NU180/ NU 180 EXAM 3: (NEW 2025/ 2026
UPDATE) NURSING AND HEALTHCARE II
GUIDE| 150 REVISED QUESTIONS & VERIFIED
ANSWERS| GRADED A+
1. A patient with a history of chronic kidney disease (stage 4) is prescribed a new medication that is
primarily renally eliminated. The nurse reviews the medication reconciliation and notes the patient
is also taking an angiotensin-converting enzyme (ACE) inhibitor, a loop diuretic, and a statin.
Which pharmacokinetic principle is most critical to consider when initiating the new medication?
A. Increased volume of distribution due to edema
B. Reduced first-pass metabolism due to decreased hepatic blood flow
C. Accumulation of the drug and its active metabolites due to decreased glomerular filtration rate
D. Enhanced protein binding due to hypoalbuminemia
Answer: C
Rationale: In stage 4 CKD, GFR is severely reduced, leading to impaired renal clearance. Many drugs
and their metabolites accumulate, increasing risk of toxicity. ACE inhibitors and diuretics can further
reduce renal function, but the primary concern is accumulation. Volume of distribution changes are less
predictable and not the most critical. First-pass metabolism is hepatic, not primarily affected by renal
function. Protein binding may be altered but does not outweigh clearance reduction.
2. A nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who is on
mechanical ventilation with lung-protective settings. The provider orders a bolus of a
neuromuscular blocking agent (NMBA) followed by continuous infusion. The nurse understands
that the primary rationale for using NMBA in this context is to:
A. Prevent ventilator dyssynchrony and reduce oxygen consumption
B. Facilitate prone positioning by paralyzing the patient
C. Decrease intracranial pressure in patients with concomitant head injury
D. Allow for permissive hypercapnia without patient discomfort
Answer: A
Rationale: In severe ARDS, NMBA use improves chest wall compliance, reduces patient-ventilator
dyssynchrony, and decreases oxygen consumption by eliminating respiratory muscle work. While NMBA
can facilitate prone positioning, this is not the primary rationale. Permissive hypercapnia is used with or
without NMBA, but NMBA does not directly address hypercapnia. ICP reduction is not the primary goal
in ARDS without head injury.
3. A nurse is evaluating a patient's arterial blood gas (ABG) results: pH 7.25, PaCO2 60 mm Hg,
HCO3- 24 mEq/L. The nurse interprets this as:
Page 1
,A. Metabolic acidosis with full respiratory compensation
B. Acute respiratory acidosis without renal compensation
C. Chronic respiratory acidosis with metabolic compensation
D. Mixed respiratory and metabolic acidosis
Answer: B
Rationale: The pH is acidic (7.25), PaCO2 is elevated (60 mm Hg), indicating respiratory acidosis.
HCO3- is normal (24 mEq/L), so there is no metabolic compensation. Acute respiratory acidosis
typically presents with normal HCO3- because renal compensation takes 2-3 days. Chronic respiratory
acidosis would show elevated HCO3- (>30). There is no metabolic acidosis component because the
HCO3- is not low.
4. A nurse is preparing to administer a blood transfusion to a patient with a history of multiple
transfusions. The patient's type and screen shows the presence of anti-Kell antibodies. Which
action is most important for the nurse to take?
A. Obtain a signed consent for transfusion
B. Ensure the blood product is crossmatched for Kell antigen
C. Premedicate with acetaminophen and diphenhydramine
D. Initiate the transfusion at a slow rate and monitor for 15 minutes
Answer: B
Rationale: Anti-Kell antibodies can cause hemolytic transfusion reactions. It is critical that the donor
blood is negative for the Kell antigen to prevent antibody-antigen interaction. Premedication and slow
rate are general precautions but do not address the specific antibody. Consent is required but not the
most important action given the antibody history.
5. A nurse is assessing a patient who has been on parenteral nutrition (PN) for 7 days. The patient
suddenly develops confusion, tremors, and hyperreflexia. Vital signs show heart rate 110 bpm,
blood pressure 160/90 mm Hg, temperature 37.8°C. Which complication is most likely?
A. Hyperglycemic hyperosmolar state
B. Refeeding syndrome with hypophosphatemia
C. Catheter-related bloodstream infection
D. Fat overload syndrome
Answer: B
Rationale: Refeeding syndrome occurs when malnourished patients receive aggressive nutrition, leading
to electrolyte shifts (especially hypophosphatemia) and neurological symptoms. Hyperglycemia typically
presents with polyuria, not tremors/hyperreflexia. Infection would more likely cause fever and chills. Fat
overload syndrome presents with hypertriglyceridemia and respiratory distress.
6. A nurse educator is teaching a group of nursing students about the use of the Braden Scale for
predicting pressure ulcer risk. The educator asks which patient scenario places a patient at the
highest risk based on the scale. The students should identify:
A. A patient who is confined to bed, has occasional incontinence, and eats 50% of meals
B. A patient who is able to walk occasionally, has urinary incontinence, and eats more than 75% of meals
C. A patient who is chairfast, has fecal incontinence, and eats less than 25% of meals
Page 2
,D. A patient who is bedfast, has dual incontinence, and is on NPO status
Answer: D
Rationale: The Braden Scale assesses sensory perception, moisture, activity, mobility, nutrition, and
friction/shear. Bedfast status (activity=1), dual incontinence (moisture=1), and NPO status (nutrition=1)
yield the lowest possible scores in these categories, indicating very high risk. Option A has slightly
better mobility and nutrition. Option B has better mobility and nutrition. Option C is chairfast but not
bedfast, and NPO is worse than eating <25%.
7. A nurse is reviewing the medication orders for a patient with a diagnosis of diabetic ketoacidosis
(DKA). The patient's blood glucose is 480 mg/dL, potassium 3.2 mEq/L, bicarbonate 12 mEq/L,
and pH 7.1. The nurse notes the following orders: 1) 0.9% normal saline at 1 L/hr, 2) regular
insulin IV bolus 0.1 units/kg followed by 0.1 units/kg/hr, 3) potassium chloride 40 mEq IV when
potassium < 3.3 mEq/L. Which order requires clarification?
A. The insulin bolus is too high for DKA
B. The potassium replacement should be held until the insulin infusion is started
C. The normal saline infusion rate should be reduced after the first liter
D. The potassium threshold for replacement is too low
Answer: C
Rationale: In DKA, initial fluid resuscitation with 0.9% NS at 15-20 mL/kg/hr (1 L/hr for typical adult) is
appropriate. However, after the first liter, the rate should be reduced to 250-500 mL/hr to avoid fluid
overload, especially in patients with renal or cardiac compromise. The insulin bolus and infusion are
standard. Potassium replacement is indicated when K+ < 3.3 mEq/L to prevent hypokalemia from
insulin therapy. The threshold is correct.
8. A nurse is caring for a patient who has just undergone a liver transplant. The patient's
immunosuppressive regimen includes tacrolimus, mycophenolate mofetil, and corticosteroids. The
nurse monitors for signs of tacrolimus toxicity. Which laboratory value is most indicative of
potential toxicity?
A. Elevated serum creatinine
B. Elevated liver enzymes (AST/ALT)
C. Low white blood cell count
D. Hyperglycemia
Answer: A
Rationale: Tacrolimus is nephrotoxic; elevated serum creatinine is a key indicator of toxicity. Liver
enzymes are monitored for rejection but not directly for tacrolimus toxicity. Mycophenolate causes
leukopenia. Corticosteroids cause hyperglycemia. Elevated creatinine warrants checking tacrolimus
trough levels.
9. A nurse is evaluating a patient's electrocardiogram (ECG) and notes the following: heart rate
150 bpm, regular rhythm, narrow QRS complex (<0.12 sec), and no visible P waves. The nurse
interprets this rhythm as:
A. Atrial fibrillation
Page 3
, B. Atrial flutter
C. Supraventricular tachycardia (SVT)
D. Sinus tachycardia
Answer: C
Rationale: SVT is characterized by a regular, narrow-complex tachycardia with rates typically 150-250
bpm and absent or abnormal P waves. Atrial fibrillation has an irregularly irregular rhythm. Atrial
flutter has a 'sawtooth' pattern. Sinus tachycardia has visible P waves with normal morphology. SVT is
the best fit given the absence of P waves and regular narrow QRS.
10. A nurse is caring for a patient with a chest tube connected to a water-seal drainage system. The
nurse observes continuous bubbling in the water-seal chamber. What is the most appropriate
initial action?
A. Clamp the chest tube immediately
B. Reposition the patient and encourage coughing
C. Assess the chest tube system for an air leak
D. Notify the provider for possible suction adjustment
Answer: C
Rationale: Continuous bubbling in the water-seal chamber indicates an air leak in the system (either from
the patient (e.g., bronchopleural fistula) or from the tubing/drainage system). The nurse should first
assess the system for leaks by checking connections and the dressing. Clamping can cause tension
pneumothorax. Repositioning may help with intermittent bubbling but not continuous. Suction
adjustment does not address an air leak.
11. A patient with chronic heart failure is admitted with dyspnea and peripheral edema. Current
medications include lisinopril, metoprolol, and furosemide. The nurse reviews the latest laboratory
results: serum potassium 5.8 mEq/L, BUN 45 mg/dL, creatinine 2.1 mg/dL. Which intervention
should the nurse question?
A. Administer spironolactone 25 mg orally daily
B. Continue lisinopril as prescribed
C. Give furosemide 40 mg intravenously now
D. Hold metoprolol until heart rate is above 60/min
Answer: A
Rationale: Spironolactone is a potassium-sparing diuretic that can worsen hyperkalemia. With serum
potassium 5.8 mEq/L, administering spironolactone is contraindicated due to risk of life-threatening
arrhythmias. Lisinopril (ACE inhibitor) may also increase potassium but is typically continued with
monitoring. Furosemide is appropriate for edema. Metoprolol is not contraindicated by elevated
potassium.
12. A nurse is caring for a patient who has just returned from the operating room following a
laparoscopic cholecystectomy. The patient reports severe right shoulder pain. Which action should
the nurse take first?
A. Administer morphine sulfate 2 mg intravenously as prescribed
B. Reposition the patient onto the left side with knees flexed
Page 4
UPDATE) NURSING AND HEALTHCARE II
GUIDE| 150 REVISED QUESTIONS & VERIFIED
ANSWERS| GRADED A+
1. A patient with a history of chronic kidney disease (stage 4) is prescribed a new medication that is
primarily renally eliminated. The nurse reviews the medication reconciliation and notes the patient
is also taking an angiotensin-converting enzyme (ACE) inhibitor, a loop diuretic, and a statin.
Which pharmacokinetic principle is most critical to consider when initiating the new medication?
A. Increased volume of distribution due to edema
B. Reduced first-pass metabolism due to decreased hepatic blood flow
C. Accumulation of the drug and its active metabolites due to decreased glomerular filtration rate
D. Enhanced protein binding due to hypoalbuminemia
Answer: C
Rationale: In stage 4 CKD, GFR is severely reduced, leading to impaired renal clearance. Many drugs
and their metabolites accumulate, increasing risk of toxicity. ACE inhibitors and diuretics can further
reduce renal function, but the primary concern is accumulation. Volume of distribution changes are less
predictable and not the most critical. First-pass metabolism is hepatic, not primarily affected by renal
function. Protein binding may be altered but does not outweigh clearance reduction.
2. A nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who is on
mechanical ventilation with lung-protective settings. The provider orders a bolus of a
neuromuscular blocking agent (NMBA) followed by continuous infusion. The nurse understands
that the primary rationale for using NMBA in this context is to:
A. Prevent ventilator dyssynchrony and reduce oxygen consumption
B. Facilitate prone positioning by paralyzing the patient
C. Decrease intracranial pressure in patients with concomitant head injury
D. Allow for permissive hypercapnia without patient discomfort
Answer: A
Rationale: In severe ARDS, NMBA use improves chest wall compliance, reduces patient-ventilator
dyssynchrony, and decreases oxygen consumption by eliminating respiratory muscle work. While NMBA
can facilitate prone positioning, this is not the primary rationale. Permissive hypercapnia is used with or
without NMBA, but NMBA does not directly address hypercapnia. ICP reduction is not the primary goal
in ARDS without head injury.
3. A nurse is evaluating a patient's arterial blood gas (ABG) results: pH 7.25, PaCO2 60 mm Hg,
HCO3- 24 mEq/L. The nurse interprets this as:
Page 1
,A. Metabolic acidosis with full respiratory compensation
B. Acute respiratory acidosis without renal compensation
C. Chronic respiratory acidosis with metabolic compensation
D. Mixed respiratory and metabolic acidosis
Answer: B
Rationale: The pH is acidic (7.25), PaCO2 is elevated (60 mm Hg), indicating respiratory acidosis.
HCO3- is normal (24 mEq/L), so there is no metabolic compensation. Acute respiratory acidosis
typically presents with normal HCO3- because renal compensation takes 2-3 days. Chronic respiratory
acidosis would show elevated HCO3- (>30). There is no metabolic acidosis component because the
HCO3- is not low.
4. A nurse is preparing to administer a blood transfusion to a patient with a history of multiple
transfusions. The patient's type and screen shows the presence of anti-Kell antibodies. Which
action is most important for the nurse to take?
A. Obtain a signed consent for transfusion
B. Ensure the blood product is crossmatched for Kell antigen
C. Premedicate with acetaminophen and diphenhydramine
D. Initiate the transfusion at a slow rate and monitor for 15 minutes
Answer: B
Rationale: Anti-Kell antibodies can cause hemolytic transfusion reactions. It is critical that the donor
blood is negative for the Kell antigen to prevent antibody-antigen interaction. Premedication and slow
rate are general precautions but do not address the specific antibody. Consent is required but not the
most important action given the antibody history.
5. A nurse is assessing a patient who has been on parenteral nutrition (PN) for 7 days. The patient
suddenly develops confusion, tremors, and hyperreflexia. Vital signs show heart rate 110 bpm,
blood pressure 160/90 mm Hg, temperature 37.8°C. Which complication is most likely?
A. Hyperglycemic hyperosmolar state
B. Refeeding syndrome with hypophosphatemia
C. Catheter-related bloodstream infection
D. Fat overload syndrome
Answer: B
Rationale: Refeeding syndrome occurs when malnourished patients receive aggressive nutrition, leading
to electrolyte shifts (especially hypophosphatemia) and neurological symptoms. Hyperglycemia typically
presents with polyuria, not tremors/hyperreflexia. Infection would more likely cause fever and chills. Fat
overload syndrome presents with hypertriglyceridemia and respiratory distress.
6. A nurse educator is teaching a group of nursing students about the use of the Braden Scale for
predicting pressure ulcer risk. The educator asks which patient scenario places a patient at the
highest risk based on the scale. The students should identify:
A. A patient who is confined to bed, has occasional incontinence, and eats 50% of meals
B. A patient who is able to walk occasionally, has urinary incontinence, and eats more than 75% of meals
C. A patient who is chairfast, has fecal incontinence, and eats less than 25% of meals
Page 2
,D. A patient who is bedfast, has dual incontinence, and is on NPO status
Answer: D
Rationale: The Braden Scale assesses sensory perception, moisture, activity, mobility, nutrition, and
friction/shear. Bedfast status (activity=1), dual incontinence (moisture=1), and NPO status (nutrition=1)
yield the lowest possible scores in these categories, indicating very high risk. Option A has slightly
better mobility and nutrition. Option B has better mobility and nutrition. Option C is chairfast but not
bedfast, and NPO is worse than eating <25%.
7. A nurse is reviewing the medication orders for a patient with a diagnosis of diabetic ketoacidosis
(DKA). The patient's blood glucose is 480 mg/dL, potassium 3.2 mEq/L, bicarbonate 12 mEq/L,
and pH 7.1. The nurse notes the following orders: 1) 0.9% normal saline at 1 L/hr, 2) regular
insulin IV bolus 0.1 units/kg followed by 0.1 units/kg/hr, 3) potassium chloride 40 mEq IV when
potassium < 3.3 mEq/L. Which order requires clarification?
A. The insulin bolus is too high for DKA
B. The potassium replacement should be held until the insulin infusion is started
C. The normal saline infusion rate should be reduced after the first liter
D. The potassium threshold for replacement is too low
Answer: C
Rationale: In DKA, initial fluid resuscitation with 0.9% NS at 15-20 mL/kg/hr (1 L/hr for typical adult) is
appropriate. However, after the first liter, the rate should be reduced to 250-500 mL/hr to avoid fluid
overload, especially in patients with renal or cardiac compromise. The insulin bolus and infusion are
standard. Potassium replacement is indicated when K+ < 3.3 mEq/L to prevent hypokalemia from
insulin therapy. The threshold is correct.
8. A nurse is caring for a patient who has just undergone a liver transplant. The patient's
immunosuppressive regimen includes tacrolimus, mycophenolate mofetil, and corticosteroids. The
nurse monitors for signs of tacrolimus toxicity. Which laboratory value is most indicative of
potential toxicity?
A. Elevated serum creatinine
B. Elevated liver enzymes (AST/ALT)
C. Low white blood cell count
D. Hyperglycemia
Answer: A
Rationale: Tacrolimus is nephrotoxic; elevated serum creatinine is a key indicator of toxicity. Liver
enzymes are monitored for rejection but not directly for tacrolimus toxicity. Mycophenolate causes
leukopenia. Corticosteroids cause hyperglycemia. Elevated creatinine warrants checking tacrolimus
trough levels.
9. A nurse is evaluating a patient's electrocardiogram (ECG) and notes the following: heart rate
150 bpm, regular rhythm, narrow QRS complex (<0.12 sec), and no visible P waves. The nurse
interprets this rhythm as:
A. Atrial fibrillation
Page 3
, B. Atrial flutter
C. Supraventricular tachycardia (SVT)
D. Sinus tachycardia
Answer: C
Rationale: SVT is characterized by a regular, narrow-complex tachycardia with rates typically 150-250
bpm and absent or abnormal P waves. Atrial fibrillation has an irregularly irregular rhythm. Atrial
flutter has a 'sawtooth' pattern. Sinus tachycardia has visible P waves with normal morphology. SVT is
the best fit given the absence of P waves and regular narrow QRS.
10. A nurse is caring for a patient with a chest tube connected to a water-seal drainage system. The
nurse observes continuous bubbling in the water-seal chamber. What is the most appropriate
initial action?
A. Clamp the chest tube immediately
B. Reposition the patient and encourage coughing
C. Assess the chest tube system for an air leak
D. Notify the provider for possible suction adjustment
Answer: C
Rationale: Continuous bubbling in the water-seal chamber indicates an air leak in the system (either from
the patient (e.g., bronchopleural fistula) or from the tubing/drainage system). The nurse should first
assess the system for leaks by checking connections and the dressing. Clamping can cause tension
pneumothorax. Repositioning may help with intermittent bubbling but not continuous. Suction
adjustment does not address an air leak.
11. A patient with chronic heart failure is admitted with dyspnea and peripheral edema. Current
medications include lisinopril, metoprolol, and furosemide. The nurse reviews the latest laboratory
results: serum potassium 5.8 mEq/L, BUN 45 mg/dL, creatinine 2.1 mg/dL. Which intervention
should the nurse question?
A. Administer spironolactone 25 mg orally daily
B. Continue lisinopril as prescribed
C. Give furosemide 40 mg intravenously now
D. Hold metoprolol until heart rate is above 60/min
Answer: A
Rationale: Spironolactone is a potassium-sparing diuretic that can worsen hyperkalemia. With serum
potassium 5.8 mEq/L, administering spironolactone is contraindicated due to risk of life-threatening
arrhythmias. Lisinopril (ACE inhibitor) may also increase potassium but is typically continued with
monitoring. Furosemide is appropriate for edema. Metoprolol is not contraindicated by elevated
potassium.
12. A nurse is caring for a patient who has just returned from the operating room following a
laparoscopic cholecystectomy. The patient reports severe right shoulder pain. Which action should
the nurse take first?
A. Administer morphine sulfate 2 mg intravenously as prescribed
B. Reposition the patient onto the left side with knees flexed
Page 4
