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 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
Show answer and rationale
Correct answer: C — Serum potassium level 3.0 mEq/L after 1 week of therapy
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
Question 2
The nurse should plan to use a wet-to-dry dressing for which patient?
A. A patient who has a pressure injury with pink granulation tissue.
B. A patient who has a surgical incision with pink, approximated edges.
C. A patient who has a full-thickness burn filled with dry, black material.
D. A patient who has a wound with purulent drainage and dry brown areas.
Show answer and rationale
Correct answer: D — A patient who has a wound with purulent drainage and dry brown areas.
Correct Answer: D
Rationale: Wet-to-dry dressing is used for wounds with purulent drainage to promote healing by mechanical debridement. Purulent drainage indicates infection, making it necessary to remove dead tissue. Dry brown areas suggest necrosis, which requires removal to allow healthy tissue regeneration. Wet-to-dry dressing helps in this process by moistening the wound, facilitating the removal of necrotic tissue with each dressing change. This promotes a clean wound bed conducive to healing.
Summary of Other Choices:
A: Pink granulation tissue indicates healing, not requiring mechanical debridement.
B: Surgical incision with pink, approximated edges indicates a well-healing wound, not requiring wet-to-dry dressing.
C: Full-thickness burn with dry, black material suggests eschar formation, which requires specialized burn care, not wet-to-dry dressing.
Question 3
When assessing the pulse of a 6-year-old boy, the nurse notices that his heart rate varies with his respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. The nurse's next action would be to:
A. Immediately notify the physician.
B. Consider this finding normal in children and young adults.
C. Check the child's blood pressure, and note any variation with respiration.
D. Document that this child has bradycardia, and continue with the assessment.
Show answer and rationale
Correct answer: B — Consider this finding normal in children and young adults.
The correct answer is B: Consider this finding normal in children and young adults.
Rationale:
1. This phenomenon is known as respiratory sinus arrhythmia, which is a normal variation in heart rate seen in children and young adults.
2. It occurs due to the physiological response of the autonomic nervous system to changes in intrathoracic pressure during respiration.
3. In children, the heart rate normally speeds up during inspiration and slows down during expiration.
4. Since this is a normal finding, there is no need to notify the physician or consider it as bradycardia.
Summary of other choices:
A: Not necessary to immediately notify the physician as this is a normal finding.
C: Checking the blood pressure is not indicated as the pulse variation with respiration is a separate phenomenon.
D: Documenting bradycardia is incorrect as this is not the case here.
Question 4
How should you determine whether a murmur is systolic or diastolic?
A. Palpate the carotid pulse.
B. Palpate the radial pulse.
C. Judge the relative length of systole and diastole by auscultation.
D. Correlate the murmur with a bedside heart monitor.
Show answer and rationale
Correct answer: C — Judge the relative length of systole and diastole by auscultation.
To determine whether a murmur is systolic or diastolic, you should judge the relative length of systole and diastole by auscultation. Systolic murmurs occur during systole, which is the phase of the cardiac cycle when the heart is contracting and pushing blood out of the chambers. Diastolic murmurs occur during diastole, which is the phase when the heart is relaxing and filling with blood. By carefully listening to the timing of the murmur in relation to the cardiac cycle, you can determine if it is systolic or diastolic. Palpating the carotid pulse (Choice A) or radial pulse (Choice B) can help assess the pulse characteristics, but it does not directly determine whether a murmur is systolic or diastolic. Correlating the murmur with a bedside heart monitor (Choice D) may provide additional information about heart rate or rhythm, but it does not specifically indicate
Question 5
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.
Show answer and rationale
Correct answer: A — While Ebony is giving Ms. Potter a bath, she asks her how her day has been and listens carefully.
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.
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Question 6
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.
A client in a long-term care facility reports to the nurse that he has not had a bowel movement in 2 days. Which intervention should the nurse implement first?
A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes.
B. Notify the healthcare provider and request a prescription for a large-volume enema.
C. Assess the client's medical record to determine the client's normal bowel pattern.
D. Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day.
Correct answer:
When a client reports a change in bowel habits, the first step for the nurse is to assess the client's normal bowel pattern by reviewing the medical records. This assessment helps the nurse understand the client's baseline, which is crucial before initiating any interventions. By determining the client's usual bowel habits, the nurse can identify deviations from the norm and make informed decisions on the appropriate course of action. Assessing the client's medical record is a critical first step in addressing the client's bowel concerns. Choices A, B, and D are incorrect because they jump to interventions without first establishing the client's normal bowel pattern. Offering warm prune juice, requesting a large-volume enema, or increasing fluids may not be appropriate until the nurse knows the client's regular bowel habits and can assess the situation effectively.
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.
A 55-year-old woman presents with difficulty walking and reports a feeling of 'pins and needles' in her legs. She has a history of diabetes mellitus. On examination, she has decreased sensation in the lower extremities and absent ankle reflexes. What is the most likely diagnosis?
A. Peripheral neuropathy
B. Multiple sclerosis
C. Spinal cord compression
D. Parkinson's disease
Correct answer:
The correct answer is A: Peripheral neuropathy. Given the patient's age, symptoms, history of diabetes mellitus, decreased sensation in lower extremities, and absent ankle reflexes, peripheral neuropathy is the most likely diagnosis. Peripheral neuropathy is a common complication of diabetes and presents with sensory symptoms like 'pins and needles,' decreased sensation, and loss of reflexes. Multiple sclerosis (B) typically presents with symptoms that involve the central nervous system and often presents with visual disturbances and muscle weakness. Spinal cord compression (C) typically presents with symptoms like weakness and sensory changes in specific dermatomal patterns, which are not consistent with the patient's presentation. Parkinson's disease (D) presents with motor symptoms such as tremors, rigidity, and bradykinesia, which are not seen in this patient.
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%.
Correct answer:
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.
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.
A 34-year-old man is brought to the ED after being pinned to the wall of a building by a cement truck. He is in obvious shock, and has deformities and marked swelling of both thighs. Although no open wounds are present, his shock:
A. "Cannot be explained without concomitant pelvic fracture"
B. Signifies a loss of approximately 15%
C. Is consistent with blood loss from bilateral femoral fracture
D. Will likely be reversed if appropriate traction splints are applied
Correct answer:
The correct answer is C: The shock in this scenario is consistent with blood loss from bilateral femoral fracture.
Rationale:
1. Bilateral femoral fractures can lead to significant blood loss due to injury to major blood vessels in the thighs, causing hypovolemic shock.
2. The deformities, marked swelling, and absence of open wounds point towards significant internal bleeding.
3. The shock is likely due to the blood loss from the femoral fractures, making choice C the most appropriate.
Summary:
A: Pelvic fracture may cause shock, but in this case, the femoral fractures are more likely the primary source of blood loss.
B: Loss of 15% blood volume is not significant enough to cause the severe shock observed in this patient.
D: Applying traction splints may stabilize the fractures but will not directly address the underlying blood loss causing the shock.
Which of the following is considered to be the greatest single modifiable risk factor for cardiac disease?
A. Obesity
B. Hypertension
C. Hyperlipidemia
D. Smoking
Correct answer:
The correct answer is D: Smoking. Smoking is considered the greatest single modifiable risk factor for cardiac disease due to its direct negative impact on cardiovascular health. Smoking increases the risk of heart disease by damaging blood vessels, raising blood pressure, increasing heart rate, and promoting the buildup of fatty deposits in the arteries. Quitting smoking has been shown to significantly reduce the risk of developing heart disease.
A: Obesity is a significant risk factor for heart disease, but smoking has a greater impact on cardiovascular health.
B: Hypertension is a major risk factor for heart disease, but smoking has a more significant impact on cardiovascular health.
C: Hyperlipidemia (high cholesterol) is a significant risk factor for heart disease, but smoking is considered the greatest single modifiable risk factor for cardiac disease.
During thoracentesis, which of the following nursing intervention will be most crucial?
A. Place patient in a quiet and cool room
B. Maintain strict aseptic technique
C. Advice patient to sit perfectly still during needle insertion until it has been withdrawn from the chest
D. Apply pressure over the puncture site as soon as the needle is withdrawn
Correct answer:
The correct answer is B: Maintain strict aseptic technique. This is crucial during thoracentesis to prevent infection. Step 1: Before the procedure, sterile equipment and supplies must be used. Step 2: Proper hand hygiene is essential to reduce the risk of introducing pathogens. Step 3: During the procedure, maintaining a sterile field helps minimize the risk of contamination. Step 4: After the procedure, ensuring proper disposal of all used supplies prevents the spread of infection.
Summary:
A: Placing the patient in a quiet and cool room may be comforting but is not directly related to the safety of the procedure.
C: Advising the patient to sit still is important for accurate needle insertion but does not address infection prevention.
D: Applying pressure over the puncture site is important but does not prevent infection if aseptic technique is not maintained.
The health care provider prescribes topical 5-FU for a patient with actinic keratosis on the left cheek. The nurse should include which statement in the patient’s instructions?
A. 5-FU will shrink the lesion to prepare for surgical excision.
B. Your cheek area will be eroded and it will take several weeks to heal.
C. You may develop nausea and anorexia, but good nutrition is important during treatment.
D. You will need to avoid crowds because of the risk for infection caused by chemotherapy.
Correct answer:
The correct answer is B: Your cheek area will be eroded and it will take several weeks to heal.
Rationale:
1. 5-FU is a topical chemotherapy agent used to treat actinic keratosis by causing erosion of the affected skin area.
2. Erosion of the skin is an expected side effect of 5-FU treatment and indicates that the medication is working to treat the actinic keratosis.
3. Healing after the erosion process can take several weeks as the skin regenerates.
4. This statement provides accurate information about the expected effects of 5-FU treatment on the patient's cheek area.
Summary:
- Option A is incorrect as 5-FU is not used to shrink the lesion for surgical excision but to treat actinic keratosis topically.
- Option C is incorrect as nausea and anorexia are not common side effects of topical 5-FU treatment for actinic keratosis.
- Option D is incorrect as
RN exams fundamentals practice questions, set 36 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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