NUR280 EXAM QUESTIONS AND
ANSWERS. VERIFIED 2025/2026.
The nurse is reviewing medical prescriptions for newly admitted clients. It
would be a priority for the nurse to follow up with the physician if a client with
(a) a potassium level of 4.5mEq/L has Kayexalate (sodium polystyrene)
prescribed
(b) a Dilantin (phenytoin) level of 8 mcg/ml is placed on seizure precautions
(c) sensitivity to Aspirin (acetylsalicylic acid) is prescribed Tylenol (acetaminophen)
(d) sensitivity to Penicillin is prescribed Zithromax (azithromycin) - ANS 1. A. The normal
potassium level is 3.5 - 5.0 mEq/L. Giving Kayexalate in this situation may cause the client to lose
potassium, causing hypokalemia, therefore the drug is not indicated; the therapeutic level for
Dilantin is 10 - 20 mcg/ml, a level of 8 is sub therapeutic thereby increasing the risk of seizure
activity. Acetaminophen can be safely prescribed to clients with ASA sensitivity. Azithromycin
(Zithromax) can be safely prescribed for clients with sensitivity to Penicillin.
The nurse should intervene if the nurse notes a staff member
(a) obtaining a clients consent prior to their operative procedure after receiving
Ativan (lorazepam)
(b) placing a client on the affected side following surgical repair of a retinal
detachment
(c) handling a wet cast with the palms of the hands
1 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
, (d) using a broad base of support while transferring a client - ANS 2. A. Informed consent,
explanation and decision making must occur before sedation is given; therapeutic interventions
for retinal detachment include bedrest with the area of detachment in a dependent position to
promote healing; the cast should be handled with the palms of the hands while wet to prevent
denting; a broad base of support is used during transfers to prevent muscle injury.
The community health nurse is caring for the following clients. It would be a
priority for the nurse to initiate a multidisciplinary conference for the client who
is
(a) 12 years old with Autism who is starting a new school and recently had a
URI (upper respiratory tract infection)
(b) 16 years old, has type 1 Diabetes Mellitus, is unemployed and had a recent
Hemoglobin A1c of 13%
(c) 52 years old, with Myasthenia Gravis, recently prescribed Mestinon (pyridostigmine) and
employed as a mail carrier
(d) 70 years old, has schizophrenia, lives alone and reports hearing
non threatening voices. - ANS 3. B. An adolescent with uncontrolled Diabetes Mellitus would
require the greatest number of disciplines (multidisciplinary) to manage their care i.e. Medicine,
Nursing, Social Work, Nutritionist; the other choices do not require as many providers of care to
meet their needs.
The nurse from the postpartum unit has been temporarily assigned to the
medical surgical unit. It would be most appropriate to assign this nurse to the
client who
(a) has returned from right total hip replacement surgery four hours ago
(b) is being observed for increased intracranial pressure
(c) had surgery two hours ago to remove the appendix
(d) is two weeks post partum being maintained on a mechanical ventilator for respiratory failure
- ANS 4. C. The management of a client following abdominal surgery is standard. The
2 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
,postpartum nurse routinely cares for mothers following caesarean section; therefore it is
appropriate to assign this client; The other choices are not appropriate to assign to this nurse.
The nurse in a well baby clinic has assessed several children today. It would
be a priority for the nurse to suggest follow up for the child who is
(a) 2 months old with a positive babinski reflex
(b) 5 months old and does not hold their own bottle
(c) 10 months old who cries around strangers
(d) 18 months old who needs support while ambulating - ANS 5. D. A child experiencing
normal growth and development should be ambulating independently by 12 months; the
Babinski reflex disappears after 2 years of age; an infant typically holds their own bottle by 6
months; stranger anxiety usually develops at approximately 7 months
The nurse is caring for a mechanically ventilated client who was declared brain
dead. An Advance Directive is not documented on the medical record. It
would be most appropriate to obtain consent 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 - ANS 6. C. Consent for organ donation is given by a client's
next of kin in the absence of an Advance Directive
The nurse has received report on four clients. The nurse should first
assess the client who has:
(a) Chronic Obstructive Pulmonary Disease (COPD) with a pulse oximetry reading of 90%
(b) Parkinson's Disease and is demanding to leave the hospital against medical advice (AMA)
(c) been admitted with suspected Guillian Barre Syndrome and has begun plasmapheresis
therapy
3 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
, (d) Congestive Heart Failure (CHF) whose pitting edema has increased to 2(+) - ANS 7. C. The
client admitted with Guillain-Barre' Syndrome should be assessed first because of the possibility
of rapid progression of this illness and neuromuscular respiratory failure; clients with COPD are
likely to have pulse oximetry readings of 90% related to chronic hypoxia; this client along with
the other two choices are important, but not the priority.
It would be appropriate to assign which of these tasks to the CNA?
(a) Feeding a client who is experiencing dysphagia
(b) One-on-one client observation for safety
(c) Removal of an indwelling catheter
(d) Performing a simple dressing change - ANS B. The Certified Nursing Assistant may be
assigned to a client that requires one- to-one observation for safety; the other choices require
skilled nursing intervention by a LPN (Licensed Practical Nurse) or RN (Registered Nurse).
The nurse should intervene if a staff member is observed:
(a) discussing a client's diagnosis with visiting family members
(b) collaborating with another nurse to review a prescription for blood transfusion
(c) interrupting other staff members discussing a client in the cafeteria
(d) reviewing a clients lab values with the nutritionist - ANS 9. A. To maintain confidentiality
the nurse should not discuss the client's diagnosis with family members; it is advisable that two
nurses review the prescription for blood transfusion to identify the client, blood type, Rh factor,
expiration date and the blood numbers; interrupting staff members discussing a client in a
public place should be done to maintain client confidentiality; collaborating with the nutritionist
is an appropriate nursing intervention. Safe Effective Care Environment; Management of Care
The nurse is preparing a staff presentation on legal and ethical issues in nursing. The nurse
would be correct to include which of the following examples?
(a) Putting a client in a geriatric chair with the lap tray in front of the client in the day room to
watch television is false imprisonment
4 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
ANSWERS. VERIFIED 2025/2026.
The nurse is reviewing medical prescriptions for newly admitted clients. It
would be a priority for the nurse to follow up with the physician if a client with
(a) a potassium level of 4.5mEq/L has Kayexalate (sodium polystyrene)
prescribed
(b) a Dilantin (phenytoin) level of 8 mcg/ml is placed on seizure precautions
(c) sensitivity to Aspirin (acetylsalicylic acid) is prescribed Tylenol (acetaminophen)
(d) sensitivity to Penicillin is prescribed Zithromax (azithromycin) - ANS 1. A. The normal
potassium level is 3.5 - 5.0 mEq/L. Giving Kayexalate in this situation may cause the client to lose
potassium, causing hypokalemia, therefore the drug is not indicated; the therapeutic level for
Dilantin is 10 - 20 mcg/ml, a level of 8 is sub therapeutic thereby increasing the risk of seizure
activity. Acetaminophen can be safely prescribed to clients with ASA sensitivity. Azithromycin
(Zithromax) can be safely prescribed for clients with sensitivity to Penicillin.
The nurse should intervene if the nurse notes a staff member
(a) obtaining a clients consent prior to their operative procedure after receiving
Ativan (lorazepam)
(b) placing a client on the affected side following surgical repair of a retinal
detachment
(c) handling a wet cast with the palms of the hands
1 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
, (d) using a broad base of support while transferring a client - ANS 2. A. Informed consent,
explanation and decision making must occur before sedation is given; therapeutic interventions
for retinal detachment include bedrest with the area of detachment in a dependent position to
promote healing; the cast should be handled with the palms of the hands while wet to prevent
denting; a broad base of support is used during transfers to prevent muscle injury.
The community health nurse is caring for the following clients. It would be a
priority for the nurse to initiate a multidisciplinary conference for the client who
is
(a) 12 years old with Autism who is starting a new school and recently had a
URI (upper respiratory tract infection)
(b) 16 years old, has type 1 Diabetes Mellitus, is unemployed and had a recent
Hemoglobin A1c of 13%
(c) 52 years old, with Myasthenia Gravis, recently prescribed Mestinon (pyridostigmine) and
employed as a mail carrier
(d) 70 years old, has schizophrenia, lives alone and reports hearing
non threatening voices. - ANS 3. B. An adolescent with uncontrolled Diabetes Mellitus would
require the greatest number of disciplines (multidisciplinary) to manage their care i.e. Medicine,
Nursing, Social Work, Nutritionist; the other choices do not require as many providers of care to
meet their needs.
The nurse from the postpartum unit has been temporarily assigned to the
medical surgical unit. It would be most appropriate to assign this nurse to the
client who
(a) has returned from right total hip replacement surgery four hours ago
(b) is being observed for increased intracranial pressure
(c) had surgery two hours ago to remove the appendix
(d) is two weeks post partum being maintained on a mechanical ventilator for respiratory failure
- ANS 4. C. The management of a client following abdominal surgery is standard. The
2 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
,postpartum nurse routinely cares for mothers following caesarean section; therefore it is
appropriate to assign this client; The other choices are not appropriate to assign to this nurse.
The nurse in a well baby clinic has assessed several children today. It would
be a priority for the nurse to suggest follow up for the child who is
(a) 2 months old with a positive babinski reflex
(b) 5 months old and does not hold their own bottle
(c) 10 months old who cries around strangers
(d) 18 months old who needs support while ambulating - ANS 5. D. A child experiencing
normal growth and development should be ambulating independently by 12 months; the
Babinski reflex disappears after 2 years of age; an infant typically holds their own bottle by 6
months; stranger anxiety usually develops at approximately 7 months
The nurse is caring for a mechanically ventilated client who was declared brain
dead. An Advance Directive is not documented on the medical record. It
would be most appropriate to obtain consent 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 - ANS 6. C. Consent for organ donation is given by a client's
next of kin in the absence of an Advance Directive
The nurse has received report on four clients. The nurse should first
assess the client who has:
(a) Chronic Obstructive Pulmonary Disease (COPD) with a pulse oximetry reading of 90%
(b) Parkinson's Disease and is demanding to leave the hospital against medical advice (AMA)
(c) been admitted with suspected Guillian Barre Syndrome and has begun plasmapheresis
therapy
3 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
, (d) Congestive Heart Failure (CHF) whose pitting edema has increased to 2(+) - ANS 7. C. The
client admitted with Guillain-Barre' Syndrome should be assessed first because of the possibility
of rapid progression of this illness and neuromuscular respiratory failure; clients with COPD are
likely to have pulse oximetry readings of 90% related to chronic hypoxia; this client along with
the other two choices are important, but not the priority.
It would be appropriate to assign which of these tasks to the CNA?
(a) Feeding a client who is experiencing dysphagia
(b) One-on-one client observation for safety
(c) Removal of an indwelling catheter
(d) Performing a simple dressing change - ANS B. The Certified Nursing Assistant may be
assigned to a client that requires one- to-one observation for safety; the other choices require
skilled nursing intervention by a LPN (Licensed Practical Nurse) or RN (Registered Nurse).
The nurse should intervene if a staff member is observed:
(a) discussing a client's diagnosis with visiting family members
(b) collaborating with another nurse to review a prescription for blood transfusion
(c) interrupting other staff members discussing a client in the cafeteria
(d) reviewing a clients lab values with the nutritionist - ANS 9. A. To maintain confidentiality
the nurse should not discuss the client's diagnosis with family members; it is advisable that two
nurses review the prescription for blood transfusion to identify the client, blood type, Rh factor,
expiration date and the blood numbers; interrupting staff members discussing a client in a
public place should be done to maintain client confidentiality; collaborating with the nutritionist
is an appropriate nursing intervention. Safe Effective Care Environment; Management of Care
The nurse is preparing a staff presentation on legal and ethical issues in nursing. The nurse
would be correct to include which of the following examples?
(a) Putting a client in a geriatric chair with the lap tray in front of the client in the day room to
watch television is false imprisonment
4 @COPYRIGHT 2025/2026 ALLRIGHTS RESERVED.
