N261 Final Exam Actual Exam V3 | N261 Nursing (N261 Final Exam) |
University of California, Los Angeles
1. A 65-year-old patient with a history of heart failure is admitted with acute shortness of
breath and crackles in the lung bases. Which initial nursing intervention is the priority?
A. Administer ordered IV furosemide
B. Notify the physician of the findings
C. Check the patient’s oxygen saturation
D. Place the patient in high-Fowler’s position
Answer: D
Rationale: Placing the patient in high-Fowler’s position promotes lung expansion and
eases work of breathing immediately. While medication and assessment are important,
physical positioning provides the fastest relief for pulmonary congestion. The nurse must
prioritize non-invasive actions that improve physiological stability before proceeding with
further assessment or notification.
2. A patient is receiving a continuous intravenous heparin infusion for a deep vein
thrombosis. The nurse notes the Activated Partial Thromboplastin Time (aPTT) is 110 seconds
(normal 25-35s). What should the nurse do first?
A. Decrease the infusion rate by half
B. Prepare the antidote protamine sulfate
C. Stop the infusion and notify the provider
D. Repeat the lab test to confirm the result
Answer: C
Rationale: An aPTT of 110 seconds is significantly above the therapeutic range, placing the
patient at high risk for hemorrhage. The priority action is to stop the heparin infusion
immediately to prevent further anticoagulation until the provider provides new orders.
The nurse must also monitor for clinical signs of bleeding and document the event as part
of patient safety protocols.
3. A patient with Type 1 Diabetes is found confused and diaphoretic. The bedside glucose
reading is 48 mg/dL. Which action should the nurse take first?
A. Call the rapid response team
B. Administer 1 unit of regular insulin
C. Give 15g of fast-acting carbohydrates
,D. Provide a high-protein snack
Answer: C
Rationale: The patient is experiencing symptomatic hypoglycemia, requiring immediate
intervention with simple sugars to raise blood glucose levels. Following the ‘Rule of 15’
ensures that the patient receives a controlled amount of glucose followed by a recheck in
15 minutes. Quick intervention prevents progression to loss of consciousness or seizures.
4. Which clinical manifestation would the nurse expect to find in a patient experiencing
autonomic dysreflexia following a spinal cord injury at T6?
A. Tachycardia and hypotension
B. Decreased perspiration in all extremities
C. Pallor and cool skin above the injury
D. Severe headache and hypertension
Answer: D
Rationale: Autonomic dysreflexia is a medical emergency characterized by sudden, severe
hypertension and a throbbing headache. It is caused by an uninhibited sympathetic
response to a noxious stimulus below the level of injury. The nurse must recognize these
signs quickly to prevent potential stroke or myocardial infarction.
5. A patient with cirrhosis has a high serum ammonia level and is exhibiting tremors and
confusion. Which medication is most appropriate for the nurse to administer?
A. Spironolactone
B. Propranolol
C. Lactulose
D. Vitamin K
Answer: C
Rationale: Lactulose is used to reduce ammonia levels in patients with hepatic
encephalopathy by promoting excretion through the bowel. The goal is to achieve 2-3 soft
stools per day to ensure effective clearing of toxins. This intervention directly addresses
the cause of the patient’s neurological symptoms and hepatic deterioration.
6. When planning care for a patient with Cushing’s syndrome, which nursing diagnosis should
be the highest priority?
A. Disturbed body image
B. Risk for fluid volume deficit
C. Impaired skin integrity
, D. Risk for infection
Answer: D
Rationale: Cushing’s syndrome involves excess cortisol, which suppresses the immune
system and increases the risk for life-threatening infections. While body image and skin
integrity are concerns, physiological safety related to infection takes priority in clinical
management. The nurse must educate the patient on hand hygiene and early symptom
recognition.
7. A patient is 2 hours post-thyroidectomy. The nurse notes frequent swallowing and a harsh,
high-pitched respiratory sound. What should the nurse suspect?
A. Airway obstruction or stridor
B. Normal post-operative recovery
C. Laryngeal nerve damage
D. Hypocalcemic tetany
Answer: A
Rationale: Stridor and frequent swallowing post-thyroidectomy suggest airway edema or
hemorrhage compressing the trachea. This is an emergent situation requiring immediate
evaluation and preparation for potential re-intubation or surgical intervention. Continuous
monitoring of respiratory effort and surgical site drainage is critical during the first 24
hours.
8. The nurse is caring for a patient with Chronic Obstructive Pulmonary Disease (COPD)
receiving oxygen via nasal cannula at 2L/min. The patient’s SpO2 is 89%. What is the best
action?
A. Increase oxygen to 6L/min via mask
B. Place the patient on a non-rebreather mask
C. Continue to monitor the patient
D. Administer a PRN bronchodilator
Answer: C
Rationale: For patients with COPD, a target SpO2 of 88-92% is often acceptable to
maintain the hypoxic drive to breathe. Increasing oxygen too much can lead to hypercapnia
and respiratory depression due to the loss of this drive. The nurse should maintain the
current flow rate while monitoring for signs of respiratory distress or carbon dioxide
narcosis.
9. A patient is admitted with suspected bacterial meningitis. Which order should the nurse
implement first?
A. Administer the first dose of IV antibiotics
University of California, Los Angeles
1. A 65-year-old patient with a history of heart failure is admitted with acute shortness of
breath and crackles in the lung bases. Which initial nursing intervention is the priority?
A. Administer ordered IV furosemide
B. Notify the physician of the findings
C. Check the patient’s oxygen saturation
D. Place the patient in high-Fowler’s position
Answer: D
Rationale: Placing the patient in high-Fowler’s position promotes lung expansion and
eases work of breathing immediately. While medication and assessment are important,
physical positioning provides the fastest relief for pulmonary congestion. The nurse must
prioritize non-invasive actions that improve physiological stability before proceeding with
further assessment or notification.
2. A patient is receiving a continuous intravenous heparin infusion for a deep vein
thrombosis. The nurse notes the Activated Partial Thromboplastin Time (aPTT) is 110 seconds
(normal 25-35s). What should the nurse do first?
A. Decrease the infusion rate by half
B. Prepare the antidote protamine sulfate
C. Stop the infusion and notify the provider
D. Repeat the lab test to confirm the result
Answer: C
Rationale: An aPTT of 110 seconds is significantly above the therapeutic range, placing the
patient at high risk for hemorrhage. The priority action is to stop the heparin infusion
immediately to prevent further anticoagulation until the provider provides new orders.
The nurse must also monitor for clinical signs of bleeding and document the event as part
of patient safety protocols.
3. A patient with Type 1 Diabetes is found confused and diaphoretic. The bedside glucose
reading is 48 mg/dL. Which action should the nurse take first?
A. Call the rapid response team
B. Administer 1 unit of regular insulin
C. Give 15g of fast-acting carbohydrates
,D. Provide a high-protein snack
Answer: C
Rationale: The patient is experiencing symptomatic hypoglycemia, requiring immediate
intervention with simple sugars to raise blood glucose levels. Following the ‘Rule of 15’
ensures that the patient receives a controlled amount of glucose followed by a recheck in
15 minutes. Quick intervention prevents progression to loss of consciousness or seizures.
4. Which clinical manifestation would the nurse expect to find in a patient experiencing
autonomic dysreflexia following a spinal cord injury at T6?
A. Tachycardia and hypotension
B. Decreased perspiration in all extremities
C. Pallor and cool skin above the injury
D. Severe headache and hypertension
Answer: D
Rationale: Autonomic dysreflexia is a medical emergency characterized by sudden, severe
hypertension and a throbbing headache. It is caused by an uninhibited sympathetic
response to a noxious stimulus below the level of injury. The nurse must recognize these
signs quickly to prevent potential stroke or myocardial infarction.
5. A patient with cirrhosis has a high serum ammonia level and is exhibiting tremors and
confusion. Which medication is most appropriate for the nurse to administer?
A. Spironolactone
B. Propranolol
C. Lactulose
D. Vitamin K
Answer: C
Rationale: Lactulose is used to reduce ammonia levels in patients with hepatic
encephalopathy by promoting excretion through the bowel. The goal is to achieve 2-3 soft
stools per day to ensure effective clearing of toxins. This intervention directly addresses
the cause of the patient’s neurological symptoms and hepatic deterioration.
6. When planning care for a patient with Cushing’s syndrome, which nursing diagnosis should
be the highest priority?
A. Disturbed body image
B. Risk for fluid volume deficit
C. Impaired skin integrity
, D. Risk for infection
Answer: D
Rationale: Cushing’s syndrome involves excess cortisol, which suppresses the immune
system and increases the risk for life-threatening infections. While body image and skin
integrity are concerns, physiological safety related to infection takes priority in clinical
management. The nurse must educate the patient on hand hygiene and early symptom
recognition.
7. A patient is 2 hours post-thyroidectomy. The nurse notes frequent swallowing and a harsh,
high-pitched respiratory sound. What should the nurse suspect?
A. Airway obstruction or stridor
B. Normal post-operative recovery
C. Laryngeal nerve damage
D. Hypocalcemic tetany
Answer: A
Rationale: Stridor and frequent swallowing post-thyroidectomy suggest airway edema or
hemorrhage compressing the trachea. This is an emergent situation requiring immediate
evaluation and preparation for potential re-intubation or surgical intervention. Continuous
monitoring of respiratory effort and surgical site drainage is critical during the first 24
hours.
8. The nurse is caring for a patient with Chronic Obstructive Pulmonary Disease (COPD)
receiving oxygen via nasal cannula at 2L/min. The patient’s SpO2 is 89%. What is the best
action?
A. Increase oxygen to 6L/min via mask
B. Place the patient on a non-rebreather mask
C. Continue to monitor the patient
D. Administer a PRN bronchodilator
Answer: C
Rationale: For patients with COPD, a target SpO2 of 88-92% is often acceptable to
maintain the hypoxic drive to breathe. Increasing oxygen too much can lead to hypercapnia
and respiratory depression due to the loss of this drive. The nurse should maintain the
current flow rate while monitoring for signs of respiratory distress or carbon dioxide
narcosis.
9. A patient is admitted with suspected bacterial meningitis. Which order should the nurse
implement first?
A. Administer the first dose of IV antibiotics
