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
A 28 year old male is brought to the E He was involved in a fight in which he was beaten with a wooden stick. His chest shows multiple severe bruises. His airway is clear, RR is 22, HR is 126 and systolic BP is 90mmHg. Which one of the following should be performed during the primary survey?
A. "GCS"
B. Cervical spine x-ray
C. TT-administration
D. Blood alcohol level
Show answer and rationale
Correct answer: A — "GCS"
The correct answer is A: "GCS" (Glasgow Coma Scale). During the primary survey in trauma, assessing the patient's level of consciousness using GCS is crucial to identify any potential brain injury. The patient's airway, breathing, and circulation are already assessed and stable based on the given information. GCS helps determine the severity of head injury and guides further management.
B: Cervical spine x-ray is not indicated during the primary survey unless there is suspicion of cervical spine injury based on mechanism of injury or physical exam findings.
C: TT-administration (tetanus toxoid) is important but is not a priority during the primary survey. It can be administered later in the secondary survey.
D: Blood alcohol level is not necessary during the primary survey for acute trauma management. It can be considered in the secondary survey for further evaluation.
Question 2
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.
Show answer and rationale
Correct answer: B — Administer an opioid analgesic.
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.
Question 3
When examining the nares of a 45-year-old patient who has complaints of rhinorrhea, itching of the nose and eyes, and sneezing, the nurse notices the following: pale turbinates, swelling of the turbinates, and clear rhinorrhea. Which of these conditions is most likely the cause?
A. Nasal polyps
B. Acute sinusitis
C. Allergic rhinitis
D. Acute rhinitis
Show answer and rationale
Correct answer: C — Allergic rhinitis
Correct Answer: C. Allergic rhinitis
Rationale: The patient's symptoms of itching, sneezing, and clear rhinorrhea are classic signs of allergic rhinitis. The pale and swollen turbinates also support this diagnosis, as they are common findings in allergic rhinitis due to inflammation from allergens.
Incorrect Choices:
A: Nasal polyps - Nasal polyps typically present with nasal congestion, loss of smell, and may be associated with asthma. They are not commonly associated with clear rhinorrhea and itching.
B: Acute sinusitis - Acute sinusitis is characterized by facial pain, pressure, purulent nasal discharge, and fever. The absence of these symptoms makes acute sinusitis less likely.
D: Acute rhinitis - Acute rhinitis, or the common cold, usually presents with thick nasal discharge, sore throat, and low-grade fever. The clear rhinorrhea and itching in this patient are more
Question 4
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.
Show answer and rationale
Correct answer: C — Vesicular breath sounds and normal in that location.
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.
Question 5
The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? Bronchovesicular breath sounds are:
A. Musical in quality.
B. Usually caused by a pathologic disease.
C. Expected near the major airways.
D. Similar to bronchial sounds except shorter in duration.
Show answer and rationale
Correct answer: C — Expected near the major airways.
Step 1: Bronchovesicular breath sounds are expected near the major airways.
Step 2: Bronchovesicular sounds are heard over the 1st and 2nd intercostal spaces along the sternal border at the front and between the scapulae on the back.
Step 3: The sounds are a combination of bronchial (heard over trachea and major bronchi) and vesicular (heard over peripheral lung fields) sounds.
Step 4: The characteristics include moderate pitch and intensity, with equal inspiration and expiration.
Step 5: Choice C is the correct answer as it accurately describes the expected location of bronchovesicular breath sounds near the major airways.
Summary:
A: Incorrect - Bronchovesicular breath sounds are not musical in quality.
B: Incorrect - Bronchovesicular breath sounds are not usually caused by a pathologic disease.
D: Incorrect - Bronchovesicular breath sounds are a combination of bronchial
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Question 6
The true leg length should be measured between which of the following points?
A. Greater trochanter to lateral malleolus
B. Umbilicus and lateral malleolus
C. ASIS and medial malleolus
D. Anterior inferior iliac spine and medial malleolus
Correct answer:
The true leg length should be measured between the ASIS (anterior superior iliac spine) and the medial malleolus. This is because the ASIS is a prominent bony landmark on the pelvis, representing the top of the femur, and the medial malleolus is the bony prominence on the inner side of the ankle, representing the bottom of the tibia. Measuring between these points provides an accurate representation of the actual length of the leg.
Choice A (Greater trochanter to lateral malleolus) is incorrect because the greater trochanter is not the starting point for measuring leg length. Choice B (Umbilicus and lateral malleolus) is incorrect as the umbilicus is not a reliable reference point for leg length measurement. Choice D (Anterior inferior iliac spine and medial malleolus) is incorrect because the AIIS is not typically used as a reference point for leg length measurement.
Which finding during an abdominal assessment suggests the presence of ascites?
A. Hyperresonance on percussion.
B. Shifting dullness on percussion.
C. Borborygmi on auscultation.
D. Rebound tenderness on palpation.
Correct answer:
The correct answer is B: Shifting dullness on percussion. Ascites is the accumulation of fluid in the peritoneal cavity. When the patient is in a supine position, the fluid settles by gravity and causes dullness upon percussion in the dependent areas. Shifting dullness occurs when the patient is turned to the side, causing the fluid to shift and the dullness to move. This finding is specific to ascites.
A: Hyperresonance on percussion is associated with bowel gas and is typically heard in cases of bowel obstruction.
C: Borborygmi on auscultation refers to hyperactive bowel sounds and is not specific to ascites.
D: Rebound tenderness on palpation indicates peritoneal irritation, often seen in cases of peritonitis, not ascites.
In summary, shifting dullness on percussion is the key finding in assessing ascites due to the movement of fluid in the peritoneal cavity.
Your adult patient called for help after he began to vomit bright red blood. On arrival, the patient is found to be tachycardic and bleeding freely from his mouth. His respirations are shallow, and his skin is cool with a blood pressure of 68 systolic. His only history involves liver disease from chronic alcoholism. He denies drinking recently. What should be the goal of your pre-hospital intervention with this patient after ensuring his airway and applying oxygen therapy?
A. Fluid resuscitation to maintain a systolic blood pressure of 80-90 systolic
B. Fluid resuscitation to maintain a blood pressure of at least 100 systolic
C. To control the hemorrhage with pharmacologic intervention
D. Maintaining a high blood oxygen saturation to continue perfusion at the cellular level
Correct answer:
The correct answer is A: Fluid resuscitation to maintain a systolic blood pressure of 80-90 systolic. In this scenario, the patient is presenting with signs of hemorrhagic shock, such as tachycardia, hypotension, and cool skin. The primary goal of pre-hospital intervention is to stabilize the patient's hemodynamic status by restoring intravascular volume. The target systolic blood pressure range of 80-90 is appropriate for this situation to ensure adequate tissue perfusion without exacerbating bleeding. Choice B (maintaining a blood pressure of at least 100 systolic) may be too aggressive and risk further bleeding. Choice C (pharmacologic intervention) is not the initial priority in this acute situation. Choice D (maintaining high blood oxygen saturation) is important but not the primary goal; fluid resuscitation takes precedence in hemorrhagic shock to improve perfusion.
Your adult patient called for help after he began to vomit bright red blood. On arrival, the patient is found to be tachycardic and bleeding freely from his mouth. His respirations are shallow, and his skin is cool with a blood pressure of 68 systolic. His only history involves liver disease from chronic alcoholism. He denies drinking recently. What should be the goal of your pre-hospital intervention with this patient after ensuring his airway and applying oxygen therapy?
A. Fluid resuscitation to maintain a systolic blood pressure of 80-90 systolic
B. Fluid resuscitation to maintain a blood pressure of at least 100 systolic
C. To control the hemorrhage with pharmacologic intervention
D. Maintaining a high blood oxygen saturation to continue perfusion at the cellular level
Correct answer:
The correct answer is A: Fluid resuscitation to maintain a systolic blood pressure of 80-90 systolic. In this scenario, the patient is presenting with signs of hemorrhagic shock, such as tachycardia, hypotension, and cool skin. The primary goal of pre-hospital intervention is to stabilize the patient's hemodynamic status by restoring intravascular volume. The target systolic blood pressure range of 80-90 is appropriate for this situation to ensure adequate tissue perfusion without exacerbating bleeding. Choice B (maintaining a blood pressure of at least 100 systolic) may be too aggressive and risk further bleeding. Choice C (pharmacologic intervention) is not the initial priority in this acute situation. Choice D (maintaining high blood oxygen saturation) is important but not the primary goal; fluid resuscitation takes precedence in hemorrhagic shock to improve perfusion.
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.
Correct answer:
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.
Which of the following examples demonstrates a holistic approach to care?
A. While Ebony is giving Ms. Potter a bath, she asks her how her day has been and listens carefully.
B. Jim rushes his residents through their meals without talking with them so that they can get their dinner faster.
C. Teresa is very religious and likes to share her religious views with her residents.
D. Lemarcus often spends so much time chatting with his residents that he does not finish all of his work.
Correct answer:
The correct answer is A. This choice demonstrates a holistic approach to care by incorporating physical care (giving a bath) with emotional support (asking about the resident's day and listening). This shows a focus on the resident's overall well-being and not just their physical needs. It acknowledges the importance of the resident's feelings and experiences in addition to their physical health.
Summary of other choices:
B: This choice shows a rushed and impersonal approach to care, focusing solely on completing tasks quickly rather than connecting with the residents.
C: While sharing religious views may provide comfort to some residents, it does not necessarily address their holistic needs and may not be welcomed by all residents.
D: Spending excessive time chatting may neglect important tasks and responsibilities, indicating a lack of balance in care provision.
The nurse is teaching a review class on the lymphatic system. A participant shows correct understanding of the material with which statement?
A. Lymph flow is propelled by the contraction of the heart.'
B. The flow of lymph is slow, compared with that of the blood.'
C. One of the functions of the lymph is to absorb lipids from the biliary tract.'
D. Lymph vessels have no valves; therefore, lymph fluid flows freely from the tissue spaces into the bloodstream.'
Correct answer:
The correct answer is B: "The flow of lymph is slow, compared with that of the blood."
Rationale:
1. Lymphatic vessels lack a central pump like the heart, which results in slower lymph flow compared to blood flow.
2. The slow movement allows for thorough filtration and immune surveillance within lymph nodes.
3. The statement reflects an accurate understanding of the physiological differences between the lymphatic and circulatory systems.
Summary:
A: Incorrect - Lymph flow is not propelled by the contraction of the heart; it is propelled by skeletal muscle contractions and respiratory movements.
C: Incorrect - Lymph's main function is to collect excess tissue fluid and return it to the bloodstream, not to absorb lipids from the biliary tract.
D: Incorrect - Lymph vessels do have one-way valves that prevent backflow, ensuring the proper direction of lymph flow.
A patient who has heart failure has recently started taking digoxin (Lanoxin) in addition to furosemide (Lasix) and captopril. Which finding by the home health nurse is a priority to communicate to the health care provider?
A. Presence of 1+ to 2+ edema in the feet and ankles
B. Palpable liver edge 2 cm below the ribs on the right side
C. Serum potassium level 3.0 mEq/L after 1 week of therapy
D. Weight increase from 120 pounds to 122 pounds over 3 days
Correct answer:
The correct answer is C. A serum potassium level of 3.0 mEq/L after 1 week of therapy is a priority finding to communicate to the healthcare provider because digoxin, furosemide, and captopril can all cause electrolyte imbalances, especially hypokalemia, which can increase the risk of digoxin toxicity leading to life-threatening dysrhythmias. It is crucial to address and monitor potassium levels closely in patients taking these medications.
A: Presence of 1+ to 2+ edema in the feet and ankles is a common finding in heart failure patients and may not be an immediate concern unless it worsens.
B: Palpable liver edge 2 cm below the ribs may indicate hepatic congestion, which can occur in heart failure, but it is not as urgent as monitoring potassium levels.
D: A weight increase of 2 pounds over 3 days can be a sign of fluid retention, which is important to monitor but
A postoperative client has three different PRN analgesics prescribed for varying levels of pain. The nurse inadvertently administers a dose that is not within the prescribed parameters. What action should the nurse take first?
A. Assess for side effects of the medication.
B. Document the client's responses.
C. Complete a medication error report.
D. Determine if the pain was relieved.
Correct answer:
In the scenario where a nurse administers a medication outside the prescribed parameters, the immediate action should be to assess the client for any potential side effects of the medication. This is crucial to ensure the client's safety and well-being. By promptly assessing for side effects, the nurse can address any adverse reactions promptly and provide necessary interventions. Once the client's safety is ensured, documenting the client's responses, completing a medication error report, and assessing pain relief can follow as part of the broader response to the medication error. Choice B is not the first priority because the immediate concern is the potential harm from the incorrect dose. Choice C is also important but comes after ensuring the client's safety. Choice D focuses on the outcome rather than the immediate need to address any side effects of the medication.
A client9s body uses physiologic mechanisms from within to respond to internal changes and maintain an essential balance. This process is known as:
A. stress.
B. homeostasis.
C. self-regulation.
D. fight-or-flight response.
Correct answer:
The correct answer is B: homeostasis. Homeostasis is the body's ability to maintain internal stability and balance in response to changes in the external environment. It involves various physiological mechanisms that regulate temperature, blood pressure, pH levels, and other vital functions. Homeostasis ensures that the body functions optimally and stays within a narrow range of conditions necessary for life.
Choice A, stress, refers to the body's response to external challenges and is not the process of maintaining internal balance. Choice C, self-regulation, is a broader term that can encompass various processes, including homeostasis but does not specifically refer to the maintenance of internal balance. Choice D, fight-or-flight response, is a specific physiological response triggered by perceived threats and is not the same as the overall process of homeostasis.
RN exams fundamentals practice questions, set 34 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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