N261 Exam 1 Actual Exam V2 | N261 Nursing (N261 Exam 1) |
University of California, Los Angeles
1. A nurse is preparing to witness a patient’s signature on an informed consent form for a
surgical procedure. Which action is the primary responsibility of the nurse in this process?
A. Explaining the risks and benefits of the surgery to the patient.
B. Verifying that the patient is signing the form voluntarily and is competent.
C. Ensuring the patient has received all necessary information from the surgeon.
D. Providing alternative treatment options if the patient expresses doubt.
Answer: B
Rationale: The nurse’s primary role in informed consent is to witness the signature, which
confirms the patient is who they say they are and is signing voluntarily. It is the provider’s
responsibility to explain the procedure, risks, and alternatives. If the nurse notes the
patient does not understand the procedure, the nurse must notify the provider before the
signature is obtained.
2. When using the SBAR communication tool to report a change in a patient’s condition to a
physician, which information should the nurse include in the ‘B’ section?
A. The patient’s admitting diagnosis and relevant medical history.
B. The nurse’s recommendation for a specific intervention.
C. A brief statement of the current problem or concern.
D. The patient’s current vital signs and physical assessment findings.
Answer: A
Rationale: The ‘B’ in SBAR stands for Background, which includes the admitting diagnosis,
medical history, and summary of treatment to date. The ‘S’ stands for Situation, which is the
immediate problem. ‘A’ is Assessment of the current state, and ‘R’ is the Recommendation
for what the nurse thinks should happen next.
3. A nurse is caring for a patient who is at high risk for falls. Which nursing intervention is the
highest priority to ensure patient safety?
A. Keeping all four side rails in the upright position at all times.
B. Placing the call light within the patient’s reach and reinforcing its use.
C. Applying physical restraints to prevent the patient from getting out of bed.
D. Administering a sedative to keep the patient calm and stationary.
,Answer: B
Rationale: Placing the call light within reach is a fundamental safety intervention that
empowers the patient to ask for help. Using four side rails is often considered a restraint
and can lead to more serious injuries if the patient tries to climb over them. Restraints and
sedatives are not first-line interventions and require specific legal and clinical
justifications.
4. A nurse is documenting a patient’s care in the electronic health record. Which entry
represents the most objective and accurate documentation?
A. Patient’s surgical incision is 5 cm long, pink, with no drainage noted.
B. The patient was uncooperative during the morning dressing change.
C. The patient seems to be in a lot of pain today.
D. The patient ate a good amount of their breakfast tray.
Answer: A
Rationale: Objective documentation uses measurable data and specific descriptions rather
than vague terms like ‘seems’ or ‘good.’ Describing the incision’s length and appearance
provides a clear clinical picture for other healthcare providers. Subjective terms like
‘uncooperative’ should be replaced with specific descriptions of the patient’s behavior.
5. During a physical assessment, the nurse prepares to assess the patient’s abdomen. In
which order should the nurse perform the assessment techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Palpation, Percussion, Auscultation, Inspection
C. Auscultation, Inspection, Palpation, Percussion
D. Inspection, Auscultation, Percussion, Palpation
Answer: D
Rationale: The correct order for abdominal assessment is inspection, auscultation,
percussion, and then palpation. This sequence is used because palpation and percussion
can stimulate bowel activity and alter the sounds heard during auscultation. By
auscultating first, the nurse ensures the bowel sounds are representative of the patient’s
actual state.
6. A nurse is caring for a patient with a diagnosis of Clostridioides difficile (C. diff). Which
infection control precaution is essential for this patient?
A. Performing hand hygiene with soap and water after contact.
B. Using alcohol-based hand sanitizer after providing care.
C. Wearing an N95 respirator when entering the room.
, D. Placing the patient in a room with negative air pressure.
Answer: A
Rationale: C. difficile spores are resistant to alcohol-based sanitizers, so handwashing with
soap and water is mandatory to mechanically remove the spores. Contact precautions are
required, which include wearing gloves and a gown. Negative pressure rooms are reserved
for airborne precautions, such as for tuberculosis.
7. A nurse is practicing therapeutic communication with a patient who is anxious about a new
diagnosis. Which statement by the nurse is an example of ‘reflecting’?
A. ‘Why do you feel so anxious about this diagnosis?’
B. ‘Don’t worry, many people live long lives with this condition.’
C. ‘You seem to be feeling overwhelmed by this news.’
D. ‘I will go get the doctor so you can ask more questions.’
Answer: C
Rationale: Reflecting involves directing the patient’s feelings back to them to encourage
further exploration of those emotions. It validates the patient’s experience without offering
false reassurance or asking ‘why’ questions, which can be perceived as accusatory. This
technique helps the patient clarify their own feelings and promotes a therapeutic
relationship.
8. A nurse is reviewing the steps of the nursing process. Which activity occurs during the
‘Evaluation’ phase?
A. Determining if the patient’s goals were met or need revision.
B. Collecting subjective and objective data from the patient.
C. Setting measurable goals and outcomes with the patient.
D. Implementing nursing interventions to address the diagnosis.
Answer: A
Rationale: Evaluation is the final step of the nursing process where the nurse compares
the patient’s current status with the desired outcomes. If the goals were not met, the nurse
must reassess and modify the plan of care. This step ensures that the nursing care is
effective and responsive to the patient’s needs.
9. A nurse is delegating tasks to an Unlicensed Assistive Personnel (UAP). Which task is
appropriate for the nurse to delegate?
A. Assisting a stable patient with a bed bath and oral care.
B. Teaching a patient how to use an incentive spirometer.
University of California, Los Angeles
1. A nurse is preparing to witness a patient’s signature on an informed consent form for a
surgical procedure. Which action is the primary responsibility of the nurse in this process?
A. Explaining the risks and benefits of the surgery to the patient.
B. Verifying that the patient is signing the form voluntarily and is competent.
C. Ensuring the patient has received all necessary information from the surgeon.
D. Providing alternative treatment options if the patient expresses doubt.
Answer: B
Rationale: The nurse’s primary role in informed consent is to witness the signature, which
confirms the patient is who they say they are and is signing voluntarily. It is the provider’s
responsibility to explain the procedure, risks, and alternatives. If the nurse notes the
patient does not understand the procedure, the nurse must notify the provider before the
signature is obtained.
2. When using the SBAR communication tool to report a change in a patient’s condition to a
physician, which information should the nurse include in the ‘B’ section?
A. The patient’s admitting diagnosis and relevant medical history.
B. The nurse’s recommendation for a specific intervention.
C. A brief statement of the current problem or concern.
D. The patient’s current vital signs and physical assessment findings.
Answer: A
Rationale: The ‘B’ in SBAR stands for Background, which includes the admitting diagnosis,
medical history, and summary of treatment to date. The ‘S’ stands for Situation, which is the
immediate problem. ‘A’ is Assessment of the current state, and ‘R’ is the Recommendation
for what the nurse thinks should happen next.
3. A nurse is caring for a patient who is at high risk for falls. Which nursing intervention is the
highest priority to ensure patient safety?
A. Keeping all four side rails in the upright position at all times.
B. Placing the call light within the patient’s reach and reinforcing its use.
C. Applying physical restraints to prevent the patient from getting out of bed.
D. Administering a sedative to keep the patient calm and stationary.
,Answer: B
Rationale: Placing the call light within reach is a fundamental safety intervention that
empowers the patient to ask for help. Using four side rails is often considered a restraint
and can lead to more serious injuries if the patient tries to climb over them. Restraints and
sedatives are not first-line interventions and require specific legal and clinical
justifications.
4. A nurse is documenting a patient’s care in the electronic health record. Which entry
represents the most objective and accurate documentation?
A. Patient’s surgical incision is 5 cm long, pink, with no drainage noted.
B. The patient was uncooperative during the morning dressing change.
C. The patient seems to be in a lot of pain today.
D. The patient ate a good amount of their breakfast tray.
Answer: A
Rationale: Objective documentation uses measurable data and specific descriptions rather
than vague terms like ‘seems’ or ‘good.’ Describing the incision’s length and appearance
provides a clear clinical picture for other healthcare providers. Subjective terms like
‘uncooperative’ should be replaced with specific descriptions of the patient’s behavior.
5. During a physical assessment, the nurse prepares to assess the patient’s abdomen. In
which order should the nurse perform the assessment techniques?
A. Inspection, Palpation, Percussion, Auscultation
B. Palpation, Percussion, Auscultation, Inspection
C. Auscultation, Inspection, Palpation, Percussion
D. Inspection, Auscultation, Percussion, Palpation
Answer: D
Rationale: The correct order for abdominal assessment is inspection, auscultation,
percussion, and then palpation. This sequence is used because palpation and percussion
can stimulate bowel activity and alter the sounds heard during auscultation. By
auscultating first, the nurse ensures the bowel sounds are representative of the patient’s
actual state.
6. A nurse is caring for a patient with a diagnosis of Clostridioides difficile (C. diff). Which
infection control precaution is essential for this patient?
A. Performing hand hygiene with soap and water after contact.
B. Using alcohol-based hand sanitizer after providing care.
C. Wearing an N95 respirator when entering the room.
, D. Placing the patient in a room with negative air pressure.
Answer: A
Rationale: C. difficile spores are resistant to alcohol-based sanitizers, so handwashing with
soap and water is mandatory to mechanically remove the spores. Contact precautions are
required, which include wearing gloves and a gown. Negative pressure rooms are reserved
for airborne precautions, such as for tuberculosis.
7. A nurse is practicing therapeutic communication with a patient who is anxious about a new
diagnosis. Which statement by the nurse is an example of ‘reflecting’?
A. ‘Why do you feel so anxious about this diagnosis?’
B. ‘Don’t worry, many people live long lives with this condition.’
C. ‘You seem to be feeling overwhelmed by this news.’
D. ‘I will go get the doctor so you can ask more questions.’
Answer: C
Rationale: Reflecting involves directing the patient’s feelings back to them to encourage
further exploration of those emotions. It validates the patient’s experience without offering
false reassurance or asking ‘why’ questions, which can be perceived as accusatory. This
technique helps the patient clarify their own feelings and promotes a therapeutic
relationship.
8. A nurse is reviewing the steps of the nursing process. Which activity occurs during the
‘Evaluation’ phase?
A. Determining if the patient’s goals were met or need revision.
B. Collecting subjective and objective data from the patient.
C. Setting measurable goals and outcomes with the patient.
D. Implementing nursing interventions to address the diagnosis.
Answer: A
Rationale: Evaluation is the final step of the nursing process where the nurse compares
the patient’s current status with the desired outcomes. If the goals were not met, the nurse
must reassess and modify the plan of care. This step ensures that the nursing care is
effective and responsive to the patient’s needs.
9. A nurse is delegating tasks to an Unlicensed Assistive Personnel (UAP). Which task is
appropriate for the nurse to delegate?
A. Assisting a stable patient with a bed bath and oral care.
B. Teaching a patient how to use an incentive spirometer.
