N261 Exam 2 Actual Exam V3 | N261 Nursing (N261 Exam 2) |
University of California, Los Angeles
1. A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen via nasal
cannula at 2L/min. The patient’s pulse oximetry shows 89% saturation. What is the priority
nursing action?
A. Increase the oxygen flow rate to 6L/min immediately.
B. Notify the healthcare provider of the low saturation.
C. Assess the patient’s respiratory rate and effort.
D. Instruct the patient to perform pursed-lip breathing.
Answer: C
Rationale: The first step in the nursing process is assessment to determine if the patient is
in acute distress. For a patient with COPD, an oxygen saturation of 88-92% is often
considered an acceptable baseline range. The nurse must evaluate the clinical presentation
before intervening or notifying the physician.
2. A nurse is caring for a patient who is 24 hours postoperative after an abdominal
hysterectomy. The patient reports sudden onset of chest pain and shortness of breath. Which
complication should the nurse suspect first?
A. Pneumonia
B. Pulmonary embolism
C. Myocardial infarction
D. Atelectasis
Answer: B
Rationale: Sudden onset of shortness of breath and chest pain in a postoperative patient
are hallmark signs of a pulmonary embolism. Postoperative patients are at high risk for
venous thromboembolism due to immobility and surgical trauma. Immediate intervention
is required to stabilize the patient’s oxygenation and circulation.
3. A patient with Type 1 Diabetes Mellitus presents with a blood glucose of 650 mg/dL and
positive ketones in the urine. The nurse anticipates an order for which type of intravenous
fluid and insulin?
A. 0.9% Normal Saline and Regular Insulin infusion
B. D5W and NPH insulin subcutaneously
C. 0.45% Normal Saline and Glargine insulin infusion
,D. Lactated Ringer’s and Lispro insulin bolus
Answer: A
Rationale: Diabetic Ketoacidosis (DKA) requires aggressive fluid resuscitation with
isotonic saline to restore circulatory volume. Regular insulin is the only type of insulin that
can be administered intravenously for the management of hyperglycemia. The nurse must
monitor potassium levels closely as insulin drives potassium back into the cells.
4. The nurse is evaluating a patient with a potassium level of 6.2 mEq/L. Which
electrocardiogram (ECG) change is most indicative of this electrolyte imbalance?
A. Prominent U waves
B. ST-segment depression
C. Tall, peaked T waves
D. Prolonged QT interval
Answer: C
Rationale: Hyperkalemia significantly affects cardiac conduction, and tall, peaked T waves
are one of the earliest signs. As potassium levels rise further, the QRS complex may widen,
eventually leading to cardiac arrest. The nurse should prepare to administer medications
such as calcium gluconate or sodium polystyrene sulfonate.
5. A patient is prescribed Warfarin (Coumadin) for atrial fibrillation. Which laboratory value
should the nurse monitor to determine the effectiveness of the therapy?
A. International Normalized Ratio (INR)
B. Activated partial thromboplastin time (aPTT)
C. Platelet count
D. Hemoglobin and Hematocrit
Answer: A
Rationale: The INR is the standard laboratory test used to monitor the therapeutic effect of
Warfarin. For most patients on anticoagulation, the target INR range is typically between
2.0 and 3.0. The aPTT is used instead to monitor the effectiveness of heparin therapy.
6. A nurse is providing discharge teaching for a patient with a new diagnosis of Heart Failure.
Which statement by the patient indicates a need for further teaching?
A. “I will weigh myself every morning at the same time.”
B. “I will take my diuretic pill right before I go to bed.”
C. “I will limit my salt intake to less than 2 grams per day.”
D. “I will call my doctor if I gain more than 3 pounds in two days.”
, Answer: B
Rationale: Diuretics should be taken in the morning to prevent nocturia, which can
interfere with sleep and increase the risk of falls in the dark. Daily weights are essential for
monitoring fluid status and identifying exacerbations early. Sodium restriction is a
standard nonpharmacologic intervention to manage fluid volume overload.
7. During a shift assessment, the nurse notes that a patient’s surgical incision has eviscerated.
What is the nurse’s immediate priority?
A. Cover the protruding organs with sterile gauze soaked in normal saline.
B. Push the organs back into the abdominal cavity gently.
C. Call the surgeon to report the change in status.
D. Place the patient in a High-Fowler’s position.
Answer: A
Rationale: Evisceration is a medical emergency where internal organs protrude through a
surgical incision. The nurse must protect the exposed tissue by covering it with sterile,
saline-soaked dressings to prevent drying and infection. The patient should be kept in a
low-Fowler’s position with knees flexed to reduce abdominal tension while waiting for
surgical intervention.
8. A patient with a history of hypertension is prescribed Spironolactone (Aldactone). Which
food choice should the nurse advise the patient to avoid?
A. Apples
B. Chicken breast
C. White bread
D. Bananas
Answer: D
Rationale: Spironolactone is a potassium-sparing diuretic that can lead to hyperkalemia.
Bananas are high in potassium and should be avoided or limited to prevent dangerous
electrolyte elevations. The nurse must educate the patient on recognizing signs of high
potassium, such as muscle weakness or arrhythmias.
9. A patient is admitted with a suspected diagnosis of bacterial meningitis. Which nursing
intervention should be implemented immediately?
A. Place the patient on droplet precautions.
B. Administer the first dose of antibiotics.
C. Obtain a sputum culture.
University of California, Los Angeles
1. A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen via nasal
cannula at 2L/min. The patient’s pulse oximetry shows 89% saturation. What is the priority
nursing action?
A. Increase the oxygen flow rate to 6L/min immediately.
B. Notify the healthcare provider of the low saturation.
C. Assess the patient’s respiratory rate and effort.
D. Instruct the patient to perform pursed-lip breathing.
Answer: C
Rationale: The first step in the nursing process is assessment to determine if the patient is
in acute distress. For a patient with COPD, an oxygen saturation of 88-92% is often
considered an acceptable baseline range. The nurse must evaluate the clinical presentation
before intervening or notifying the physician.
2. A nurse is caring for a patient who is 24 hours postoperative after an abdominal
hysterectomy. The patient reports sudden onset of chest pain and shortness of breath. Which
complication should the nurse suspect first?
A. Pneumonia
B. Pulmonary embolism
C. Myocardial infarction
D. Atelectasis
Answer: B
Rationale: Sudden onset of shortness of breath and chest pain in a postoperative patient
are hallmark signs of a pulmonary embolism. Postoperative patients are at high risk for
venous thromboembolism due to immobility and surgical trauma. Immediate intervention
is required to stabilize the patient’s oxygenation and circulation.
3. A patient with Type 1 Diabetes Mellitus presents with a blood glucose of 650 mg/dL and
positive ketones in the urine. The nurse anticipates an order for which type of intravenous
fluid and insulin?
A. 0.9% Normal Saline and Regular Insulin infusion
B. D5W and NPH insulin subcutaneously
C. 0.45% Normal Saline and Glargine insulin infusion
,D. Lactated Ringer’s and Lispro insulin bolus
Answer: A
Rationale: Diabetic Ketoacidosis (DKA) requires aggressive fluid resuscitation with
isotonic saline to restore circulatory volume. Regular insulin is the only type of insulin that
can be administered intravenously for the management of hyperglycemia. The nurse must
monitor potassium levels closely as insulin drives potassium back into the cells.
4. The nurse is evaluating a patient with a potassium level of 6.2 mEq/L. Which
electrocardiogram (ECG) change is most indicative of this electrolyte imbalance?
A. Prominent U waves
B. ST-segment depression
C. Tall, peaked T waves
D. Prolonged QT interval
Answer: C
Rationale: Hyperkalemia significantly affects cardiac conduction, and tall, peaked T waves
are one of the earliest signs. As potassium levels rise further, the QRS complex may widen,
eventually leading to cardiac arrest. The nurse should prepare to administer medications
such as calcium gluconate or sodium polystyrene sulfonate.
5. A patient is prescribed Warfarin (Coumadin) for atrial fibrillation. Which laboratory value
should the nurse monitor to determine the effectiveness of the therapy?
A. International Normalized Ratio (INR)
B. Activated partial thromboplastin time (aPTT)
C. Platelet count
D. Hemoglobin and Hematocrit
Answer: A
Rationale: The INR is the standard laboratory test used to monitor the therapeutic effect of
Warfarin. For most patients on anticoagulation, the target INR range is typically between
2.0 and 3.0. The aPTT is used instead to monitor the effectiveness of heparin therapy.
6. A nurse is providing discharge teaching for a patient with a new diagnosis of Heart Failure.
Which statement by the patient indicates a need for further teaching?
A. “I will weigh myself every morning at the same time.”
B. “I will take my diuretic pill right before I go to bed.”
C. “I will limit my salt intake to less than 2 grams per day.”
D. “I will call my doctor if I gain more than 3 pounds in two days.”
, Answer: B
Rationale: Diuretics should be taken in the morning to prevent nocturia, which can
interfere with sleep and increase the risk of falls in the dark. Daily weights are essential for
monitoring fluid status and identifying exacerbations early. Sodium restriction is a
standard nonpharmacologic intervention to manage fluid volume overload.
7. During a shift assessment, the nurse notes that a patient’s surgical incision has eviscerated.
What is the nurse’s immediate priority?
A. Cover the protruding organs with sterile gauze soaked in normal saline.
B. Push the organs back into the abdominal cavity gently.
C. Call the surgeon to report the change in status.
D. Place the patient in a High-Fowler’s position.
Answer: A
Rationale: Evisceration is a medical emergency where internal organs protrude through a
surgical incision. The nurse must protect the exposed tissue by covering it with sterile,
saline-soaked dressings to prevent drying and infection. The patient should be kept in a
low-Fowler’s position with knees flexed to reduce abdominal tension while waiting for
surgical intervention.
8. A patient with a history of hypertension is prescribed Spironolactone (Aldactone). Which
food choice should the nurse advise the patient to avoid?
A. Apples
B. Chicken breast
C. White bread
D. Bananas
Answer: D
Rationale: Spironolactone is a potassium-sparing diuretic that can lead to hyperkalemia.
Bananas are high in potassium and should be avoided or limited to prevent dangerous
electrolyte elevations. The nurse must educate the patient on recognizing signs of high
potassium, such as muscle weakness or arrhythmias.
9. A patient is admitted with a suspected diagnosis of bacterial meningitis. Which nursing
intervention should be implemented immediately?
A. Place the patient on droplet precautions.
B. Administer the first dose of antibiotics.
C. Obtain a sputum culture.
