N261 Final Exam Actual Exam V2 | N261 Nursing (N261 Final Exam) |
University of California, Los Angeles
1. A patient is admitted with suspected Acute Respiratory Distress Syndrome (ARDS). Which
assessment finding most clearly indicates the progression to the fibrotic phase of ARDS?
A. Increased pulmonary compliance and improved oxygenation
B. Presence of a productive cough with thick green sputum
C. Respiratory alkalosis shown on arterial blood gas
D. Reduced lung compliance and refractory hypoxemia
Answer: D
Rationale: The fibrotic phase of ARDS is characterized by the remodeling of lung tissue
into thick, fibrous scars which severely limits lung expansion. This results in reduced
compliance and makes oxygenation extremely difficult despite high levels of supplemental
oxygen, a condition known as refractory hypoxemia. Understanding these
pathophysiological changes is crucial for determining the necessity of mechanical
ventilation strategies.
2. A 68-year-old patient with Chronic Heart Failure (CHF) is prescribed Digoxin 0.125 mg daily.
Which laboratory value requires immediate follow-up before administration?
A. Serum Calcium 9.5 mg/dL
B. Serum Sodium 136 mEq/L
C. Serum Potassium 3.2 mEq/L
D. Serum Magnesium 2.0 mg/dL
Answer: C
Rationale: Hypokalemia significantly increases the risk of digoxin toxicity because
potassium and digoxin compete for binding sites on the sodium-potassium ATPase pump. A
potassium level of 3.2 mEq/L is below the normal range and could lead to life-threatening
dysrhythmias if digoxin is administered. The nurse must prioritize electrolyte stabilization
to ensure patient safety during pharmacologic management.
3. A nurse is caring for a patient who just underwent a subtotal thyroidectomy. The nurse
notes the patient has developed laryngeal stridor and a positive Chvostek’s sign. What is the
priority intervention?
A. Prepare to administer IV Calcium Gluconate
B. Administer IV Potassium Chloride
,C. Place the patient in a Trendelenburg position
D. Encourage the patient to cough and deep breathe
Answer: A
Rationale: A positive Chvostek’s sign and laryngeal stridor are classic indicators of
hypocalcemia, which can occur if the parathyroid glands were accidentally damaged or
removed during a thyroidectomy. Intravenous calcium gluconate is the standard
emergency treatment to stabilize neuromuscular irritability and prevent tetany. The nurse
must act quickly as stridor indicates a compromised airway, making this a high-priority
safety situation.
4. Which clinical manifestation would the nurse expect to see in a patient experiencing the
compensatory stage of hypovolemic shock?
A. Narrow pulse pressure and tachycardia
B. Bradypnea and hypotension
C. Anuria and metabolic acidosis
D. Warm, flushed skin and bounding pulses
Answer: A
Rationale: During the compensatory stage of shock, the body activates the sympathetic
nervous system to maintain cardiac output, leading to an increased heart rate and
peripheral vasoconstriction. This vasoconstriction results in a narrowed pulse pressure as
the diastolic pressure rises. Identifying these early signs allows for timely fluid
resuscitation before the patient progresses to the irreversible stage.
5. A patient with a traumatic brain injury (TBI) has an intracranial pressure (ICP) of 22 mmHg.
Which nursing action is most appropriate to include in the plan of care?
A. Maintain the head of the bed at 30 to 45 degrees
B. Cluster nursing activities to allow for longer rest periods
C. Perform vigorous endotracheal suctioning every hour
D. Keep the patient’s neck in a flexed position
Answer: A
Rationale: Elevating the head of the bed to 30 to 45 degrees facilitates venous drainage
from the brain, which helps to lower intracranial pressure. Clustered care should actually
be avoided in patients with high ICP because prolonged stimulation can cause dangerous
spikes in pressure. Maintaining neutral neck alignment and minimizing suctioning are
additional evidence-based strategies to manage ICP safely.
, 6. The nurse is evaluating the Arterial Blood Gas (ABG) results for a patient with severe
vomiting: pH 7.50, PaCO2 48 mmHg, HCO3 30 mEq/L. How should the nurse interpret these
findings?
A. Respiratory acidosis with partial compensation
B. Respiratory alkalosis with full compensation
C. Metabolic acidosis with no compensation
D. Metabolic alkalosis with partial compensation
Answer: D
Rationale: The pH of 7.50 indicates alkalosis, and the elevated HCO3 of 30 mEq/L indicates
that the cause is metabolic. The PaCO2 is elevated at 48 mmHg, suggesting that the lungs
are attempting to compensate by retaining CO2 (hypoventilation). Because the pH has not
yet returned to the normal range, the compensation is considered partial.
7. A patient is admitted with Diabetic Ketoacidosis (DKA). Which IV fluid should the nurse
anticipate administering first according to standard protocol?
A. 5% Dextrose in 0.45% Saline
B. 10% Dextrose in Water
C. 0.9% Sodium Chloride (Normal Saline)
D. 0.45% Sodium Chloride (Half-Normal Saline)
Answer: C
Rationale: Initial management of DKA focuses on restoring intravascular volume and
correcting dehydration caused by osmotic diuresis. Isotonic saline (0.9% NaCl) is the fluid
of choice for rapid volume expansion. Once blood glucose levels drop to approximately 250
mg/dL, dextrose-containing fluids are added to prevent hypoglycemia and cerebral edema.
8. A patient with Acute Kidney Injury (AKI) has a serum potassium level of 6.8 mEq/L and
shows peaked T-waves on the ECG. Which medication should the nurse be prepared to
administer to stabilize the cardiac membrane?
A. Sodium Polystyrene Sulfonate (Kayexalate)
B. Regular Insulin and Dextrose
C. Calcium Gluconate
D. Furosemide (Lasix)
Answer: C
Rationale: Calcium gluconate does not lower potassium levels but is the priority treatment
to antagonize the effects of hyperkalemia on the heart, preventing lethal dysrhythmias.
University of California, Los Angeles
1. A patient is admitted with suspected Acute Respiratory Distress Syndrome (ARDS). Which
assessment finding most clearly indicates the progression to the fibrotic phase of ARDS?
A. Increased pulmonary compliance and improved oxygenation
B. Presence of a productive cough with thick green sputum
C. Respiratory alkalosis shown on arterial blood gas
D. Reduced lung compliance and refractory hypoxemia
Answer: D
Rationale: The fibrotic phase of ARDS is characterized by the remodeling of lung tissue
into thick, fibrous scars which severely limits lung expansion. This results in reduced
compliance and makes oxygenation extremely difficult despite high levels of supplemental
oxygen, a condition known as refractory hypoxemia. Understanding these
pathophysiological changes is crucial for determining the necessity of mechanical
ventilation strategies.
2. A 68-year-old patient with Chronic Heart Failure (CHF) is prescribed Digoxin 0.125 mg daily.
Which laboratory value requires immediate follow-up before administration?
A. Serum Calcium 9.5 mg/dL
B. Serum Sodium 136 mEq/L
C. Serum Potassium 3.2 mEq/L
D. Serum Magnesium 2.0 mg/dL
Answer: C
Rationale: Hypokalemia significantly increases the risk of digoxin toxicity because
potassium and digoxin compete for binding sites on the sodium-potassium ATPase pump. A
potassium level of 3.2 mEq/L is below the normal range and could lead to life-threatening
dysrhythmias if digoxin is administered. The nurse must prioritize electrolyte stabilization
to ensure patient safety during pharmacologic management.
3. A nurse is caring for a patient who just underwent a subtotal thyroidectomy. The nurse
notes the patient has developed laryngeal stridor and a positive Chvostek’s sign. What is the
priority intervention?
A. Prepare to administer IV Calcium Gluconate
B. Administer IV Potassium Chloride
,C. Place the patient in a Trendelenburg position
D. Encourage the patient to cough and deep breathe
Answer: A
Rationale: A positive Chvostek’s sign and laryngeal stridor are classic indicators of
hypocalcemia, which can occur if the parathyroid glands were accidentally damaged or
removed during a thyroidectomy. Intravenous calcium gluconate is the standard
emergency treatment to stabilize neuromuscular irritability and prevent tetany. The nurse
must act quickly as stridor indicates a compromised airway, making this a high-priority
safety situation.
4. Which clinical manifestation would the nurse expect to see in a patient experiencing the
compensatory stage of hypovolemic shock?
A. Narrow pulse pressure and tachycardia
B. Bradypnea and hypotension
C. Anuria and metabolic acidosis
D. Warm, flushed skin and bounding pulses
Answer: A
Rationale: During the compensatory stage of shock, the body activates the sympathetic
nervous system to maintain cardiac output, leading to an increased heart rate and
peripheral vasoconstriction. This vasoconstriction results in a narrowed pulse pressure as
the diastolic pressure rises. Identifying these early signs allows for timely fluid
resuscitation before the patient progresses to the irreversible stage.
5. A patient with a traumatic brain injury (TBI) has an intracranial pressure (ICP) of 22 mmHg.
Which nursing action is most appropriate to include in the plan of care?
A. Maintain the head of the bed at 30 to 45 degrees
B. Cluster nursing activities to allow for longer rest periods
C. Perform vigorous endotracheal suctioning every hour
D. Keep the patient’s neck in a flexed position
Answer: A
Rationale: Elevating the head of the bed to 30 to 45 degrees facilitates venous drainage
from the brain, which helps to lower intracranial pressure. Clustered care should actually
be avoided in patients with high ICP because prolonged stimulation can cause dangerous
spikes in pressure. Maintaining neutral neck alignment and minimizing suctioning are
additional evidence-based strategies to manage ICP safely.
, 6. The nurse is evaluating the Arterial Blood Gas (ABG) results for a patient with severe
vomiting: pH 7.50, PaCO2 48 mmHg, HCO3 30 mEq/L. How should the nurse interpret these
findings?
A. Respiratory acidosis with partial compensation
B. Respiratory alkalosis with full compensation
C. Metabolic acidosis with no compensation
D. Metabolic alkalosis with partial compensation
Answer: D
Rationale: The pH of 7.50 indicates alkalosis, and the elevated HCO3 of 30 mEq/L indicates
that the cause is metabolic. The PaCO2 is elevated at 48 mmHg, suggesting that the lungs
are attempting to compensate by retaining CO2 (hypoventilation). Because the pH has not
yet returned to the normal range, the compensation is considered partial.
7. A patient is admitted with Diabetic Ketoacidosis (DKA). Which IV fluid should the nurse
anticipate administering first according to standard protocol?
A. 5% Dextrose in 0.45% Saline
B. 10% Dextrose in Water
C. 0.9% Sodium Chloride (Normal Saline)
D. 0.45% Sodium Chloride (Half-Normal Saline)
Answer: C
Rationale: Initial management of DKA focuses on restoring intravascular volume and
correcting dehydration caused by osmotic diuresis. Isotonic saline (0.9% NaCl) is the fluid
of choice for rapid volume expansion. Once blood glucose levels drop to approximately 250
mg/dL, dextrose-containing fluids are added to prevent hypoglycemia and cerebral edema.
8. A patient with Acute Kidney Injury (AKI) has a serum potassium level of 6.8 mEq/L and
shows peaked T-waves on the ECG. Which medication should the nurse be prepared to
administer to stabilize the cardiac membrane?
A. Sodium Polystyrene Sulfonate (Kayexalate)
B. Regular Insulin and Dextrose
C. Calcium Gluconate
D. Furosemide (Lasix)
Answer: C
Rationale: Calcium gluconate does not lower potassium levels but is the priority treatment
to antagonize the effects of hyperkalemia on the heart, preventing lethal dysrhythmias.
