NURS 495 Review Exam Questions With
Answers 100% Pass
A patient is admitted with tremors, cramps and spasms. Which lab value best supports
the patient's condition?
a. K+ 4.0
b. Mg+ 4.8
c. Na+ 135
d. Ca+ 6.5 - ANSWER d. Ca+ 6.5
Rationale: A and C are normal values for their respective electrolytes. High magnesium
is associated with respiratory depression
A patient is admitted with fluid overload. Which is a priority nursing action?
a. Listen to lungs
b. Check for hypertension
c. Monitor intake and output
d. Assess vital signs - ANSWER a. Listen to lungs
Rationale: B and D are saying the same thing, you are checking blood pressure. A is the
priority as we are concerned with pulmonary edema. This follows the ABC model for
prioritization.
The nurse assesses a patient with pneumonia and observes the patient is experiencing
shortness of breath with a pulse ox of 90%. Which action should the nurse take first?
a. Notify the doctor
b. Increase the head of the bed
c. Order a chest X-ray to assess for degree of pneumonia
,d. Check the patient's respiratory rate and lungs sounds - ANSWER b. Increase the head
of the bed
Rationale: The patient is having problems with breathing and oxygenation. The first
action should be doing something to help improve the condition. We would notify the
doctor after providing interventions. The other options are delaying treatment.
The physician orders a paracentesis. Which instructions immediately before the
procedure is most appropriate by the nurse?
a. Instruct the patient to void
b. Administer a laxative
c. Hold all patient medications
d. Administer an enema - ANSWER a. Instruct the patient to void
Rationale: A paracentesis involves draining fluid from the abdomen. If the patient
doesn't void prior to the procedure, there is a risk of puncturing the bladder.
The patient with cardiac disease has the following serum lab results: potassium 4.5
meq/L, blood glucose of 150 mg/dl, increased CK-MB, BUN is 10, LDL is 180 and urine
specific gravity is 1.030. Which actions are the most appropriate by the nurse?
a. Keep in bed and assess for chest pain
b. Recommend a low fat diet and encourage exercise
c. Place the patient in Semi-Fowler's position and increase the patient's fluids
d. Repeat blood sugar and notify the doctor - ANSWER a. Keep in bed and assess for
chest pain
Rationale: CK-MB is a cardiac enzyme that detects MI. This is the most concerning
abnormal value. Keep the patient in bed to decrease oxygen demand.
A nurse is assigned to care for the patient scheduled for a renal biopsy. Which lab is of
,immediate concern?
a. BUN:40 mg/dl
b. Serum creatinine: 3.0 mg/dl
c. Prothrombin time 20 seconds
d. Potassium: 4.9 mEq/L - ANSWER c. Prothrombin time 20 seconds
Rationale: Although A and B are abnormal values, they are expected in a patient
undergoing a renal biopsy. PTT level is elevated so the patient would be at increased
risk for bleeding with the procedure.
The patient is brought into the emergency room complaining of chest pain. The vitals
signs are BP: 150/90, Pulse: 88, resp. rate: 20. The nurse administers nitroglycerin 0.4
mg SL. To evaluate the effectiveness of this medication, the nurse assesses for the relief
of chest pain and expects to note which change in vital signs?
a. BP 160/100, P 120, RR 16
b. BP 150/90, P 70, RR 24
c. BP 100/60, P 92, RR 20
d. BP 100/60, P 70, RR 24 - ANSWER c. BP 100/60, P 92, RR 20
Rationale: Remember that with the administration of nitro, we always check the BP
because we expect it to drop. When blood pressure drops, the heart rate increases to
compensate.
The nurse determines an IV site is red along the course of the vein and is slightly
swollen. The patient denies pain and refuses an IV start because of "terrible veins."
Which action is most appropriate by the nurse?
a. Explain since IV is essential, it will not be removed unless an new one is inserted.
b. Explain the IV catheter must be removed and the patient can refuse a new catheter
, insertion
c. Maintain the IV catheter and notify the health care provider
d. Recheck the IV in 30 minutes and document the patient wishes. - ANSWER b. Explain
the IV catheter must be removed and the patient can refuse a new catheter insertion
Rationale: The patient is experiencing phlebitis. Remember that infiltrations are cool to
touch.
A patient is receiving a loop diuretic. Which foods should the nurse encourage the
patient to consume? Select all that apply
a. Angel food cake
b. Banana
c. Dried fruit
d. Orange juice
e. Hot Peppers - ANSWER b, c, and d
Rationale: Loop diuretics (like Lasix) are not potassium-sparing so the patient will need
to consume foods high in potassium.
Which food should the nurse teach a client with heart failure to limit when following a 2-g
sodium diet?
a. Apple
b. Canned tomato juice
c. Whole wheat bread
d. Hamburger - ANSWER b. Canned tomato juice
Rationale: Anything canned is usually high in salt.
Answers 100% Pass
A patient is admitted with tremors, cramps and spasms. Which lab value best supports
the patient's condition?
a. K+ 4.0
b. Mg+ 4.8
c. Na+ 135
d. Ca+ 6.5 - ANSWER d. Ca+ 6.5
Rationale: A and C are normal values for their respective electrolytes. High magnesium
is associated with respiratory depression
A patient is admitted with fluid overload. Which is a priority nursing action?
a. Listen to lungs
b. Check for hypertension
c. Monitor intake and output
d. Assess vital signs - ANSWER a. Listen to lungs
Rationale: B and D are saying the same thing, you are checking blood pressure. A is the
priority as we are concerned with pulmonary edema. This follows the ABC model for
prioritization.
The nurse assesses a patient with pneumonia and observes the patient is experiencing
shortness of breath with a pulse ox of 90%. Which action should the nurse take first?
a. Notify the doctor
b. Increase the head of the bed
c. Order a chest X-ray to assess for degree of pneumonia
,d. Check the patient's respiratory rate and lungs sounds - ANSWER b. Increase the head
of the bed
Rationale: The patient is having problems with breathing and oxygenation. The first
action should be doing something to help improve the condition. We would notify the
doctor after providing interventions. The other options are delaying treatment.
The physician orders a paracentesis. Which instructions immediately before the
procedure is most appropriate by the nurse?
a. Instruct the patient to void
b. Administer a laxative
c. Hold all patient medications
d. Administer an enema - ANSWER a. Instruct the patient to void
Rationale: A paracentesis involves draining fluid from the abdomen. If the patient
doesn't void prior to the procedure, there is a risk of puncturing the bladder.
The patient with cardiac disease has the following serum lab results: potassium 4.5
meq/L, blood glucose of 150 mg/dl, increased CK-MB, BUN is 10, LDL is 180 and urine
specific gravity is 1.030. Which actions are the most appropriate by the nurse?
a. Keep in bed and assess for chest pain
b. Recommend a low fat diet and encourage exercise
c. Place the patient in Semi-Fowler's position and increase the patient's fluids
d. Repeat blood sugar and notify the doctor - ANSWER a. Keep in bed and assess for
chest pain
Rationale: CK-MB is a cardiac enzyme that detects MI. This is the most concerning
abnormal value. Keep the patient in bed to decrease oxygen demand.
A nurse is assigned to care for the patient scheduled for a renal biopsy. Which lab is of
,immediate concern?
a. BUN:40 mg/dl
b. Serum creatinine: 3.0 mg/dl
c. Prothrombin time 20 seconds
d. Potassium: 4.9 mEq/L - ANSWER c. Prothrombin time 20 seconds
Rationale: Although A and B are abnormal values, they are expected in a patient
undergoing a renal biopsy. PTT level is elevated so the patient would be at increased
risk for bleeding with the procedure.
The patient is brought into the emergency room complaining of chest pain. The vitals
signs are BP: 150/90, Pulse: 88, resp. rate: 20. The nurse administers nitroglycerin 0.4
mg SL. To evaluate the effectiveness of this medication, the nurse assesses for the relief
of chest pain and expects to note which change in vital signs?
a. BP 160/100, P 120, RR 16
b. BP 150/90, P 70, RR 24
c. BP 100/60, P 92, RR 20
d. BP 100/60, P 70, RR 24 - ANSWER c. BP 100/60, P 92, RR 20
Rationale: Remember that with the administration of nitro, we always check the BP
because we expect it to drop. When blood pressure drops, the heart rate increases to
compensate.
The nurse determines an IV site is red along the course of the vein and is slightly
swollen. The patient denies pain and refuses an IV start because of "terrible veins."
Which action is most appropriate by the nurse?
a. Explain since IV is essential, it will not be removed unless an new one is inserted.
b. Explain the IV catheter must be removed and the patient can refuse a new catheter
, insertion
c. Maintain the IV catheter and notify the health care provider
d. Recheck the IV in 30 minutes and document the patient wishes. - ANSWER b. Explain
the IV catheter must be removed and the patient can refuse a new catheter insertion
Rationale: The patient is experiencing phlebitis. Remember that infiltrations are cool to
touch.
A patient is receiving a loop diuretic. Which foods should the nurse encourage the
patient to consume? Select all that apply
a. Angel food cake
b. Banana
c. Dried fruit
d. Orange juice
e. Hot Peppers - ANSWER b, c, and d
Rationale: Loop diuretics (like Lasix) are not potassium-sparing so the patient will need
to consume foods high in potassium.
Which food should the nurse teach a client with heart failure to limit when following a 2-g
sodium diet?
a. Apple
b. Canned tomato juice
c. Whole wheat bread
d. Hamburger - ANSWER b. Canned tomato juice
Rationale: Anything canned is usually high in salt.
