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 42-year-old man is trapped beneath his overturned tractor for hours. He is unconscious and shows no movement in his lower extremities. The most likely cause for this finding is:
A. An epidural hematoma
B. A pelvic fracture
C. Central cord syndrome
D. Intracerebral hemorrhage
Show answer and rationale
Correct answer: C — Central cord syndrome
The correct answer is C: Central cord syndrome. This syndrome typically presents with weakness or paralysis in the upper extremities and sparing of the lower extremities due to damage to the central spinal cord. In this case, the man's lack of movement in his lower extremities is indicative of central cord syndrome, likely caused by compression or injury to the cervical spinal cord during the tractor accident. The other choices can be ruled out: A) An epidural hematoma would present with signs of increased intracranial pressure, not paralysis in the lower extremities. B) A pelvic fracture would not directly cause paralysis in the lower extremities. D) Intracerebral hemorrhage would typically present with neurological deficits related to the brain, not the spinal cord.
Question 2
Which of the following would be the best way for an NA to respond to a resident with AD who exhibits inappropriate sexual behavior?
A. Let other residents know.
B. Take the resident to a private area.
C. Inform others that the resident has a dirty mind.
D. Reprimand the resident loudly.
Show answer and rationale
Correct answer: B — Take the resident to a private area.
The best way for an NA to respond to a resident with AD exhibiting inappropriate sexual behavior is to take the resident to a private area (Option B). This approach respects the resident's dignity and privacy while addressing the behavior discreetly. By taking the resident to a private area, the NA can provide appropriate redirection or support without embarrassing or shaming the resident publicly. This action promotes a therapeutic and respectful environment for the resident.
Option A is incorrect because it violates the resident's privacy and confidentiality. Option C is incorrect as it is disrespectful and stigmatizing towards the resident. Option D is inappropriate as reprimanding loudly can escalate the situation and cause distress to the resident and others.
Question 3
The nurse is examining an infant. To elicit the Moro reflex, the nurse should:
A. Perform the maneuver at the start of the examination.
B. Elicit the reflex at the end of the examination.
C. Avoid eliciting the reflex altogether.
D. Combine this reflex with other neurological assessments.
Show answer and rationale
Correct answer: B — Elicit the reflex at the end of the examination.
The Moro reflex is typically elicited by allowing the infant's head and trunk to drop slightly while supporting the infant securely. This reflex is part of the neurological assessment and is important to check for proper development. Choosing option B, to elicit the reflex at the end of the examination, allows the nurse to observe the infant's response and assess the reflex accurately after completing other assessments. Option A is incorrect because performing the maneuver at the start may startle the infant, affecting subsequent assessments. Option C is incorrect as it is essential to assess the Moro reflex for neurological evaluation. Option D is incorrect as combining the Moro reflex with other assessments may interfere with accurate observation and interpretation.
Question 4
A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. The nurse's preliminary analysis, based on this history, is that this patient may be suffering from:
A. Bronchitis.
B. Pneumonia.
C. Tuberculosis.
D. Pulmonary edema.
Show answer and rationale
Correct answer: C — Tuberculosis.
The correct answer is C: Tuberculosis. The key clues in the patient's history are rust-colored sputum, low-grade fevers, and night sweats, which are classic symptoms of tuberculosis. Rust-colored sputum is indicative of blood in the sputum, a common finding in pulmonary tuberculosis. Low-grade fevers and night sweats are also typical symptoms of tuberculosis due to the body's immune response to the infection. Bronchitis (A) typically presents with cough and mucus production without the specific symptoms described. Pneumonia (B) can present with productive cough and fever, but rust-colored sputum and night sweats are less common. Pulmonary edema (D) usually presents with symptoms like shortness of breath and pink frothy sputum, not rust-colored sputum and night sweats.
Question 5
A nurse is caring for a client with a serious bacterial infection. The client is dehydrated. Knowledge of the physical effects of the infection would support which of the following nursing diagnoses?
A. High Risk for Infection
B. Excess Fluid Volume
C. Risk for Imbalanced Body Temperature
D. Risk for Latex Allergy Response
Show answer and rationale
Correct answer: C — Risk for Imbalanced Body Temperature
The correct answer is C: Risk for Imbalanced Body Temperature. When a client has a serious bacterial infection, the body's response includes fever, which can lead to an imbalance in body temperature regulation. Dehydration can exacerbate this issue. Nursing diagnosis C is the most appropriate as it directly relates to the physical effects of the infection, helping the nurse anticipate and address potential complications.
Choice A, High Risk for Infection, is not the best choice as the client already has a bacterial infection, so the risk is not high but rather already present. Choice B, Excess Fluid Volume, is unlikely in a dehydrated client. Choice D, Risk for Latex Allergy Response, is not related to the physical effects of the bacterial infection and dehydration.
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Question 6
For EMS professionals to determine death in the pre-hospital environment, which of the following criteria must be met by the paramedic?
A. No electrical activity in the heart as confirmed by an EKG tracing indicating asystole
B. Apnea with a gag reflex as indicated by an attempt to intubate or establish another means of advanced airway
C. Independent lividity noted to the low points of the patient's body with skin that is cold and clammy
D. Pupils that are pinpoint, fixed, and non-reactive to light along with decreased muscle tone
Correct answer:
The correct answer is A: No electrical activity in the heart as confirmed by an EKG tracing indicating asystole. This is the most accurate criteria for determining death in the pre-hospital environment as it indicates complete cessation of cardiac activity. Asystole on an EKG is a definitive sign of cardiac arrest and irreversible death.
Choice B is incorrect because apnea with a gag reflex does not confirm death. A gag reflex may still be present even in a deceased individual.
Choice C is incorrect because lividity and skin condition are not definitive indicators of death and can be influenced by other factors.
Choice D is incorrect because pinpoint pupils and decreased muscle tone are not exclusive to death and can be present in other medical conditions.
Upon admission, a female client with breast cancer, liver, and spine metastases presents with constant, severe pain despite the continuous use of oxycodone (Percodan) and amitriptyline (Elavil) at home for pain management. What information is most crucial for the nurse to gather during the admission assessment?
A. Sensory pattern, area, intensity, and nature of the pain.
B. Identification of trigger points through palpation and manual pressure on painful areas.
C. Current schedule and total dosages of medications used for breakthrough pain.
D. Assessment of sympathetic responses indicative of acute pain onset.
Correct answer:
The most critical information for the nurse to obtain during the admission assessment of a client with severe pain due to breast cancer metastasis to the liver and spine is the sensory pattern, area, intensity, and nature of the pain. Understanding these details is essential to tailor appropriate pain management therapy effectively. By assessing the sensory pattern, area, intensity, and nature of pain, the nurse can better determine the underlying cause and choose the most suitable interventions to address the client's pain and improve their quality of life. Trigger points, medication dosages, and sympathetic responses are also important aspects of pain assessment but understanding the sensory aspects of pain is fundamental for providing optimal care in this scenario.
2 Which of the following is an example of an advance directive?
A. Last Will and Testament
B. Power of Attorney
C. Divorce Decree
D. Durable Power of Attorney for Health Care
Correct answer:
The correct answer is D: Durable Power of Attorney for Health Care. This is an example of an advance directive because it allows an individual to appoint someone to make healthcare decisions on their behalf if they become unable to do so. This document specifically addresses medical treatment preferences and end-of-life care.
A: Last Will and Testament deals with distribution of assets after death, not healthcare decisions.
B: Power of Attorney grants authority over legal and financial matters, not healthcare decisions.
C: Divorce Decree is a legal document dissolving a marriage, not related to healthcare directives.
In summary, the Durable Power of Attorney for Health Care is the correct choice as it specifically pertains to healthcare decision-making in advance.
The nurse is examining an infant. To elicit the Moro reflex, the nurse should:
A. Perform the maneuver at the start of the examination.
B. Elicit the reflex at the end of the examination.
C. Avoid eliciting the reflex altogether.
D. Combine this reflex with other neurological assessments.
Correct answer:
The Moro reflex is typically elicited by allowing the infant's head and trunk to drop slightly while supporting the infant securely. This reflex is part of the neurological assessment and is important to check for proper development. Choosing option B, to elicit the reflex at the end of the examination, allows the nurse to observe the infant's response and assess the reflex accurately after completing other assessments. Option A is incorrect because performing the maneuver at the start may startle the infant, affecting subsequent assessments. Option C is incorrect as it is essential to assess the Moro reflex for neurological evaluation. Option D is incorrect as combining the Moro reflex with other assessments may interfere with accurate observation and interpretation.
A 42-year-old man is trapped beneath his overturned tractor for hours. He is unconscious and shows no movement in his lower extremities. The most likely cause for this finding is:
A. An epidural hematoma
B. A pelvic fracture
C. Central cord syndrome
D. Intracerebral hemorrhage
Correct answer:
The correct answer is C: Central cord syndrome. This syndrome typically presents with weakness or paralysis in the upper extremities and sparing of the lower extremities due to damage to the central spinal cord. In this case, the man's lack of movement in his lower extremities is indicative of central cord syndrome, likely caused by compression or injury to the cervical spinal cord during the tractor accident. The other choices can be ruled out: A) An epidural hematoma would present with signs of increased intracranial pressure, not paralysis in the lower extremities. B) A pelvic fracture would not directly cause paralysis in the lower extremities. D) Intracerebral hemorrhage would typically present with neurological deficits related to the brain, not the spinal cord.
A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. The nurse's preliminary analysis, based on this history, is that this patient may be suffering from:
A. Bronchitis.
B. Pneumonia.
C. Tuberculosis.
D. Pulmonary edema.
Correct answer:
The correct answer is C: Tuberculosis. The key clues in the patient's history are rust-colored sputum, low-grade fevers, and night sweats, which are classic symptoms of tuberculosis. Rust-colored sputum is indicative of blood in the sputum, a common finding in pulmonary tuberculosis. Low-grade fevers and night sweats are also typical symptoms of tuberculosis due to the body's immune response to the infection. Bronchitis (A) typically presents with cough and mucus production without the specific symptoms described. Pneumonia (B) can present with productive cough and fever, but rust-colored sputum and night sweats are less common. Pulmonary edema (D) usually presents with symptoms like shortness of breath and pink frothy sputum, not rust-colored sputum and night sweats.
Which of the following is a guideline for a nursing assistant who is caring for a resident with an IV line?
A. The NA should disconnect the IV line when the bag is empty.
B. The NA should not measure blood pressure on an arm with an IV.
C. The NA should only get the IV site wet during the resident's bath.
D. The NA should lower the IV bag below the site for short intervals.
Correct answer:
The correct answer is B because measuring blood pressure on an arm with an IV can cause inaccurate readings and potential damage to the IV line. It is important to avoid placing any unnecessary pressure or restriction on the IV site to prevent complications such as infiltration or dislodgement. This guideline ensures the safety and well-being of the resident.
Incorrect choices:
A: Disconnecting the IV line when the bag is empty can interrupt the flow of medication or fluids, leading to potential harm to the resident.
C: Getting the IV site wet during the resident's bath can increase the risk of infection or dislodgement of the IV line.
D: Lowering the IV bag below the site for short intervals can cause improper flow rate and lead to complications like air embolism.
While conducting an EKG on your post-myocardial infarction patient, you note the presence of consistently wide QRS complexes greater than 120 ms in duration. What does this most likely indicate?
A. An intraventricular conduction delay or right/left bundle branch block
B. A complete heart block indicating no relationship between the atria and ventricles
C. The patient is likely suffering from a myocardial infarction currently
D. The patient has a congenital heart defect and should not require emergency care
Correct answer:
The correct answer is A: An intraventricular conduction delay or right/left bundle branch block. Wide QRS complexes greater than 120 ms duration typically indicate an intraventricular conduction delay, such as a bundle branch block. In the context of a post-myocardial infarction patient, this finding is common due to damage to the conduction system. Bundle branch blocks can lead to widened QRS complexes.
Summary:
B: A complete heart block is incorrect as it would typically present with a different EKG pattern.
C: While a myocardial infarction can cause conduction abnormalities, the widened QRS complexes are not indicative of an acute infarction.
D: Congenital heart defects are not typically associated with wide QRS complexes in a post-myocardial infarction patient.
You are on-scene with an adult patient who was found with an extremely altered level of consciousness, and a small amount of blood noted on his lips. There are no other obvious signs of trauma during the primary assessment other than a small tongue laceration. After ensuring an adequate airway, you discover the patient's small tongue laceration appears consistent with biting his tongue. He also has obviously swollen gums that do not appear to be caused by trauma. His vital signs are found to be within normal limits, and his pupils react to light, but his level of consciousness continues to be decreased to painful stimuli only. With the limited findings, which of the following conditions is most likely to cause the patient presentation?
A. A diabetic seizure most likely caused the patient's presentation
B. A metabolic coma is likely the cause of the patient's presentation
C. An epileptic seizure is likely responsible for causing the patient's condition
D. A cerebrovascular accident is likely the cause of the patient's condition
Correct answer:
The correct answer is C: An epileptic seizure is likely responsible for causing the patient's condition.
1. Tongue biting is a common sign seen in patients experiencing an epileptic seizure due to uncontrolled muscle movements.
2. Swollen gums without obvious trauma could be a result of clenching or grinding of teeth during a seizure.
3. Altered level of consciousness to painful stimuli is consistent with post-ictal state after a seizure.
4. Normal vital signs and reactive pupils suggest a non-metabolic cause.
Summary:
A: Diabetic seizure is less likely as the patient's vital signs are normal.
B: Metabolic coma is less likely due to the absence of metabolic abnormalities.
D: Cerebrovascular accident is less likely as there are no focal neurological deficits present.
Which of the following statements is true of urination?
A. Indwelling catheters do not affect muscle tone.
B. Fluids high in sodium increase urinary output.
C. A lack of privacy can affect urination, as can stress.
D. The bladder holds more urine as people age, causing them to urinate less frequently.
Correct answer:
Rationale for correct answer (C): A lack of privacy and stress can affect urination as it can lead to inhibition of the relaxation response needed for the bladder to empty fully. Privacy and relaxation are crucial for efficient urination. Stress can also trigger the fight-or-flight response, causing the bladder muscles to contract and prevent proper voiding. Hence, C is the correct statement.
Summary of why other choices are incorrect:
A: Indwelling catheters can affect muscle tone as they may lead to muscle atrophy and loss of muscle tone in the pelvic floor.
B: Fluids high in sodium may actually decrease urinary output due to increased retention of water in the body.
D: The bladder's capacity decreases with age, leading to more frequent urination rather than less.
RN exams fundamentals practice questions, set 38 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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