N261 Exam 3 Actual Exam V3 | N261 Nursing (N261 Exam 3) |
University of California, Los Angeles
1. A nurse is providing discharge education to a client diagnosed with heart failure. Which
instruction is most critical for the patient to follow to prevent acute exacerbation?
A. Decrease daily intake of fibrous vegetables
B. Monitor and record daily weights at the same time each morning
C. Perform vigorous aerobic exercise for 60 minutes daily
D. Increase fluid intake to at least 3 liters per day
Answer: B
Rationale: Monitoring daily weights is the gold standard for early detection of fluid
retention in heart failure patients. A weight gain of more than 2 to 3 pounds in 24 hours or
5 pounds in a week should be reported to the healthcare provider immediately. This allows
for early pharmacological adjustment to prevent hospitalization for pulmonary edema.
2. A client is admitted with a potassium level of 6.8 mEq/L. Which of the following nursing
actions is the highest priority?
A. Encourage the intake of orange juice and bananas
B. Obtain a 24-hour urine collection sample
C. Place the client on a continuous cardiac monitor
D. Administer a dose of spironolactone as ordered
Answer: C
Rationale: Hyperkalemia can cause lethal cardiac dysrhythmias, including ventricular
fibrillation or asystole. Continuous cardiac monitoring is essential to detect early changes
such as peaked T-waves or widened QRS complexes. The nurse must prioritize safety and
immediate assessment of cardiac rhythm before administering medications or collecting
urine.
3. The nurse is caring for a client with Type 1 Diabetes Mellitus who is diaphoretic, shaky, and
complaining of a headache. What should be the nurse’s first action?
A. Administer the scheduled dose of glargine insulin
B. Check the client’s capillary blood glucose level
C. Call the healthcare provider for a neurological consult
D. Provide the client with a high-protein snack
,Answer: B
Rationale: The symptoms described are classic signs of hypoglycemia, which requires
immediate verification and intervention. Checking the blood glucose level provides the data
needed to determine if the patient requires fast-acting carbohydrates. Prompt recognition
and treatment of hypoglycemia prevent progression to seizure or loss of consciousness.
4. A client returns from surgery following a total hip arthroplasty. Which position is most
appropriate for the nurse to maintain to prevent dislocation?
A. High Fowler’s position with knees flexed
B. Abduction of the affected hip using a pillow or wedge
C. Adduction of the affected leg across the midline
D. Complete bed rest in a prone position
Answer: B
Rationale: Maintaining hip abduction is crucial after a total hip replacement to keep the
femoral head securely within the acetabulum. An abduction pillow or wedge prevents the
legs from crossing the midline, which is a common cause of dislocation. The nurse should
also instruct the patient to avoid bending the hip more than 90 degrees.
5. Which of the following tasks is most appropriate for the RN to delegate to an unlicensed
assistive personnel (UAP)?
A. Assessing the breath sounds of a patient with a new chest tube
B. Providing discharge teaching for a patient with a new colostomy
C. Assisting a stable patient with ambulation for the first time post-op
D. Measuring and recording the output from a Foley catheter
Answer: D
Rationale: Measuring and recording output is a routine technical task that falls within the
scope of practice for a UAP. Assessment, teaching, and evaluating the first ambulation of a
post-operative patient are nursing responsibilities that require clinical judgment. Proper
delegation ensures that the RN can focus on complex clinical decisions and patient stability.
6. A nurse is assessing a client with chronic obstructive pulmonary disease (COPD). Which
finding should the nurse report immediately to the healthcare provider?
A. Increased use of accessory muscles and new onset confusion
B. SpO2 of 89% on 2L of oxygen via nasal cannula
C. A change in the color and consistency of sputum
D. Presence of a barrel chest and clubbing of fingers
, Answer: A
Rationale: New onset confusion and increased work of breathing are indicators of acute
respiratory failure or worsening hypercapnia. While a barrel chest and low SpO2 are
common in chronic COPD, acute neurological changes suggest hypoxia or CO2 narcosis.
Immediate intervention is required to stabilize the patient’s airway and oxygenation status.
7. A client with liver cirrhosis and ascites is prescribed lactulose. What is the primary
therapeutic goal of this medication?
A. To reduce the amount of fluid in the peritoneal cavity
B. To prevent the development of esophageal varices
C. To decrease the pressure within the portal venous system
D. To lower blood ammonia levels and improve mentation
Answer: D
Rationale: Lactulose is an osmotic laxative used to treat hepatic encephalopathy by
promoting the excretion of ammonia through the stool. It works by acidifying the colon,
which converts ammonia into ammonium, an ion that cannot be reabsorbed into the blood.
The effectiveness of the therapy is measured by a reduction in confusion and improved
neurological status.
8. An elderly client is admitted for dehydration. The nurse notes the client is confused and
attempting to pull out the IV line. Which is the best initial nursing action?
A. Apply bilateral wrist restraints immediately
B. Ask a family member or sitter to stay at the bedside
C. Request a prescription for a sedative medication
D. Inform the client that they cannot leave the hospital
Answer: B
Rationale: Using a sitter or family member is a less restrictive intervention than physical
or chemical restraints. The nurse should always attempt the least restrictive method first
to ensure patient safety while respecting autonomy. Restraints should only be used as a last
resort when all other safety measures have failed to protect the client.
9. A nurse is caring for a client who is post-operative day 2 from abdominal surgery. The client
reports sudden chest pain and shortness of breath. What is the nurse’s priority action?
A. Administer an ordered PRN dose of morphine
B. Perform a full head-to-toe physical assessment
C. Encourage the client to use the incentive spirometer
University of California, Los Angeles
1. A nurse is providing discharge education to a client diagnosed with heart failure. Which
instruction is most critical for the patient to follow to prevent acute exacerbation?
A. Decrease daily intake of fibrous vegetables
B. Monitor and record daily weights at the same time each morning
C. Perform vigorous aerobic exercise for 60 minutes daily
D. Increase fluid intake to at least 3 liters per day
Answer: B
Rationale: Monitoring daily weights is the gold standard for early detection of fluid
retention in heart failure patients. A weight gain of more than 2 to 3 pounds in 24 hours or
5 pounds in a week should be reported to the healthcare provider immediately. This allows
for early pharmacological adjustment to prevent hospitalization for pulmonary edema.
2. A client is admitted with a potassium level of 6.8 mEq/L. Which of the following nursing
actions is the highest priority?
A. Encourage the intake of orange juice and bananas
B. Obtain a 24-hour urine collection sample
C. Place the client on a continuous cardiac monitor
D. Administer a dose of spironolactone as ordered
Answer: C
Rationale: Hyperkalemia can cause lethal cardiac dysrhythmias, including ventricular
fibrillation or asystole. Continuous cardiac monitoring is essential to detect early changes
such as peaked T-waves or widened QRS complexes. The nurse must prioritize safety and
immediate assessment of cardiac rhythm before administering medications or collecting
urine.
3. The nurse is caring for a client with Type 1 Diabetes Mellitus who is diaphoretic, shaky, and
complaining of a headache. What should be the nurse’s first action?
A. Administer the scheduled dose of glargine insulin
B. Check the client’s capillary blood glucose level
C. Call the healthcare provider for a neurological consult
D. Provide the client with a high-protein snack
,Answer: B
Rationale: The symptoms described are classic signs of hypoglycemia, which requires
immediate verification and intervention. Checking the blood glucose level provides the data
needed to determine if the patient requires fast-acting carbohydrates. Prompt recognition
and treatment of hypoglycemia prevent progression to seizure or loss of consciousness.
4. A client returns from surgery following a total hip arthroplasty. Which position is most
appropriate for the nurse to maintain to prevent dislocation?
A. High Fowler’s position with knees flexed
B. Abduction of the affected hip using a pillow or wedge
C. Adduction of the affected leg across the midline
D. Complete bed rest in a prone position
Answer: B
Rationale: Maintaining hip abduction is crucial after a total hip replacement to keep the
femoral head securely within the acetabulum. An abduction pillow or wedge prevents the
legs from crossing the midline, which is a common cause of dislocation. The nurse should
also instruct the patient to avoid bending the hip more than 90 degrees.
5. Which of the following tasks is most appropriate for the RN to delegate to an unlicensed
assistive personnel (UAP)?
A. Assessing the breath sounds of a patient with a new chest tube
B. Providing discharge teaching for a patient with a new colostomy
C. Assisting a stable patient with ambulation for the first time post-op
D. Measuring and recording the output from a Foley catheter
Answer: D
Rationale: Measuring and recording output is a routine technical task that falls within the
scope of practice for a UAP. Assessment, teaching, and evaluating the first ambulation of a
post-operative patient are nursing responsibilities that require clinical judgment. Proper
delegation ensures that the RN can focus on complex clinical decisions and patient stability.
6. A nurse is assessing a client with chronic obstructive pulmonary disease (COPD). Which
finding should the nurse report immediately to the healthcare provider?
A. Increased use of accessory muscles and new onset confusion
B. SpO2 of 89% on 2L of oxygen via nasal cannula
C. A change in the color and consistency of sputum
D. Presence of a barrel chest and clubbing of fingers
, Answer: A
Rationale: New onset confusion and increased work of breathing are indicators of acute
respiratory failure or worsening hypercapnia. While a barrel chest and low SpO2 are
common in chronic COPD, acute neurological changes suggest hypoxia or CO2 narcosis.
Immediate intervention is required to stabilize the patient’s airway and oxygenation status.
7. A client with liver cirrhosis and ascites is prescribed lactulose. What is the primary
therapeutic goal of this medication?
A. To reduce the amount of fluid in the peritoneal cavity
B. To prevent the development of esophageal varices
C. To decrease the pressure within the portal venous system
D. To lower blood ammonia levels and improve mentation
Answer: D
Rationale: Lactulose is an osmotic laxative used to treat hepatic encephalopathy by
promoting the excretion of ammonia through the stool. It works by acidifying the colon,
which converts ammonia into ammonium, an ion that cannot be reabsorbed into the blood.
The effectiveness of the therapy is measured by a reduction in confusion and improved
neurological status.
8. An elderly client is admitted for dehydration. The nurse notes the client is confused and
attempting to pull out the IV line. Which is the best initial nursing action?
A. Apply bilateral wrist restraints immediately
B. Ask a family member or sitter to stay at the bedside
C. Request a prescription for a sedative medication
D. Inform the client that they cannot leave the hospital
Answer: B
Rationale: Using a sitter or family member is a less restrictive intervention than physical
or chemical restraints. The nurse should always attempt the least restrictive method first
to ensure patient safety while respecting autonomy. Restraints should only be used as a last
resort when all other safety measures have failed to protect the client.
9. A nurse is caring for a client who is post-operative day 2 from abdominal surgery. The client
reports sudden chest pain and shortness of breath. What is the nurse’s priority action?
A. Administer an ordered PRN dose of morphine
B. Perform a full head-to-toe physical assessment
C. Encourage the client to use the incentive spirometer
