N261 Final Exam Actual Exam V1 | N261 Nursing (N261 Final Exam) |
University of California, Los Angeles
1. A patient with acute decompensated heart failure is prescribed intravenous furosemide.
Which assessment finding most clearly indicates that the medication is having the desired
effect?
A. Decrease in blood pressure from 150/90 to 120/80 mmHg.
B. Reduction in bilateral crackles upon lung auscultation.
C. Increase in serum potassium levels to 4.5 mEq/L.
D. Decrease in heart rate from 110 to 88 beats per minute.
Answer: B
Rationale: Furosemide is a loop diuretic intended to reduce fluid volume overload in heart
failure patients. The primary goal in acute decompensated heart failure is to relieve
pulmonary congestion. A reduction in crackles indicates that fluid is being mobilized from
the alveoli, which directly addresses the clinical priority of gas exchange.
2. A nurse is caring for a patient who is 24 hours post-abdominal surgery. The patient’s
respiratory rate is 8 breaths/min and oxygen saturation is 88%. Which action should the
nurse take first?
A. Stimulate the patient and encourage deep breathing.
B. Administer naloxone per standing orders.
C. Notify the rapid response team.
D. Check the medical record for opioid administration.
Answer: A
Rationale: Initial nursing management for suspected opioid-induced respiratory
depression involves physical stimulation and verbal cues. If the patient does not respond to
stimulation, further interventions like naloxone may be warranted. The nurse must
prioritize immediate airway and ventilation support before navigating medication records
or calling for emergency teams.
3. A patient is admitted with a diagnosis of Diabetic Ketoacidosis (DKA). The nurse notes a
blood glucose level of 450 mg/dL and the presence of Kussmaul respirations. What is the
physiological purpose of Kussmaul respirations?
A. To reduce carbon dioxide levels and compensate for metabolic acidosis.
B. To increase the partial pressure of oxygen in the blood.
,C. To promote the excretion of ketones through the breath.
D. To prevent the development of pulmonary edema.
Answer: A
Rationale: Kussmaul respirations are deep, rapid breaths that occur as a compensatory
mechanism for metabolic acidosis. By blowing off carbon dioxide (an acid), the body
attempts to raise the pH back toward a normal range. This is a classic sign of the body
trying to restore acid-base balance during severe hyperglycemic crises.
4. While assessing a patient with a chest tube for a pneumothorax, the nurse observes
continuous bubbling in the water-seal chamber. How should the nurse interpret this finding?
A. It is an expected finding while the lung is re-expanding.
B. The suction pressure is set too high.
C. The pneumothorax has completely resolved.
D. There is a leak in the chest tube system.
Answer: D
Rationale: Continuous bubbling in the water-seal chamber indicates an air leak within the
drainage system or at the insertion site. Intermittent bubbling is normal during expiration
or coughing while a pneumothorax is present, but continuous bubbling is not. The nurse
should troubleshoot the system by checking connections and clamping briefly to locate the
leak.
5. A patient with Chronic Obstructive Pulmonary Disease (COPD) is receiving oxygen via nasal
cannula at 2L/min. The nurse notices the patient is becoming increasingly lethargic and
somnolent. What is the most likely cause?
A. Oxygen-induced hypoventilation.
B. Development of a secondary bacterial pneumonia.
C. Acute anxiety related to dyspnea.
D. Normal progression of the chronic disease state.
Answer: A
Rationale: In some COPD patients, the drive to breathe is triggered by low oxygen levels
rather than high carbon dioxide levels. Providing too much supplemental oxygen can
suppress this hypoxic drive, leading to CO2 retention and lethargy. The nurse must
carefully monitor mental status and arterial blood gases in these patients when oxygen
therapy is initiated.
, 6. A patient is prescribed warfarin for atrial fibrillation. Which laboratory value should the
nurse monitor to determine the therapeutic effectiveness of this medication?
A. Activated partial thromboplastin time (aPTT).
B. Bleeding time.
C. Platelet count.
D. International Normalized Ratio (INR).
Answer: D
Rationale: The INR is the standard laboratory test used to monitor the effectiveness of
warfarin therapy. For patients with atrial fibrillation, a therapeutic INR range is typically
between 2.0 and 3.0. Proper monitoring is essential to prevent both thromboembolic
events and excessive bleeding complications.
7. A patient presents to the emergency department with suspected bacterial meningitis.
Which nursing action is the highest priority?
A. Obtain blood cultures and assist with a lumbar puncture.
B. Place the patient on droplet precautions.
C. Administer the first dose of broad-spectrum antibiotics.
D. Assess for Brudzinski’s and Kernig’s signs.
Answer: B
Rationale: Safety and infection control are paramount when meningitis is suspected.
Placing the patient on droplet precautions protects other patients and staff from potential
transmission. While cultures and antibiotics are critical, the safety protocol must be
implemented immediately upon suspicion of the disease.
8. A nurse is caring for a patient with Acute Kidney Injury (AKI). The patient’s potassium level
is 6.8 mEq/L. Which medication should the nurse anticipate administering first to protect the
heart?
A. Intravenous Calcium Gluconate.
B. Sodium polystyrene sulfonate (Kayexalate).
C. Regular Insulin and Dextrose 50%.
D. Furosemide (Lasix).
Answer: A
Rationale: Calcium gluconate is administered in severe hyperkalemia to stabilize the
myocardial cell membrane and prevent life-threatening arrhythmias. It does not lower the
potassium level but provides immediate cardioprotection. Following stabilization, other
University of California, Los Angeles
1. A patient with acute decompensated heart failure is prescribed intravenous furosemide.
Which assessment finding most clearly indicates that the medication is having the desired
effect?
A. Decrease in blood pressure from 150/90 to 120/80 mmHg.
B. Reduction in bilateral crackles upon lung auscultation.
C. Increase in serum potassium levels to 4.5 mEq/L.
D. Decrease in heart rate from 110 to 88 beats per minute.
Answer: B
Rationale: Furosemide is a loop diuretic intended to reduce fluid volume overload in heart
failure patients. The primary goal in acute decompensated heart failure is to relieve
pulmonary congestion. A reduction in crackles indicates that fluid is being mobilized from
the alveoli, which directly addresses the clinical priority of gas exchange.
2. A nurse is caring for a patient who is 24 hours post-abdominal surgery. The patient’s
respiratory rate is 8 breaths/min and oxygen saturation is 88%. Which action should the
nurse take first?
A. Stimulate the patient and encourage deep breathing.
B. Administer naloxone per standing orders.
C. Notify the rapid response team.
D. Check the medical record for opioid administration.
Answer: A
Rationale: Initial nursing management for suspected opioid-induced respiratory
depression involves physical stimulation and verbal cues. If the patient does not respond to
stimulation, further interventions like naloxone may be warranted. The nurse must
prioritize immediate airway and ventilation support before navigating medication records
or calling for emergency teams.
3. A patient is admitted with a diagnosis of Diabetic Ketoacidosis (DKA). The nurse notes a
blood glucose level of 450 mg/dL and the presence of Kussmaul respirations. What is the
physiological purpose of Kussmaul respirations?
A. To reduce carbon dioxide levels and compensate for metabolic acidosis.
B. To increase the partial pressure of oxygen in the blood.
,C. To promote the excretion of ketones through the breath.
D. To prevent the development of pulmonary edema.
Answer: A
Rationale: Kussmaul respirations are deep, rapid breaths that occur as a compensatory
mechanism for metabolic acidosis. By blowing off carbon dioxide (an acid), the body
attempts to raise the pH back toward a normal range. This is a classic sign of the body
trying to restore acid-base balance during severe hyperglycemic crises.
4. While assessing a patient with a chest tube for a pneumothorax, the nurse observes
continuous bubbling in the water-seal chamber. How should the nurse interpret this finding?
A. It is an expected finding while the lung is re-expanding.
B. The suction pressure is set too high.
C. The pneumothorax has completely resolved.
D. There is a leak in the chest tube system.
Answer: D
Rationale: Continuous bubbling in the water-seal chamber indicates an air leak within the
drainage system or at the insertion site. Intermittent bubbling is normal during expiration
or coughing while a pneumothorax is present, but continuous bubbling is not. The nurse
should troubleshoot the system by checking connections and clamping briefly to locate the
leak.
5. A patient with Chronic Obstructive Pulmonary Disease (COPD) is receiving oxygen via nasal
cannula at 2L/min. The nurse notices the patient is becoming increasingly lethargic and
somnolent. What is the most likely cause?
A. Oxygen-induced hypoventilation.
B. Development of a secondary bacterial pneumonia.
C. Acute anxiety related to dyspnea.
D. Normal progression of the chronic disease state.
Answer: A
Rationale: In some COPD patients, the drive to breathe is triggered by low oxygen levels
rather than high carbon dioxide levels. Providing too much supplemental oxygen can
suppress this hypoxic drive, leading to CO2 retention and lethargy. The nurse must
carefully monitor mental status and arterial blood gases in these patients when oxygen
therapy is initiated.
, 6. A patient is prescribed warfarin for atrial fibrillation. Which laboratory value should the
nurse monitor to determine the therapeutic effectiveness of this medication?
A. Activated partial thromboplastin time (aPTT).
B. Bleeding time.
C. Platelet count.
D. International Normalized Ratio (INR).
Answer: D
Rationale: The INR is the standard laboratory test used to monitor the effectiveness of
warfarin therapy. For patients with atrial fibrillation, a therapeutic INR range is typically
between 2.0 and 3.0. Proper monitoring is essential to prevent both thromboembolic
events and excessive bleeding complications.
7. A patient presents to the emergency department with suspected bacterial meningitis.
Which nursing action is the highest priority?
A. Obtain blood cultures and assist with a lumbar puncture.
B. Place the patient on droplet precautions.
C. Administer the first dose of broad-spectrum antibiotics.
D. Assess for Brudzinski’s and Kernig’s signs.
Answer: B
Rationale: Safety and infection control are paramount when meningitis is suspected.
Placing the patient on droplet precautions protects other patients and staff from potential
transmission. While cultures and antibiotics are critical, the safety protocol must be
implemented immediately upon suspicion of the disease.
8. A nurse is caring for a patient with Acute Kidney Injury (AKI). The patient’s potassium level
is 6.8 mEq/L. Which medication should the nurse anticipate administering first to protect the
heart?
A. Intravenous Calcium Gluconate.
B. Sodium polystyrene sulfonate (Kayexalate).
C. Regular Insulin and Dextrose 50%.
D. Furosemide (Lasix).
Answer: A
Rationale: Calcium gluconate is administered in severe hyperkalemia to stabilize the
myocardial cell membrane and prevent life-threatening arrhythmias. It does not lower the
potassium level but provides immediate cardioprotection. Following stabilization, other
