N261 Exam 3 Actual Exam V1 | N261 Nursing (N261 Exam 3) |
University of California, Los Angeles
1. A 68-year-old patient with heart failure is being discharged on Furosemide (Lasix). Which
statement by the patient indicates a need for further teaching regarding medication safety?
A. I should limit my intake of bananas and orange juice.
B. I will weigh myself every morning before breakfast.
C. I will call the doctor if I feel dizzy when standing up.
D. I will take my medication early in the day.
Answer: A
Rationale: Furosemide is a loop diuretic that causes the loss of potassium, so patients
should be encouraged to eat potassium-rich foods like bananas rather than limit them.
Weight monitoring is essential for heart failure management to track fluid retention.
Orthostatic hypotension is a common side effect of diuretics, so reporting dizziness is
appropriate for safety.
2. A patient is admitted with Diabetic Ketoacidosis (DKA). The nurse notes a blood glucose of
450 mg/dL and a potassium level of 3.2 mEq/L. Which action should the nurse take first?
A. Start a regular insulin intravenous infusion.
B. Administer a bolus of normal saline.
C. Notify the provider and anticipate potassium replacement.
D. Check the patient’s urine for ketones.
Answer: C
Rationale: In DKA management, insulin therapy should not be started if the potassium
level is below 3.3 mEq/L because insulin will further drive potassium into the cells,
potentially causing life-threatening arrhythmias. Fluid resuscitation is a priority, but
correcting the hypokalemia takes precedence before starting insulin. The nurse must
prioritize the serum potassium level to ensure the safety of subsequent insulin
administration.
3. A nurse is caring for a patient with Chronic Kidney Disease (CKD) who is scheduled for
hemodialysis. Which assessment finding is the most critical to report to the healthcare
provider?
A. Serum creatinine of 4.5 mg/dL.
B. Blood pressure of 150/90 mmHg before dialysis.
,C. Bilateral 2+ pitting edema in the lower extremities.
D. Absence of a thrill over the arteriovenous fistula.
Answer: D
Rationale: The absence of a thrill or bruit over an arteriovenous fistula indicates potential
clotting or obstruction, which is a medical emergency for a dialysis patient. While elevated
creatinine and edema are expected in CKD, the loss of vascular access prevents life-
sustaining treatment. The nurse must immediately report this to preserve the access site
and ensure the patient can receive dialysis.
4. During a multidisciplinary team meeting, a nurse advocates for a patient from a culture
that emphasizes collective decision-making. Which action best demonstrates culturally
competent care?
A. Insisting that the patient makes their own decision to maintain autonomy.
B. Allowing the family to be present and involved in all care discussions.
C. Restricting visitors to immediate family only during physician rounds.
D. Providing all educational materials in the patient’s native language only.
Answer: B
Rationale: Cultural competence involves recognizing that the Western ideal of individual
autonomy may not apply to all patients, many of whom value family-centered decision-
making. Involving the family in discussions respects the patient’s cultural values and
enhances the psychosocial support system. The nurse’s role is to facilitate this involvement
while ensuring the patient’s underlying needs and preferences are met.
5. A patient with a history of COPD is receiving oxygen therapy via nasal cannula at 2L/min.
Which finding requires the nurse’s immediate intervention?
A. SpO2 of 90% at rest.
B. The patient appears drowsy and difficult to arouse.
C. Respiratory rate of 22 breaths per minute.
D. Clubbing of the fingers.
Answer: B
Rationale: In patients with COPD, excessive oxygen administration can lead to CO2
retention and subsequent carbon dioxide narcosis, which manifests as somnolence or
decreased consciousness. An SpO2 of 90% is often acceptable for chronic lung disease, and
clubbing is a chronic finding. The change in mental status is an acute sign of respiratory
failure or acid-base imbalance that requires urgent assessment.
, 6. A patient is diagnosed with SIADH (Syndrome of Inappropriate Antidiuretic Hormone).
Which nursing intervention is most appropriate?
A. Implementing a strict fluid restriction.
B. Administering intravenous 0.45% Sodium Chloride.
C. Encouraging a fluid intake of at least 3 liters per day.
D. Assessing for signs of dehydration such as poor skin turgor.
Answer: A
Rationale: SIADH involves excessive secretion of ADH, leading to water retention and
dilutional hyponatremia. Restricting fluid intake is the primary intervention to prevent
further hemodilution and worsening of the electrolyte imbalance. Hypotonic solutions like
0.45% Saline would worsen the condition, and dehydration is the opposite of the clinical
presentation in SIADH.
7. A nurse is teaching a patient with Addison’s disease about their medication regimen.
Which instruction is vital for preventing an Addisonian crisis?
A. Stop taking the medication if you experience nausea or vomiting.
B. Take the medication once a week at the same time.
C. Double the dose if you are undergoing significant physical stress or surgery.
D. Limit your salt intake to prevent high blood pressure.
Answer: C
Rationale: Patients with Addison’s disease lack adequate cortisol and must increase their
steroid dosage during periods of stress, illness, or surgery to mimic the body’s natural
response. Abruptly stopping steroids can precipitate a life-threatening adrenal crisis.
Unlike patients with heart failure, Addison’s patients may actually need increased sodium
during periods of heat or heavy exercise.
8. A patient with a traumatic brain injury (TBI) has an intracranial pressure (ICP) of 22 mmHg.
Which nursing action is contraindicated?
A. Performing frequent endotracheal suctioning to clear secretions.
B. Elevating the head of the bed to 30 degrees.
C. Maintaining the patient’s neck in a neutral, midline position.
D. Grouping nursing activities to allow for rest periods.
Answer: A
Rationale: Endotracheal suctioning increases intrathoracic pressure and can trigger
coughing, both of which significantly elevate intracranial pressure. Suctioning should only
University of California, Los Angeles
1. A 68-year-old patient with heart failure is being discharged on Furosemide (Lasix). Which
statement by the patient indicates a need for further teaching regarding medication safety?
A. I should limit my intake of bananas and orange juice.
B. I will weigh myself every morning before breakfast.
C. I will call the doctor if I feel dizzy when standing up.
D. I will take my medication early in the day.
Answer: A
Rationale: Furosemide is a loop diuretic that causes the loss of potassium, so patients
should be encouraged to eat potassium-rich foods like bananas rather than limit them.
Weight monitoring is essential for heart failure management to track fluid retention.
Orthostatic hypotension is a common side effect of diuretics, so reporting dizziness is
appropriate for safety.
2. A patient is admitted with Diabetic Ketoacidosis (DKA). The nurse notes a blood glucose of
450 mg/dL and a potassium level of 3.2 mEq/L. Which action should the nurse take first?
A. Start a regular insulin intravenous infusion.
B. Administer a bolus of normal saline.
C. Notify the provider and anticipate potassium replacement.
D. Check the patient’s urine for ketones.
Answer: C
Rationale: In DKA management, insulin therapy should not be started if the potassium
level is below 3.3 mEq/L because insulin will further drive potassium into the cells,
potentially causing life-threatening arrhythmias. Fluid resuscitation is a priority, but
correcting the hypokalemia takes precedence before starting insulin. The nurse must
prioritize the serum potassium level to ensure the safety of subsequent insulin
administration.
3. A nurse is caring for a patient with Chronic Kidney Disease (CKD) who is scheduled for
hemodialysis. Which assessment finding is the most critical to report to the healthcare
provider?
A. Serum creatinine of 4.5 mg/dL.
B. Blood pressure of 150/90 mmHg before dialysis.
,C. Bilateral 2+ pitting edema in the lower extremities.
D. Absence of a thrill over the arteriovenous fistula.
Answer: D
Rationale: The absence of a thrill or bruit over an arteriovenous fistula indicates potential
clotting or obstruction, which is a medical emergency for a dialysis patient. While elevated
creatinine and edema are expected in CKD, the loss of vascular access prevents life-
sustaining treatment. The nurse must immediately report this to preserve the access site
and ensure the patient can receive dialysis.
4. During a multidisciplinary team meeting, a nurse advocates for a patient from a culture
that emphasizes collective decision-making. Which action best demonstrates culturally
competent care?
A. Insisting that the patient makes their own decision to maintain autonomy.
B. Allowing the family to be present and involved in all care discussions.
C. Restricting visitors to immediate family only during physician rounds.
D. Providing all educational materials in the patient’s native language only.
Answer: B
Rationale: Cultural competence involves recognizing that the Western ideal of individual
autonomy may not apply to all patients, many of whom value family-centered decision-
making. Involving the family in discussions respects the patient’s cultural values and
enhances the psychosocial support system. The nurse’s role is to facilitate this involvement
while ensuring the patient’s underlying needs and preferences are met.
5. A patient with a history of COPD is receiving oxygen therapy via nasal cannula at 2L/min.
Which finding requires the nurse’s immediate intervention?
A. SpO2 of 90% at rest.
B. The patient appears drowsy and difficult to arouse.
C. Respiratory rate of 22 breaths per minute.
D. Clubbing of the fingers.
Answer: B
Rationale: In patients with COPD, excessive oxygen administration can lead to CO2
retention and subsequent carbon dioxide narcosis, which manifests as somnolence or
decreased consciousness. An SpO2 of 90% is often acceptable for chronic lung disease, and
clubbing is a chronic finding. The change in mental status is an acute sign of respiratory
failure or acid-base imbalance that requires urgent assessment.
, 6. A patient is diagnosed with SIADH (Syndrome of Inappropriate Antidiuretic Hormone).
Which nursing intervention is most appropriate?
A. Implementing a strict fluid restriction.
B. Administering intravenous 0.45% Sodium Chloride.
C. Encouraging a fluid intake of at least 3 liters per day.
D. Assessing for signs of dehydration such as poor skin turgor.
Answer: A
Rationale: SIADH involves excessive secretion of ADH, leading to water retention and
dilutional hyponatremia. Restricting fluid intake is the primary intervention to prevent
further hemodilution and worsening of the electrolyte imbalance. Hypotonic solutions like
0.45% Saline would worsen the condition, and dehydration is the opposite of the clinical
presentation in SIADH.
7. A nurse is teaching a patient with Addison’s disease about their medication regimen.
Which instruction is vital for preventing an Addisonian crisis?
A. Stop taking the medication if you experience nausea or vomiting.
B. Take the medication once a week at the same time.
C. Double the dose if you are undergoing significant physical stress or surgery.
D. Limit your salt intake to prevent high blood pressure.
Answer: C
Rationale: Patients with Addison’s disease lack adequate cortisol and must increase their
steroid dosage during periods of stress, illness, or surgery to mimic the body’s natural
response. Abruptly stopping steroids can precipitate a life-threatening adrenal crisis.
Unlike patients with heart failure, Addison’s patients may actually need increased sodium
during periods of heat or heavy exercise.
8. A patient with a traumatic brain injury (TBI) has an intracranial pressure (ICP) of 22 mmHg.
Which nursing action is contraindicated?
A. Performing frequent endotracheal suctioning to clear secretions.
B. Elevating the head of the bed to 30 degrees.
C. Maintaining the patient’s neck in a neutral, midline position.
D. Grouping nursing activities to allow for rest periods.
Answer: A
Rationale: Endotracheal suctioning increases intrathoracic pressure and can trigger
coughing, both of which significantly elevate intracranial pressure. Suctioning should only
