriate?
A. Ask the patient to shrug their shoulders against resistance.
B. Assess the patient's ability to chew and detect light touch on the face.
C. Check for gag reflex and swallowing.
D. Evaluate the patient's hearing ability.
Correct answer:
The correct answer is B: Assess the patient's ability to chew and detect light touch on the face. This is the most appropriate action for assessing cranial nerve V (trigeminal nerve) as this nerve is responsible for sensory functions of the face and motor function of the muscles of mastication. By assessing the patient's ability to chew and detecting light touch on the face, the nurse can evaluate the integrity of the trigeminal nerve.
Choice A is incorrect because assessing the patient's ability to shrug their shoulders against resistance would be more indicative of assessing cranial nerve XI (accessory nerve). Choice C is incorrect because checking for gag reflex and swallowing is more related to cranial nerves IX (glossopharyngeal) and X (vagus). Choice D is incorrect because evaluating the patient's hearing ability is related to cranial nerve VIII (vestibulocochlear).
The ANA, which is committed to monitoring the regulation, education, and use of NAPs, recommends adherence to which one of the following principles:
A. It is the nursing profession that determines the scope of nursing practice.
B. It is the RN who defines and supervises the education, training, and use of any unlicensed assistant roles.
C. It is the assigned NAP who is responsible and accountable for his or her nursing practice.
D. It is the purpose of the RN to work in a supportive role to the assistive personnel.
Correct answer:
The correct answer is A because the American Nurses Association (ANA) believes that it is the nursing profession itself that should have the authority to determine the scope of nursing practice. This principle emphasizes the importance of nursing professionals being actively involved in defining and regulating their own practice.
Choice B is incorrect because while RNs may have a role in supervising unlicensed assistive personnel, it is not solely the responsibility of the RN to define and supervise the education and training of NAPs.
Choice C is incorrect because ultimate responsibility and accountability for nursing practice lies with the licensed nurse, not the unlicensed NAP.
Choice D is incorrect because the purpose of the RN is not just to work in a supportive role to assistive personnel; rather, it is to provide comprehensive nursing care and lead the nursing team.
RN exams fundamentals practice questions, set 32 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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