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
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
Show answer and rationale
Correct answer: A — A 10-year-old patient with superficial burns over 60% of the body
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.
Question 2
A nurse is positioning a sterile drape to extend the working area when performing a urinary catheterization. Which of the following is an appropriate technique for this procedure?
A. Use sterile gloves to handle the entire drape surface.
B. Fold the lower edges of the drape over the sterile-gloved hands.
C. Touch only the outer two inches of the drape when not wearing sterile gloves.
D. When reaching over the drape do not allow clothing to touch the drape.
Show answer and rationale
Correct answer: A — Use sterile gloves to handle the entire drape surface.
The correct answer is A because using sterile gloves to handle the entire drape surface ensures the sterility of the working area during the urinary catheterization procedure. By using sterile gloves, the nurse maintains aseptic technique and prevents contamination of the sterile field.
Choice B is incorrect because folding the lower edges of the drape over the sterile-gloved hands may lead to contamination of the sterile field as the gloves are not in direct contact with the drape surface.
Choice C is incorrect because touching only the outer two inches of the drape when not wearing sterile gloves does not ensure complete sterility and may still lead to contamination of the working area.
Choice D is incorrect because allowing clothing to touch the drape can introduce contaminants to the sterile field, compromising the aseptic technique required for the procedure.
Question 3
Which one of the following statement is true?
A. Hypotonic fluids should be used to limit brain edema in patients with severe head injury
B. Elevated intracranial pressure will not affect cerebral perfusion
C. CSF cannot be displaced from cranial vault
D. Cerebral blood flow is increased when PaCO2 is below 30mmHg --> below 50mmHg
Show answer and rationale
Correct answer: D — Cerebral blood flow is increased when PaCO2 is below 30mmHg --> below 50mmHg
The correct answer is D because cerebral blood flow is directly influenced by PaCO2 levels. When PaCO2 is below 30-50mmHg, cerebral blood vessels constrict, leading to decreased cerebral blood flow. This vasoconstriction is a protective mechanism to prevent excessive blood flow and maintain stable cerebral perfusion pressure. Therefore, the statement that cerebral blood flow is increased when PaCO2 is below 30-50mmHg is true.
Explanation for why the other choices are incorrect:
A: Hypotonic fluids can exacerbate brain edema by causing fluid shifts, so they should not be used to limit brain edema in severe head injury.
B: Elevated intracranial pressure impairs cerebral perfusion due to decreased perfusion pressure gradient, leading to decreased cerebral blood flow.
C: CSF can be displaced from the cranial vault due to changes in intracranial pressure and volume shifts.
Question 4
The nurse is assessing a client with chronic bronchitis. Which finding is most concerning?
A. Productive cough with thick sputum.
B. Clubbing of fingers.
C. Peripheral cyanosis.
D. Oxygen saturation of 88%.
Show answer and rationale
Correct answer: D — Oxygen saturation of 88%.
The correct answer is D: Oxygen saturation of 88%. This finding is most concerning because it indicates hypoxemia, which can lead to serious complications in a client with chronic bronchitis. Hypoxemia can result in tissue damage and impaired organ function. A low oxygen saturation level requires immediate intervention to prevent further deterioration.
Choice A (Productive cough with thick sputum) is a common symptom of chronic bronchitis and may indicate an exacerbation, but it is not as immediately concerning as hypoxemia.
Choice B (Clubbing of fingers) is a late sign of chronic hypoxemia and may be present in clients with chronic bronchitis, but it is not as urgent as a low oxygen saturation level.
Choice C (Peripheral cyanosis) is also a sign of hypoxemia, but oxygen saturation level provides a more accurate assessment of the client's oxygenation status.
Question 5
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
Show answer and rationale
Correct answer: C — ASIS and medial malleolus
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.
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Question 6
During an oral examination of a 4-year-old Native-American child, the nurse notices that her uvula is partially split. Which of these statements is accurate?
A. This condition is a cleft palate and is common in Native Americans.
B. A bifid uvula may occur in some Native-American groups.
C. This condition is due to an injury and should be reported to the authorities.
D. A bifid uvula is palatinus, which frequently occurs in Native Americans.
Correct answer:
The correct answer is B: A bifid uvula may occur in some Native-American groups. A bifid uvula refers to a split or forked uvula, which is a variation of normal anatomy and can be seen in certain populations, including some Native-American groups. This condition is usually benign and does not typically cause any health issues. It is important for healthcare providers to be aware of such variations to avoid unnecessary concern or intervention.
Explanation for incorrect options:
A: This condition is not a cleft palate, which is a more severe congenital condition involving a gap in the roof of the mouth.
C: There is no indication that the bifid uvula is due to an injury or that it should be reported to authorities.
D: "Palatinus" is not a term commonly used to describe a bifid uvula, and the statement about its frequency in Native Americans is not supported by evidence.
Thyroid hormones primarily regulate the following:
A. Heart rate and respiration
B. Bile production and potassium
C. Kidney and liver function
D. Metabolism and growth
Correct answer:
The correct answer is D: Metabolism and growth. Thyroid hormones, such as T3 and T4, play a crucial role in regulating metabolism by influencing the body's energy production and consumption. They also help in the growth and development of various tissues and organs. This is supported by scientific research and physiological understanding.
Explanation for other choices:
A: Heart rate and respiration - While thyroid hormones can indirectly influence heart rate and respiration through their effects on metabolism, they are not the primary regulators of these functions.
B: Bile production and potassium - Thyroid hormones do not have a direct role in regulating bile production or potassium levels in the body.
C: Kidney and liver function - While thyroid hormones can affect kidney and liver function to some extent, their primary role lies in metabolism and growth regulation.
Which finding in a patient with asthma indicates a need for immediate intervention?
A. Use of accessory muscles during respiration.
B. Oxygen saturation of 92% on room air.
C. Mild expiratory wheezing.
D. Peak expiratory flow rate of 85% of personal best.
Correct answer:
The correct answer is A: Use of accessory muscles during respiration. This finding in a patient with asthma indicates a need for immediate intervention because it signifies severe respiratory distress and impending respiratory failure. Accessory muscle use suggests that the patient is struggling to breathe and is unable to maintain adequate oxygenation. This requires prompt medical attention to prevent further deterioration.
Summary:
B: Oxygen saturation of 92% on room air may indicate mild hypoxemia but is not as urgent as the use of accessory muscles.
C: Mild expiratory wheezing is a common finding in asthma exacerbations and may not necessarily require immediate intervention.
D: Peak expiratory flow rate of 85% of personal best indicates moderate airflow limitation but does not necessarily require immediate intervention unless accompanied by other severe symptoms.
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.
A 25-year-old radio announcer comes to the clinic for an annual examination. His BMI is 26.0 kg/m2. He is concerned about his weight. Based on this information, what is appropriate counsel for the patient during the visit?
A. Refer the patient to a nutritionist because he is anorexic.
B. Reassure the patient that he has a normal body weight.
C. Give the patient information about reduction of fat, cholesterol, and calories because he is overweight.
D. Give the patient information about reduction of fat and cholesterol because he is obese.
Correct answer:
The correct answer is C: Give the patient information about reduction of fat, cholesterol, and calories because he is overweight.
Rationale:
1. BMI of 26.0 kg/m2 indicates the patient is overweight, not underweight (anorexic) (Choice A) or obese (Choice D).
2. Patient's concern about weight indicates the need for guidance on healthy habits.
3. Providing information on reducing fat, cholesterol, and calories aligns with addressing weight concerns.
Incorrect Choices:
A: Refer the patient to a nutritionist because he is anorexic - Incorrect because the patient is overweight, not anorexic.
B: Reassure the patient that he has a normal body weight - Incorrect as BMI of 26.0 kg/m2 indicates overweight, not normal weight.
D: Give the patient information about reduction of fat and cholesterol because he is obese - Incorrect as the patient is overweight, not obese.
The nurse is teaching a patient who will begin receiving targeted therapy for cancer. The patient asks how targeted therapy differs from other types of chemotherapies. The nurse will explain that targeted therapy
A. Damages cancer cell DNA to prevent cell replication.
B. Directly kills or damages cancerous cells.
C. Interferes with specific molecules in cancer cells.
D. Prevents metastasis of cancer cells.
Correct answer:
The correct answer is C: Targeted therapy interferes with specific molecules in cancer cells. This type of therapy is designed to target specific abnormalities or molecules that are unique to cancer cells, which helps to inhibit their growth and spread. By focusing on these specific targets, targeted therapy can be more precise and effective compared to traditional chemotherapies.
A: Damaging cancer cell DNA to prevent cell replication is more characteristic of traditional chemotherapy, not targeted therapy.
B: Directly killing or damaging cancerous cells is a general mechanism of action for various cancer treatments, not specific to targeted therapy.
D: Preventing metastasis of cancer cells is not the primary mechanism of action of targeted therapy, which primarily focuses on inhibiting the growth and spread of cancer cells through specific molecular targeting.
Which of the following statements is true of chest tubes?
A. The drainage system must be kept above the level of the resident's chest.
B. The chest drainage must be observed for amount and color.
C. The tubing should be kinked.
D. Chest tubes will only be in the front of the body
Correct answer:
The correct answer is B: The chest drainage must be observed for amount and color. This statement is true because monitoring the amount and color of chest drainage is crucial in assessing the resident's condition, detecting any signs of bleeding or infection. It helps in determining the effectiveness of the chest tube in removing air or fluid from the pleural space.
Incorrect choices:
A: The drainage system must be kept above the level of the resident's chest - This is incorrect as the drainage system should be kept below the level of the resident's chest to facilitate drainage.
C: The tubing should be kinked - Kinking the tubing can obstruct the flow of drainage, which is harmful.
D: Chest tubes will only be in the front of the body - Chest tubes can be placed in various locations depending on the specific condition being treated, not just in the front of the body.
A nurse is using assessment data gathered about a patient and combining critical thinking to develop a nursing diagnosis. What is the nurse doing?
A. Assigning clinical cues
B. Defining characteristics
C. Diagnostic reasoning NursingStoreRN
D. Diagnostic labeling
Correct answer:
The correct answer is C: Diagnostic reasoning. The nurse is utilizing assessment data to analyze and interpret the information to develop a nursing diagnosis. This involves critical thinking skills to make conclusions and create a plan of care.
A: Assigning clinical cues - This choice is incorrect as it refers to identifying objective and subjective data during assessment, not the process of analyzing and synthesizing data to form a diagnosis.
B: Defining characteristics - This choice is incorrect as it typically refers to the specific manifestations or symptoms associated with a particular nursing diagnosis, not the process of diagnosing itself.
D: Diagnostic labeling - This choice is incorrect as it refers to the final step in the nursing diagnosis process where the nurse assigns a label to the identified problem, not the overall process of diagnostic reasoning.
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.
Correct answer:
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.
The ability of an individual to cope with death is dependent upon a number of factors. Which person likely has the most difficulty coping with a death?
A. A parent whose 17-year-old child died in an auto accident the night before graduation
B. A child of 8 years whose grandparent dies a week before a planned visit
C. The spouse of an alcoholic who is killed in an automobile accident
D. The grandparent of a child born with Tay-Sachs disease
Correct answer:
The correct answer is A because losing a child is considered one of the most devastating experiences a person can face, regardless of the circumstances. The sudden death of a young person on the brink of adulthood adds layers of complexity and emotional pain. The loss of potential, unfulfilled dreams, and the traumatic nature of the accident all contribute to the intense grief and difficulty in coping.
Choice B is incorrect because while the child may experience grief and confusion, the emotional impact is typically less compared to losing a child. Choice C is incorrect as the relationship with the alcoholic spouse may have been strained due to addiction, potentially lessening the emotional attachment. Choice D is incorrect as the grandparent may experience grief over the loss of their grandchild, but the intensity is generally lower than losing a child directly.
RN exams fundamentals practice questions, set 35 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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