NUR280 Actual Exam Questions With Correct/Verified Answers
{100%correct}Graded A+
1. The nurse is reviewing medical prescrip- 1. A. The normal potassium
tions for newly admitted clients. It level is 3.5 - 5.0 mEq/L. Giv-
would be a priority for the nurse to follow ing Kayexalate in this situa-
up with the physician if a client with tion may cause the client to
(a) a potassium level of 4.5mEq/L has lose potassium, causing hy-
Kayexalate (sodium polystyrene) pokalemia, therefore the drug
prescribed is not indicated; the therapeu-
(b) a Dilantin (phenytoin) level of 8 mcg/ml tic level for Dilantin is 10 - 20
is placed on seizure precautions mcg/ml, a level of 8 is sub
(c) sensitivity to Aspirin (acetylsali- therapeutic thereby increasing
cylic acid) is prescribed Tylenol (aceta- the risk of seizure activity.
minophen) Acetaminophen can be safe-
(d) sensitivity to Penicillin is prescribed ly prescribed to clients with
Zithromax (azithromycin) ASA sensitivity. Azithromycin
(Zithromax) can be safely pre-
scribed for clients with sensitiv-
ity to Penicillin.
2. The nurse should intervene if the nurse 2. A. Informed consent, ex-
notes a staff member planation and decision mak-
(a) obtaining a clients consent prior to ing must occur before sedation
their operative procedure after receiving is given; therapeutic interven-
Ativan (lorazepam) tions for retinal detachment in-
(b) placing a client on the affected side clude bedrest with the area of
following surgical repair of a retinal detachment in a dependent po-
detachment sition to promote healing; the
(c) handling a wet cast with the palms of cast should be handled with
the hands the palms of the hands while
(d) using a broad base of support while wet to prevent denting; a broad
transferring a client base of support is used during
transfers to prevent muscle in-
jury.
3. The community health nurse is caring for 3. B. An adolescent with un-
the following clients. It would be a controlled Diabetes Mellitus
priority for the nurse to initiate a multidis- would require the greatest
ciplinary conference for the client who number of disciplines (multi-
is disciplinary) to manage their
(a) 12 years old with Autism who is start- care i.e. Medicine, Nursing, So-
, NUR280
ing a new school and recently had a cial Work, Nutritionist; the other
URI (upper respiratory tract infection) choices do not require as many
(b) 16 years old, has type 1 Diabetes Mel- providers of care to meet their
litus, is unemployed and had a recent needs.
Hemoglobin A1c of 13%
(c) 52 years old, with Myasthenia Gravis,
recently prescribed Mestinon (pyridostig-
mine) and employed as a mail carrier
(d) 70 years old, has schizophrenia, lives
alone and reports hearing
non threatening voices.
4. The nurse from the postpartum unit has 4. C. The management of
been temporarily assigned to the a client following abdominal
medical surgical unit. It would be most surgery is standard. The post-
appropriate to assign this nurse to the partum nurse routinely cares
client who for mothers following caesare-
(a) has returned from right total hip re- an section; therefore it is ap-
placement surgery four hours ago propriate to assign this client;
(b) is being observed for increased in- The other choices are not
tracranial pressure appropriate to assign to this
(c) had surgery two hours ago to remove nurse.
the appendix
(d) is two weeks post partum being main-
tained on a mechanical ventilator for res-
piratory failure
5. The nurse in a well baby clinic has as- 5. D. A child experiencing nor-
sessed several children today. It would mal growth and development
be a priority for the nurse to suggest should be ambulating inde-
follow up for the child who is pendently by 12 months; the
(a) 2 months old with a positive babinski Babinski reflex disappears af-
reflex ter 2 years of age; an infant
(b) 5 months old and does not hold their typically holds their own bot-
own bottle tle by 6 months; stranger anxi-
(c) 10 months old who cries around ety usually develops at approx-
strangers imately 7 months
(d) 18 months old who needs support
while ambulating
, NUR280
6. The nurse is caring for a mechanically 6. C. Consent for organ dona-
ventilated client who was declared brain tion is given by a client's next
dead. An Advance Directive is not docu- of kin in the absence of an Ad-
mented on the medical record. It vance Directive
would be most appropriate to obtain con-
sent for organ donation from the
(a) client's primary care provider
(b) client's nurse manager
(c) closest living family member
(d) hospital's ethics committee
7. The nurse has received report on four 7. C. The client admitted
clients. The nurse should first with Guillain-Barre' Syndrome
assess the client who has: should be assessed first be-
(a) Chronic Obstructive Pulmonary Dis- cause of the possibility of rapid
ease (COPD) with a pulse oximetry read- progression of this illness and
ing of 90% neuromuscular respiratory fail-
(b) Parkinson's Disease and is demanding ure; clients with COPD are like-
to leave the hospital against medical ad- ly to have pulse oximetry read-
vice (AMA) ings of 90% related to chronic
(c) been admitted with suspected Guillian hypoxia; this client along with
Barre Syndrome and has begun plasma- the other two choices are im-
pheresis therapy portant, but not the priority.
(d) Congestive Heart Failure (CHF) whose
pitting edema has increased to 2(+)
8. It would be appropriate to assign which of B. The Certified Nursing As-
these tasks to the CNA? sistant may be assigned to a
(a) Feeding a client who is experiencing client that requires one- to-one
dysphagia observation for safety; the oth-
(b) One-on-one client observation for er choices require skilled nurs-
safety ing intervention by a LPN (Li-
(c) Removal of an indwelling catheter censed Practical Nurse) or RN
(d) Performing a simple dressing change (Registered Nurse).
9. The nurse should intervene if a staff mem- 9. A. To maintain confidential-
ber is observed: ity the nurse should not dis-
(a) discussing a client's diagnosis with cuss the client's diagnosis with
visiting family members family members; it is advis-
, NUR280
(b) collaborating with another nurse to re- able that two nurses review the
view a prescription for blood transfusion prescription for blood transfu-
(c) interrupting other staff members dis- sion to identify the client, blood
cussing a client in the cafeteria type, Rh factor, expiration date
(d) reviewing a clients lab values with the and the blood numbers; in-
nutritionist terrupting staff members dis-
cussing a client in a public
place should be done to main-
tain client confidentiality; col-
laborating with the nutritionist
is an appropriate nursing in-
tervention. Safe Effective Care
Environment; Management of
Care
10. The nurse is preparing a staff presenta- A. Putting a client in a geriatric
tion on legal and ethical issues in nurs- chair with the lap tray in front of
ing. The nurse would be correct to include them restricts movement which
which of the following examples? constitutes false imprisonment;
(a) Putting a client in a geriatric chair with choice B is an example of as-
the lap tray in front of the client in the day sault not battery; C is an ex-
room to watch television is false impris- ample of negligence not mal-
onment practice and D is an example of
(b) Telling a client that you will put in a battery not assault. Safe Effec-
feeding tube if the client does not eat is tive Care Environment; Man-
an example of battery agement of Care
(c) Telling a client with bipolar disorder
who is suicidal that they have a right to
refuse to take their medications is an ex-
ample of malpractice
(d) Placing hands on a client who says "do
not touch me" is an example of assault
11. The nurse from the pediatric unit has been 11. C. Vomiting and diar-
temporarily assigned to the rhea can be managed on a
Emergency Department. It would be most non-emergent basis; clients re-
appropriate to assign that nurse porting "indigestion" may be
to the client who experiencing a cardiac event;
(a) reports epigastric pain that "feels like clinical manifestations sug-
{100%correct}Graded A+
1. The nurse is reviewing medical prescrip- 1. A. The normal potassium
tions for newly admitted clients. It level is 3.5 - 5.0 mEq/L. Giv-
would be a priority for the nurse to follow ing Kayexalate in this situa-
up with the physician if a client with tion may cause the client to
(a) a potassium level of 4.5mEq/L has lose potassium, causing hy-
Kayexalate (sodium polystyrene) pokalemia, therefore the drug
prescribed is not indicated; the therapeu-
(b) a Dilantin (phenytoin) level of 8 mcg/ml tic level for Dilantin is 10 - 20
is placed on seizure precautions mcg/ml, a level of 8 is sub
(c) sensitivity to Aspirin (acetylsali- therapeutic thereby increasing
cylic acid) is prescribed Tylenol (aceta- the risk of seizure activity.
minophen) Acetaminophen can be safe-
(d) sensitivity to Penicillin is prescribed ly prescribed to clients with
Zithromax (azithromycin) ASA sensitivity. Azithromycin
(Zithromax) can be safely pre-
scribed for clients with sensitiv-
ity to Penicillin.
2. The nurse should intervene if the nurse 2. A. Informed consent, ex-
notes a staff member planation and decision mak-
(a) obtaining a clients consent prior to ing must occur before sedation
their operative procedure after receiving is given; therapeutic interven-
Ativan (lorazepam) tions for retinal detachment in-
(b) placing a client on the affected side clude bedrest with the area of
following surgical repair of a retinal detachment in a dependent po-
detachment sition to promote healing; the
(c) handling a wet cast with the palms of cast should be handled with
the hands the palms of the hands while
(d) using a broad base of support while wet to prevent denting; a broad
transferring a client base of support is used during
transfers to prevent muscle in-
jury.
3. The community health nurse is caring for 3. B. An adolescent with un-
the following clients. It would be a controlled Diabetes Mellitus
priority for the nurse to initiate a multidis- would require the greatest
ciplinary conference for the client who number of disciplines (multi-
is disciplinary) to manage their
(a) 12 years old with Autism who is start- care i.e. Medicine, Nursing, So-
, NUR280
ing a new school and recently had a cial Work, Nutritionist; the other
URI (upper respiratory tract infection) choices do not require as many
(b) 16 years old, has type 1 Diabetes Mel- providers of care to meet their
litus, is unemployed and had a recent needs.
Hemoglobin A1c of 13%
(c) 52 years old, with Myasthenia Gravis,
recently prescribed Mestinon (pyridostig-
mine) and employed as a mail carrier
(d) 70 years old, has schizophrenia, lives
alone and reports hearing
non threatening voices.
4. The nurse from the postpartum unit has 4. C. The management of
been temporarily assigned to the a client following abdominal
medical surgical unit. It would be most surgery is standard. The post-
appropriate to assign this nurse to the partum nurse routinely cares
client who for mothers following caesare-
(a) has returned from right total hip re- an section; therefore it is ap-
placement surgery four hours ago propriate to assign this client;
(b) is being observed for increased in- The other choices are not
tracranial pressure appropriate to assign to this
(c) had surgery two hours ago to remove nurse.
the appendix
(d) is two weeks post partum being main-
tained on a mechanical ventilator for res-
piratory failure
5. The nurse in a well baby clinic has as- 5. D. A child experiencing nor-
sessed several children today. It would mal growth and development
be a priority for the nurse to suggest should be ambulating inde-
follow up for the child who is pendently by 12 months; the
(a) 2 months old with a positive babinski Babinski reflex disappears af-
reflex ter 2 years of age; an infant
(b) 5 months old and does not hold their typically holds their own bot-
own bottle tle by 6 months; stranger anxi-
(c) 10 months old who cries around ety usually develops at approx-
strangers imately 7 months
(d) 18 months old who needs support
while ambulating
, NUR280
6. The nurse is caring for a mechanically 6. C. Consent for organ dona-
ventilated client who was declared brain tion is given by a client's next
dead. An Advance Directive is not docu- of kin in the absence of an Ad-
mented on the medical record. It vance Directive
would be most appropriate to obtain con-
sent for organ donation from the
(a) client's primary care provider
(b) client's nurse manager
(c) closest living family member
(d) hospital's ethics committee
7. The nurse has received report on four 7. C. The client admitted
clients. The nurse should first with Guillain-Barre' Syndrome
assess the client who has: should be assessed first be-
(a) Chronic Obstructive Pulmonary Dis- cause of the possibility of rapid
ease (COPD) with a pulse oximetry read- progression of this illness and
ing of 90% neuromuscular respiratory fail-
(b) Parkinson's Disease and is demanding ure; clients with COPD are like-
to leave the hospital against medical ad- ly to have pulse oximetry read-
vice (AMA) ings of 90% related to chronic
(c) been admitted with suspected Guillian hypoxia; this client along with
Barre Syndrome and has begun plasma- the other two choices are im-
pheresis therapy portant, but not the priority.
(d) Congestive Heart Failure (CHF) whose
pitting edema has increased to 2(+)
8. It would be appropriate to assign which of B. The Certified Nursing As-
these tasks to the CNA? sistant may be assigned to a
(a) Feeding a client who is experiencing client that requires one- to-one
dysphagia observation for safety; the oth-
(b) One-on-one client observation for er choices require skilled nurs-
safety ing intervention by a LPN (Li-
(c) Removal of an indwelling catheter censed Practical Nurse) or RN
(d) Performing a simple dressing change (Registered Nurse).
9. The nurse should intervene if a staff mem- 9. A. To maintain confidential-
ber is observed: ity the nurse should not dis-
(a) discussing a client's diagnosis with cuss the client's diagnosis with
visiting family members family members; it is advis-
, NUR280
(b) collaborating with another nurse to re- able that two nurses review the
view a prescription for blood transfusion prescription for blood transfu-
(c) interrupting other staff members dis- sion to identify the client, blood
cussing a client in the cafeteria type, Rh factor, expiration date
(d) reviewing a clients lab values with the and the blood numbers; in-
nutritionist terrupting staff members dis-
cussing a client in a public
place should be done to main-
tain client confidentiality; col-
laborating with the nutritionist
is an appropriate nursing in-
tervention. Safe Effective Care
Environment; Management of
Care
10. The nurse is preparing a staff presenta- A. Putting a client in a geriatric
tion on legal and ethical issues in nurs- chair with the lap tray in front of
ing. The nurse would be correct to include them restricts movement which
which of the following examples? constitutes false imprisonment;
(a) Putting a client in a geriatric chair with choice B is an example of as-
the lap tray in front of the client in the day sault not battery; C is an ex-
room to watch television is false impris- ample of negligence not mal-
onment practice and D is an example of
(b) Telling a client that you will put in a battery not assault. Safe Effec-
feeding tube if the client does not eat is tive Care Environment; Man-
an example of battery agement of Care
(c) Telling a client with bipolar disorder
who is suicidal that they have a right to
refuse to take their medications is an ex-
ample of malpractice
(d) Placing hands on a client who says "do
not touch me" is an example of assault
11. The nurse from the pediatric unit has been 11. C. Vomiting and diar-
temporarily assigned to the rhea can be managed on a
Emergency Department. It would be most non-emergent basis; clients re-
appropriate to assign that nurse porting "indigestion" may be
to the client who experiencing a cardiac event;
(a) reports epigastric pain that "feels like clinical manifestations sug-
