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
The first two steps in approaching an emergency are
A. Perform first aid and assess the situation
B. Call the victim's family and then call 9
C. Assess the situation and the victim
D. Get assistance and perform CPR
Show answer and rationale
Correct answer: C — Assess the situation and the victim
The correct answer is C because, in an emergency, the first step should always be to assess the situation to ensure your safety and the safety of others. Once the situation is assessed, then you can move on to assessing the victim to determine the appropriate course of action. Performing first aid or CPR without assessing the situation and victim's condition can potentially make the situation worse. Choice A is incorrect because performing first aid should not be the immediate first step without assessing the situation first. Choice B is incorrect because calling the victim's family is not a priority in an emergency situation. Choice D is incorrect because getting assistance and performing CPR should come after assessing the situation and the victim's condition.
Question 2
The first two steps in approaching an emergency are
A. Perform first aid and assess the situation
B. Call the victim's family and then call 9
C. Assess the situation and the victim
D. Get assistance and perform CPR
Show answer and rationale
Correct answer: C — Assess the situation and the victim
The correct answer is C because, in an emergency, the first step should always be to assess the situation to ensure your safety and the safety of others. Once the situation is assessed, then you can move on to assessing the victim to determine the appropriate course of action. Performing first aid or CPR without assessing the situation and victim's condition can potentially make the situation worse. Choice A is incorrect because performing first aid should not be the immediate first step without assessing the situation first. Choice B is incorrect because calling the victim's family is not a priority in an emergency situation. Choice D is incorrect because getting assistance and performing CPR should come after assessing the situation and the victim's condition.
Question 3
Which of the following can a nursing assistant do if poisoning is suspected?
A. Suggest the resident put his finger down his throat to induce vomiting.
B. Feed the resident crackers or bread to soak up the poison.
C. Give the resident medication and then call poison control.
D. Look for a container that will help him find out what the resident took or ate.
Show answer and rationale
Correct answer: D — Look for a container that will help him find out what the resident took or ate.
The correct answer is D because looking for a container that will help identify what the resident took or ate can provide crucial information to healthcare providers. By identifying the source of poisoning, appropriate treatment can be administered promptly.
Explanation:
- A (inducing vomiting) can be dangerous as it may worsen the situation by causing further harm.
- B (feeding crackers or bread) is not recommended as it may interfere with medical treatment and delay proper care.
- C (giving medication without knowing the exact poison) can be harmful and may worsen the resident's condition.
In summary, option D is the most appropriate as it focuses on gathering essential information to assist healthcare professionals in providing effective treatment.
Question 4
The nurse is reviewing a patient’s plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?
A. Etiology
B. Nursing diagnosis
C. Collaborative problem
D. Defining characteristic
Show answer and rationale
Correct answer: C — Collaborative problem
The correct answer is C: Collaborative problem. The nurse needs to revise this part of the diagnostic statement because impaired physical mobility related to tibial fracture is a nursing diagnosis, not a collaborative problem. Collaborative problems are issues that require both medical and nursing interventions, whereas nursing diagnoses are within the scope of nursing practice. The etiology identifies the cause of the problem (tibial fracture), the nursing diagnosis states the problem (impaired physical mobility), and the defining characteristic is the evidence that supports the diagnosis (inability to ambulate). Therefore, the nurse should revise the part stating collaborative problem as it does not align with the nature of the issue presented in the scenario.
Question 5
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
Show answer and rationale
Correct answer: A — No electrical activity in the heart as confirmed by an EKG tracing indicating asystole
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.
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Question 6
96.0 to 99.5 degrees Fahrenheit is the normal temperature range of which age group?
A. Toddler
B. Adolescent
C. Neonate
D. Middle adult
Correct answer:
Neonate, is correct because the normal body temperature range for newborns (birth to 28 days) is approximately 96.0°F to 99.5°F, depending on measurement site (e.g., axillary). Neonates have immature thermoregulation, leading to a slightly wider and lower range than adults. Toddler (1-3 years), typically has a range closer to 97.5°F-100.4°F. Adolescent, aligns with adult norms (97°F-99°F). Middle adult, also falls within 97°F-99°F, narrower than the neonate range. Neonates susceptibility to environmental changes and less efficient hypothalamus function explain this broader range. Clinical practice confirms 96.0°F-99.5°F as typical for neonates, especially in controlled settings like nurseries, making C the accurate answer based on pediatric physiology.
A patient recovering from a stroke demonstrates neglect on the left side. Which intervention is MOST appropriate to address this deficit?
A. Position objects on the unaffected side
B. Encourage scanning to the left side
C. Provide verbal cues to the right side
D. Focus therapy on the unaffected side
Correct answer:
The correct answer is B: Encourage scanning to the left side. This intervention is appropriate because it helps the patient actively engage in exploring their neglected side, promoting awareness and attention to that side. By encouraging scanning to the left, the patient can improve their ability to attend to and interact with stimuli on the neglected side.
A: Position objects on the unaffected side does not actively engage the patient in addressing the neglect on the left side.
C: Providing verbal cues to the right side may not effectively stimulate the neglected side and may not promote active engagement.
D: Focusing therapy on the unaffected side does not directly address the neglect on the left side and may not lead to improvement in neglect symptoms.
The direction of blood flow through the heart is best described by which of these?
A. Vena cava → right atrium → right ventricle → lungs → pulmonary artery → left atrium → left ventricle
B. Right atrium → right ventricle → pulmonary artery → lungs → pulmonary vein → left atrium → left ventricle
C. Aorta → right atrium → right ventricle → lungs → pulmonary vein → left atrium → left ventricle → vena cava
D. Right atrium → right ventricle → pulmonary vein → lungs → pulmonary artery → left atrium → left ventricle
Correct answer:
The correct answer is B because it accurately describes the path of blood flow through the heart. Blood enters the right atrium from the vena cava, then goes to the right ventricle, gets pumped to the lungs through the pulmonary artery, returns to the heart from the lungs via the pulmonary vein, enters the left atrium, and finally flows to the left ventricle for systemic circulation. The other choices have inaccuracies in the sequence of chambers and blood vessels through which the blood flows, making them incorrect. Choice A has the pulmonary artery leading to the left atrium, which is incorrect. Choice C has the aorta before entering the right atrium, which is also incorrect. Choice D has the pulmonary vein leading to the pulmonary artery, which is incorrect.
A nurse is preparing a bag of chemotherapy agent for one of the patients. The nurse accidentally pierces a hole through the bag while attempting to spike it. A moderate amount of chemotherapy spills onto the ground. Which of the following actions should the nurse perform first?
A. Cordon off the area and notify housekeeping/facilities of the spill.
B. Call the pharmacy to have the chemotherapy redosed.
C. Continue to prime chemotherapy tubing.
D. Clean up the spill with wet paper towels.
Correct answer:
The correct answer is A: Cordon off the area and notify housekeeping/facilities of the spill. This is the first action the nurse should take to ensure the safety of everyone in the area. By cordoning off the area, the nurse prevents others from being exposed to the spilled chemotherapy, which can be harmful. Notifying housekeeping/facilities is crucial as they are trained to handle hazardous spills properly. Calling the pharmacy to redose the chemotherapy (B) is not the priority at this moment as safety measures should be taken first. Continuing to prime chemotherapy tubing (C) or cleaning up the spill with wet paper towels (D) can potentially expose the nurse to the hazardous substance and should not be done before ensuring proper safety measures are in place.
A patient with a venous thromboembolism (VTE) is started on enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are necessary. Which response by the nurse is accurate?
A. “Administration of two anticoagulants reduces the risk for recurrent venous thrombosis.â€
B. “Lovenox will start to dissolve the clot, and Coumadin will prevent any more clots from occurring.â€
C. “The Lovenox will work immediately, but the Coumadin takes several days to have an effect on coagulation.â€
D. “Because of the potential for a pulmonary embolism, it is important for you to have more than one anticoagulant.â€
Correct answer:
The correct answer is C. Lovenox (enoxaparin) is a low molecular weight heparin that works immediately to prevent further clot formation. Warfarin (Coumadin) takes several days to reach therapeutic levels and inhibit clotting factors. Therefore, the combination of both medications ensures immediate anticoagulant effects from Lovenox while waiting for Coumadin to take full effect.
Explanation of other choices:
A: Incorrect. Using two anticoagulants does not necessarily reduce the risk for recurrent venous thrombosis.
B: Incorrect. Lovenox and Coumadin have different mechanisms of action and do not function solely in clot dissolution and prevention.
D: Incorrect. The presence of a VTE does not inherently indicate an increased risk for pulmonary embolism.
A young man is concerned about a hard mass he has just noticed in the midline of his palate. On examination, it is indeed hard and in the midline. There are no mucosal abnormalities associated with this lesion. He is experiencing no other symptoms. What will you tell him is the most likely diagnosis?
A. Leukoplakia
B. Torus palatinus
C. Thrush (candidiasis)
D. Kaposi's sarcoma
Correct answer:
The most likely diagnosis for a hard mass in the midline of the palate with no associated mucosal abnormalities is Torus palatinus (Choice B). This is a benign bony growth that typically occurs in the midline of the hard palate. The absence of mucosal abnormalities and the hard nature of the mass are indicative of a bony growth rather than a soft tissue lesion like leukoplakia (Choice A), thrush (Choice C), or Kaposi's sarcoma (Choice D). Leukoplakia is a white patch that cannot be scraped off, thrush is a fungal infection causing creamy white lesions, and Kaposi's sarcoma usually presents as purplish lesions in immunocompromised individuals. In this case, the hard midline mass without mucosal changes points towards Torus palatinus as the most likely diagnosis.
The nurse is reviewing a patient’s plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?
A. Etiology
B. Nursing diagnosis
C. Collaborative problem
D. Defining characteristic
Correct answer:
The correct answer is C: Collaborative problem. The nurse needs to revise the collaborative problem part of the diagnostic statement because "Impaired physical mobility related to tibial fracture as evidenced by patient’s inability to ambulate" is a nursing diagnosis, not a collaborative problem. Collaborative problems involve issues that require both nursing and medical interventions, whereas nursing diagnoses focus on the nurse's role in addressing the patient's health issues. Therefore, the nurse should revise the collaborative problem part to accurately reflect the collaborative aspect of the patient's care. Etiology (A), nursing diagnosis (B), and defining characteristic (D) are not the parts of the diagnostic statement that need revision in this scenario.
“Impaired skin integrity related to excess friction evidenced by redness.†The diagnostic focus in this nursing diagnosis is:
A. Impaired
B. Skin integrity
C. Excess friction
D. Redness
Correct answer:
The correct answer is B: Skin integrity. In this nursing diagnosis, the focus is on the skin being impaired due to excess friction, as evidenced by redness. Skin integrity refers to the structural and functional intactness of the skin. The redness indicates a disruption in the skin's normal state, signifying impaired skin integrity. The other choices are incorrect because:
A: Impaired - This term describes the overall condition but does not specifically address the issue of skin integrity.
C: Excess friction - While this contributes to the issue, the primary focus should be on the resulting impaired skin integrity.
D: Redness - While redness is an important indicator, it is a manifestation of the impaired skin integrity rather than the main diagnostic focus.
You are reviewing assessment data of a 45-year-old male patient who had recent surgery and rates his pain at 8 on a 10-point scale. As you review the electronic health record, you note which of the following cues related to the patient's pain? Select all that apply.
A. Normal skin turgor
B. Normal S1, S2 heart sounds
C. Glowing skin
D. Tachypnea (rapid breathing)
Correct answer:
The correct answer is D: Tachypnea (rapid breathing). This is a cue related to the patient's pain because pain can lead to increased respiratory rate as a physiological response. The body's natural reaction to pain is to increase breathing to provide more oxygen to tissues. Therefore, tachypnea is a relevant cue to assess pain levels.
A: Normal skin turgor is not directly related to pain assessment. Skin turgor is typically assessed to evaluate hydration status.
B: Normal S1, S2 heart sounds are not directly related to pain assessment. Heart sounds are assessed to evaluate cardiac function.
C: Glowing skin is not a typical cue related to pain assessment. Glowing skin may be associated with overall health and well-being but is not directly related to pain.
A young man is concerned about a hard mass he has just noticed in the midline of his palate. On examination, it is indeed hard and in the midline. There are no mucosal abnormalities associated with this lesion. He is experiencing no other symptoms. What will you tell him is the most likely diagnosis?
A. Leukoplakia
B. Torus palatinus
C. Thrush (candidiasis)
D. Kaposi's sarcoma
Correct answer:
The most likely diagnosis for a hard mass in the midline of the palate with no associated mucosal abnormalities is Torus palatinus (Choice B). This is a benign bony growth that typically occurs in the midline of the hard palate. The absence of mucosal abnormalities and the hard nature of the mass are indicative of a bony growth rather than a soft tissue lesion like leukoplakia (Choice A), thrush (Choice C), or Kaposi's sarcoma (Choice D). Leukoplakia is a white patch that cannot be scraped off, thrush is a fungal infection causing creamy white lesions, and Kaposi's sarcoma usually presents as purplish lesions in immunocompromised individuals. In this case, the hard midline mass without mucosal changes points towards Torus palatinus as the most likely diagnosis.
RN exams fundamentals practice questions, set 41 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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