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
You work in the emergency department, and an 88-year-old Spanish-speaking patient was just brought by ambulance with chest pain. You do not speak Spanish and there is no in-person interpreter available. Your best option to ensure communication is:
A. Identify a friend or family member who can provide interpreter services. It's better to have someone in person.
B. Leverage technology to ensure communication. Your hospital recently invested in video interpreter services.
C. Use gestures, simple words, and a loud voice to work through the history and physical exam.
D. Call another floor and see if they have anyone who knows Spanish. The patient can probably wait for a while.
Show answer and rationale
Correct answer: B — Leverage technology to ensure communication. Your hospital recently invested in video interpreter services.
The correct answer is B: Leverage technology to ensure communication. Your hospital recently invested in video interpreter services.
Rationale:
1. Utilizing technology like video interpreter services ensures accurate and real-time communication, overcoming language barriers effectively.
2. Video interpreter services provide professional interpreters who are trained in medical terminology, ensuring accurate transmission of information.
3. It maintains patient confidentiality and adheres to HIPAA regulations by using secure communication platforms.
4. It promotes cultural competency and patient-centered care by facilitating understanding and building trust with the patient.
Summary of other choices:
A: Identifying a friend or family member can compromise patient confidentiality and accuracy of interpretation.
C: Using gestures and simple words may lead to miscommunication, misunderstanding, and potential medical errors.
D: Delaying care by calling another floor for a Spanish speaker can jeopardize timely treatment for the patient's chest pain.
Question 2
A client is 2 days post operative. The vital signs are: BP - 120/70, HR - 110, RR - 26, and Temperature - 100.4 degrees Fahrenheit (38 degrees Celsius). The client suddenly becomes profoundly short of breath, skin color is gray. Which assessment would have alerted the nurse first to the client's change in condition?
A. Heart rate
B. Respiratory rate
C. Blood pressure
D. Temperature
Show answer and rationale
Correct answer: B — Respiratory rate
The correct answer is B: Respiratory rate. A sudden change in the client's respiratory rate, especially if the client becomes profoundly short of breath, indicates a critical change in condition such as respiratory distress or failure. This is a priority assessment as it directly relates to the client's oxygenation and respiratory status. In this scenario, the client's increased respiratory rate of 26 breaths per minute, along with the symptoms of profound shortness of breath and gray skin color, indicates potential respiratory compromise. Monitoring the respiratory rate would have alerted the nurse first to the client's deteriorating condition.
Summary of other choices:
A: Heart rate - Although an elevated heart rate of 110 bpm is present, it is less indicative of respiratory distress compared to the respiratory rate in this situation.
C: Blood pressure - The blood pressure of 120/70 is within normal range and may not be the first indicator of respiratory distress.
D: Temperature - A temperature of 100.4 degrees Fahrenheit is slightly
Question 3
A middle-aged man comes in because he has noticed multiple small, blood-red, raised lesions over his anterior chest and abdomen for the past several months. They are not painful and he has not noted any bleeding or bruising. He is concerned this may be consistent with a dangerous condition. What should you do?
A. Reassure him that there is nothing to worry about.
B. Do laboratory work to check for platelet problems.
C. Obtain an extensive history regarding blood problems and bleeding disorders.
D. Do a skin biopsy in the office.
Show answer and rationale
Correct answer: D — Do a skin biopsy in the office.
The correct answer is D: Do a skin biopsy in the office. This is the most appropriate action to take in this scenario as the presence of multiple small, blood-red, raised lesions without pain or bleeding warrants further investigation to determine the underlying cause. A skin biopsy would provide histological information about the nature of the lesions, helping to differentiate between various skin conditions such as angiomas, petechiae or purpura. This would guide the appropriate management and rule out any serious underlying conditions.
Choice A (Reassure him that there is nothing to worry about) is incorrect as the appearance of these lesions warrants further investigation rather than immediate reassurance. Choice B (Do laboratory work to check for platelet problems) is not the most appropriate initial step without first obtaining more specific information about the nature of the lesions. Choice C (Obtain an extensive history regarding blood problems and bleeding disorders) may be necessary later but is not the initial step in this case.
Question 4
Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These responses are referred to as:
A. Intuition.
B. The nursing process.
C. Clinical knowledge.
D. Diagnostic reasoning.
Show answer and rationale
Correct answer: A — Intuition.
Step-by-step rationale:
1. Intuition is the correct answer because it refers to the subconscious processing of assessment data by expert nurses.
2. Expert nurses rely on intuition to make quick and accurate decisions based on their experience and pattern recognition.
3. Intuition allows nurses to act without consciously labeling or analyzing the assessment data.
4. The nursing process (B) involves a systematic approach to care, not necessarily based on subconscious responses.
5. Clinical knowledge (C) is important but does not specifically refer to the subconscious pattern recognition seen in intuition.
6. Diagnostic reasoning (D) involves a more deliberate and analytical process compared to the quick, pattern-based responses of intuition.
Summary:
Intuition is the correct choice as it describes the subconscious response of expert nurses to assessment data. The other options, the nursing process, clinical knowledge, and diagnostic reasoning, do not specifically capture the automatic, pattern-based nature of expert nurse responses.
Question 5
A 70-year-old alcoholic patient with acute lethargy, confusion, and incontinence is admitted to the hospital ED. His wife tells you that he fell down the stairs about a month ago but 'he didn't have a scratch afterward.' She feels that he has become gradually less active and sleepier over the last 10 days or so. Which of the following collaborative interventions will you implement first?
A. Place on the hospital alcohol withdrawal protocol.
B. Transfer to radiology for a CT scan.
C. Insert a retention catheter to straight drainage.
D. Give phenytoin (Dilantin) 100 mg PO.
Show answer and rationale
Correct answer: B — Transfer to radiology for a CT scan.
The correct answer is B: Transfer to radiology for a CT scan. This is the first collaborative intervention to implement because the patient's history of falling down the stairs a month ago with subsequent absence of visible injuries raises concern for possible head trauma. The acute lethargy, confusion, and incontinence could be indicative of a traumatic brain injury or intracranial bleeding. A CT scan is crucial to assess for any structural brain abnormalities that may require immediate intervention.
Choice A: Placing on the hospital alcohol withdrawal protocol is not the first priority as the patient's symptoms are more suggestive of a potential head injury rather than alcohol withdrawal.
Choice C: Inserting a retention catheter to straight drainage may be necessary for managing incontinence, but it does not address the primary concern of assessing for potential head trauma.
Choice D: Giving phenytoin (Dilantin) 100 mg PO is not appropriate as the patient's symptoms are not necessarily indicative of seizures and administering ant
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Question 6
Which one of the following should be performed first in any patient whose injuries may include multiple closed extremity fractures?
A. "A thorough assessment of four limb perfusion"
B. "Maneuvers to prevent necrosis of the skin"
C. "Extremity compartment syndrome release"
D. "Ensuring adequate oxygenation and ventilation"
Correct answer:
Correct Answer: D - "Ensuring adequate oxygenation and ventilation"
Rationale: Ensuring adequate oxygenation and ventilation is crucial in any patient with potential multiple closed extremity fractures to address any immediate life-threatening issues like hypoxia or respiratory distress. Without proper oxygenation and ventilation, the patient's condition can deteriorate rapidly. It is the top priority in the ABCs of trauma care (Airway, Breathing, Circulation). Once the patient's respiratory status is stable, further assessment and management of limb perfusion, prevention of skin necrosis, and evaluation for compartment syndrome can be carried out.
Summary of other choices:
A: "A thorough assessment of four limb perfusion" - While limb perfusion assessment is important, ensuring adequate oxygenation and ventilation takes precedence due to its immediate life-saving implications.
B: "Maneuvers to prevent necrosis of the skin" - Preventing skin necrosis is important, but addressing respiratory concerns is critical for the patient's overall
A client is 2 days post operative. The vital signs are: BP - 120/70, HR - 110, RR - 26, and Temperature - 100.4 degrees Fahrenheit (38 degrees Celsius). The client suddenly becomes profoundly short of breath, skin color is gray. Which assessment would have alerted the nurse first to the client's change in condition?
A. Heart rate
B. Respiratory rate
C. Blood pressure
D. Temperature
Correct answer:
The correct answer is B: Respiratory rate. A sudden change in the client's respiratory rate, especially if the client becomes profoundly short of breath, indicates a critical change in condition such as respiratory distress or failure. This is a priority assessment as it directly relates to the client's oxygenation and respiratory status. In this scenario, the client's increased respiratory rate of 26 breaths per minute, along with the symptoms of profound shortness of breath and gray skin color, indicates potential respiratory compromise. Monitoring the respiratory rate would have alerted the nurse first to the client's deteriorating condition.
Summary of other choices:
A: Heart rate - Although an elevated heart rate of 110 bpm is present, it is less indicative of respiratory distress compared to the respiratory rate in this situation.
C: Blood pressure - The blood pressure of 120/70 is within normal range and may not be the first indicator of respiratory distress.
D: Temperature - A temperature of 100.4 degrees Fahrenheit is slightly
Which of the following is a strategy for a nursing assistant to use for managing stress?
A. The NA should drink whenever it makes her feel more relaxed.
B. The NA should get enough sleep.
C. The NA should skip meals so she can get more done.
D. The NA should take regular smoking breaks.
Correct answer:
The correct answer is B: The NA should get enough sleep. Adequate sleep is essential for managing stress as it helps the body and mind recover, improve focus, and regulate emotions. It also boosts the immune system and overall well-being.
Explanation:
1. Sleep is crucial for stress management: Lack of sleep can increase stress levels and make it harder to cope with challenges.
2. Restorative benefits of sleep: Quality sleep allows the body to repair and regenerate, promoting physical and mental health.
3. Cognitive function and stress: Sufficient sleep enhances cognitive abilities, decision-making, and problem-solving skills, enabling better stress management.
4. Emotional regulation: Sleep plays a vital role in mood regulation, reducing irritability and emotional reactivity to stressors.
Summary of Incorrect Choices:
A: Drinking to relax can lead to dependency and worsen stress in the long run.
C: Skipping meals can disrupt energy levels, impair concentration, and increase stress due to nutritional deficiencies.
D: Smoking breaks may
Postural drainage with percussion and vibration is ordered twice daily for a patient with chronic bronchitis. Which intervention should the nurse include in the plan of care?
A. Schedule the procedure 1 hour after the patient eats.
B. Maintain the patient in the lateral position for 20 minutes.
C. Give the prescribed albuterol (Ventolin HFA) before the therapy.
D. Perform percussion before assisting the patient to the drainage position.
Correct answer:
Correct Answer: B
Rationale: Maintaining the patient in the lateral position for 20 minutes after postural drainage with percussion and vibration helps to facilitate drainage of secretions from the affected lung segments. This position helps to target specific lung segments and allows gravity to assist in moving secretions towards larger airways for easier expectoration.
Incorrect Choices:
A: Scheduling the procedure 1 hour after the patient eats is not necessary for postural drainage with percussion and vibration. It is more important to maintain the patient in the proper position for effective drainage.
C: Giving albuterol before therapy is not directly related to postural drainage with percussion and vibration. Albuterol is a bronchodilator that may be prescribed for bronchospasm but is not directly related to postural drainage.
D: Performing percussion before assisting the patient to the drainage position is incorrect. Percussion should be performed after the patient is in the appropriate position to facilitate secretion movement.
A 70-year-old alcoholic patient with acute lethargy, confusion, and incontinence is admitted to the hospital ED. His wife tells you that he fell down the stairs about a month ago but 'he didn't have a scratch afterward.' She feels that he has become gradually less active and sleepier over the last 10 days or so. Which of the following collaborative interventions will you implement first?
A. Place on the hospital alcohol withdrawal protocol.
B. Transfer to radiology for a CT scan.
C. Insert a retention catheter to straight drainage.
D. Give phenytoin (Dilantin) 100 mg PO.
Correct answer:
The correct answer is B: Transfer to radiology for a CT scan. This is the first collaborative intervention to implement because the patient's history of falling down the stairs a month ago with subsequent absence of visible injuries raises concern for possible head trauma. The acute lethargy, confusion, and incontinence could be indicative of a traumatic brain injury or intracranial bleeding. A CT scan is crucial to assess for any structural brain abnormalities that may require immediate intervention.
Choice A: Placing on the hospital alcohol withdrawal protocol is not the first priority as the patient's symptoms are more suggestive of a potential head injury rather than alcohol withdrawal.
Choice C: Inserting a retention catheter to straight drainage may be necessary for managing incontinence, but it does not address the primary concern of assessing for potential head trauma.
Choice D: Giving phenytoin (Dilantin) 100 mg PO is not appropriate as the patient's symptoms are not necessarily indicative of seizures and administering ant
A 45-year-old woman with a history of hypertension presents with a complaint of headache, blurred vision, and nausea. Her blood pressure is 200/120 mm Hg. What is the most likely diagnosis?
A. Primary hypertension
B. Hypertensive crisis
C. Migraine
D. Cluster headache
Correct answer:
The correct answer is B: Hypertensive crisis. The patient's symptoms of headache, blurred vision, and nausea, along with severely elevated blood pressure (200/120 mm Hg), suggest a hypertensive emergency. In this situation, the elevated blood pressure is causing end-organ damage, leading to symptoms. Treatment is urgent to prevent further complications.
Choice A: Primary hypertension is unlikely as the sudden onset of severe symptoms and extremely high blood pressure indicate an acute issue rather than chronic primary hypertension.
Choice C: Migraine typically presents with specific symptoms like throbbing head pain, sensitivity to light or sound, and may have an aura. The lack of these symptoms and the presence of severely elevated blood pressure make migraine less likely.
Choice D: Cluster headaches are characterized by severe, unilateral head pain with associated symptoms like eye redness or tearing. The lack of these specific symptoms and the presence of markedly elevated blood pressure make cluster headache less likely.
A child has been admitted to the burn unit after pulling a pan of hot water off the stove. Given the fact that there is primarily second- and third-degree burns, the health care worker should prioritize care to focus on which of the following? Select all that apply.
A. Focus on replacing fluids that have been lost from the vascular, interstitial, and cellular compartments.
B. Assess for indications that the child's airway has been compromised by assessing breath sounds and voice quality.
C. Maintain sterile field when doing dressing changes and debridement.
D. Withhold foods/nutrition since the GI tract may have slowed down in response to stress.
Correct answer:
The correct answer is A: Focus on replacing fluids that have been lost from the vascular, interstitial, and cellular compartments. In burn injuries, there is a significant loss of fluids due to damage to the skin barrier. Prioritizing fluid replacement helps prevent hypovolemic shock and maintains adequate tissue perfusion. This is crucial in managing burn patients to prevent complications like organ failure.
Choices B, C, and D are incorrect:
B: Assessing for airway compromise is important but not the top priority in this scenario. Fluid resuscitation takes precedence in managing burn injuries.
C: Maintaining a sterile field is important for infection prevention but is not the immediate priority over fluid replacement.
D: Withholding nutrition is not recommended as burn injuries increase the body's metabolic demands. Providing adequate nutrition supports healing and recovery, so withholding food can be detrimental.
In summary, fluid replacement is prioritized in burn injuries to prevent shock and maintain tissue perfusion.
Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These responses are referred to as:
A. Intuition.
B. The nursing process.
C. Clinical knowledge.
D. Diagnostic reasoning.
Correct answer:
Step-by-step rationale:
1. Intuition is the correct answer because it refers to the subconscious processing of assessment data by expert nurses.
2. Expert nurses rely on intuition to make quick and accurate decisions based on their experience and pattern recognition.
3. Intuition allows nurses to act without consciously labeling or analyzing the assessment data.
4. The nursing process (B) involves a systematic approach to care, not necessarily based on subconscious responses.
5. Clinical knowledge (C) is important but does not specifically refer to the subconscious pattern recognition seen in intuition.
6. Diagnostic reasoning (D) involves a more deliberate and analytical process compared to the quick, pattern-based responses of intuition.
Summary:
Intuition is the correct choice as it describes the subconscious response of expert nurses to assessment data. The other options, the nursing process, clinical knowledge, and diagnostic reasoning, do not specifically capture the automatic, pattern-based nature of expert nurse responses.
Which of the following is the major goal of ambulatory care facilities?
A. to save money by not paying hospital rates
B. to provide care to patients capable of self-care at home
C. to perform major surgery in a community setting
D. to perform tests prior to being admitted to the hospital
Correct answer:
The correct answer is B: to provide care to patients capable of self-care at home. Ambulatory care facilities focus on providing medical services to patients who do not require overnight hospitalization and can manage their care at home. This includes services such as outpatient surgeries, diagnostic tests, treatments, and follow-up care. By choosing option B, it aligns with the primary goal of ambulatory care facilities, which is to offer convenient and cost-effective care to patients who can safely recover at home.
Explanation of other choices:
A: to save money by not paying hospital rates - Incorrect. While cost-effectiveness is a benefit of ambulatory care facilities, it is not the major goal.
C: to perform major surgery in a community setting - Incorrect. Ambulatory care facilities typically focus on minor surgeries and procedures, not major surgeries.
D: to perform tests prior to being admitted to the hospital - Incorrect. This goal is more related to pre-admission testing rather than the primary goal of ambulatory care
A 45-year-old woman with a history of hypertension presents with a complaint of headache, blurred vision, and nausea. Her blood pressure is 200/120 mm Hg. What is the most likely diagnosis?
A. Primary hypertension
B. Hypertensive crisis
C. Migraine
D. Cluster headache
Correct answer:
The correct answer is B: Hypertensive crisis. The patient's symptoms of headache, blurred vision, and nausea, along with severely elevated blood pressure (200/120 mm Hg), suggest a hypertensive emergency. In this situation, the elevated blood pressure is causing end-organ damage, leading to symptoms. Treatment is urgent to prevent further complications.
Choice A: Primary hypertension is unlikely as the sudden onset of severe symptoms and extremely high blood pressure indicate an acute issue rather than chronic primary hypertension.
Choice C: Migraine typically presents with specific symptoms like throbbing head pain, sensitivity to light or sound, and may have an aura. The lack of these symptoms and the presence of severely elevated blood pressure make migraine less likely.
Choice D: Cluster headaches are characterized by severe, unilateral head pain with associated symptoms like eye redness or tearing. The lack of these specific symptoms and the presence of markedly elevated blood pressure make cluster headache less likely.
RN exams fundamentals practice questions, set 4 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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