Nu 310 Final Actual Exam Newest With Complete Questions And Correct Detailed Answers|
Brand New Version!
Question 1
Which of the following clinical findings would be the most significant reason to delay a patient’s
discharge from the hospital following a surgical procedure?
A) A reported pain level of 4/10 while walking
B) Inability to void independently since the surgery
C) A stable hemoglobin level of 8.0 g/dL
D) A resting heart rate of 100 beats per minute
E) A request for a final consultation with the dietitian
Correct Answer: B) Inability to void since surgery
Rationale: Postoperative urinary retention is a common but serious complication that must
be resolved before a patient is safe for discharge. It can lead to bladder distention and
potential renal reflux. While a hemoglobin of 8 or a heart rate of 100 requires monitoring,
they are often stable baselines for certain patients, whereas the inability to void is an acute
functional failure.
Question 2
A patient presents with a temperature of 101°F, HR 100, and RR 30. He is using accessory
muscles to breathe, and crackles are audible at the lung bases. What is the nurse's first priority?
A) Obtain a sputum sample and blood cultures
B) Administer oxygen to maintain O2 saturation >95%
C) Infuse a one-liter bolus of normal saline
D) Start the first dose of IV antibiotics
E) Perform a complete head-to-toe skin assessment
Correct Answer: B) Give him oxygen so his O2 sat is >95%
Rationale: According to the ABC (Airway, Breathing, Circulation) priority framework,
respiratory distress and hypoxia must be addressed immediately. Oxygen administration is
the most urgent intervention to stabilize the patient before moving on to diagnostic tests
(cultures) or curative treatments (antibiotics).
Question 3
While reviewing lab results, the nurse notes a patient has a serum potassium level of 6.0 mEq/L.
Which clinical finding should the nurse expect to assess?
A) Heart palpitations
B) Severe muscle spasms
C) Dark amber-colored urine
D) Extreme drowsiness
E) Hyperactive bowel sounds
Correct Answer: A) Heart palpitations
Rationale: Hyperkalemia (potassium > 5.0 mEq/L) significantly impacts cardiac electrical
, 2
conduction. It can lead to life-threatening dysrhythmias, such as peaked T-waves or
ventricular fibrillation. Patients often report these cardiac changes as palpitations or chest
discomfort.
Question 4
A patient is being discharged after receiving chemotherapy for Acute Myeloid Leukemia (AML).
Which finding must the patient be instructed to report to the provider immediately?
A) Mild nausea and one episode of vomiting
B) Muscle twitching and cramping
C) Generalized fatigue after light activity
D) Vertigo when changing from lying to sitting
E) A metallic taste in the mouth
Correct Answer: B) Muscle twitching and cramping
Rationale: Muscle twitching and cramping in a post-chemotherapy patient are hallmark
signs of electrolyte imbalances, specifically hyperkalemia or hypocalcemia, which are
associated with Tumor Lysis Syndrome. If left untreated, this can lead to acute renal failure
and cardiac arrest.
Question 5
What is typically the first clinical indicator of pneumonia in an 80-year-old male patient?
A) High fever and rigors (chills)
B) Altered mental status or confusion
C) Productive cough with green sputum
D) Sharp pleuritic chest pain
E) Increased respiratory rate of 20
Correct Answer: B) Altered mental status
Rationale: Older adults often present with "atypical" symptoms of infection. While younger
patients typically present with fever and cough, the elderly often exhibit sudden confusion,
lethargy, or altered mental status as the primary sign of pneumonia or a urinary tract
infection.
Question 6
A patient has a serum calcium level of 16 mg/dL. The nurse should monitor for which potential
complication?
A) Increased risk of falls
B) Acute kidney injury
C) Bacterial pneumonia
D) Severe heart palpitations
E) Increased bowel motility
Correct Answer: B) Acute kidney injury
Rationale: Severe hypercalcemia (calcium > 10.5 mg/dL) can lead to nephrocalcinosis and
, 3
renal vasoconstriction, which causes Acute Kidney Injury (AKI). It also causes an osmotic
diuresis, leading to dehydration, which further compromises renal function.
Question 7
Under which of the following circumstances would it be INCORRECT for a nurse to clamp a
chest tube?
A) While changing out the drainage system unit
B) While assessing the system for potential air leaks
C) While the patient is ambulating with physical therapy
D) While briefly lifting the system above the level of the chest during a turn
E) None of the above; it is always safe to clamp a chest tube
Correct Answer: C) When having the patient ambulate with PT
Rationale: A chest tube should never be clamped during ambulation or transport. Clamping
the tube prevents the escape of air or fluid from the pleural space, which can rapidly lead
to a tension pneumothorax, a life-threatening emergency.
Question 8
A patient develops Syndrome of Inappropriate Antidiuretic Hormone (SIADH) following
chemotherapy. What is the most critical risk for this patient?
A) Muscle cramps and twitching
B) Seizure-like activity
C) Cardiac palpitations
D) Anorexia and pallor
E) Severe hypertension
Correct Answer: B) Seizure like activity
Rationale: SIADH causes excessive water retention, which leads to dilutional hyponatremia.
When serum sodium levels drop significantly (typically < 120 mEq/L), brain cells swell
(cerebral edema), resulting in confusion, seizures, coma, and potentially death.
Question 9
A postoperative patient has an SpO2 of 95%, increased work of breathing, and fine crackles at
the lung bases. Which nursing intervention is most appropriate?
A) Apply a nasal cannula at 2L/min
B) Administer 125mL/hr of normal saline
C) Encourage the use of the incentive spirometer
D) Request an order for IV antibiotics
E) Place the patient in a prone position
Correct Answer: C) Have him use incentive spirometer
Rationale: Fine crackles and increased respiratory effort post-surgery are classic signs of
atelectasis (collapsed alveoli). The incentive spirometer (IS) promotes deep breathing and
, 4
alveolar expansion, which is the primary treatment for reversing atelectasis and preventing
pneumonia.
Question 10
Which of the following patients should the nurse evaluate first after the shift report?
A) A post-op patient reporting pain as 7/10
B) A patient with a DVT who is now complaining of shortness of breath
C) A patient with intermittent bubbling in the chest tube water seal
D) A patient with pneumonia and positive blood cultures
E) A patient scheduled for an elective cholecystectomy
Correct Answer: B) A patient with a DVT who is complaining of shortness of breath
Rationale: In a patient with a known Deep Vein Thrombosis (DVT), the sudden onset of
shortness of breath is highly suggestive of a Pulmonary Embolism (PE). This is a life-
threatening emergency that takes priority over stable pain or expected findings in other
patients.
Question 11
A patient with uncontrolled asthma is still short of breath after receiving an albuterol nebulizer.
What is the nurse's next expected action?
A) Perform STAT Pulmonary Function Tests (PFTs)
B) Administer IV Corticosteroids
C) Place the patient on continuous high-flow oxygen
D) Administer the first dose of IV antibiotics
E) Encourage the patient to lie flat and rest
Correct Answer: B) Give IV Steroids
Rationale: When a short-acting bronchodilator (Albuterol) fails to fully resolve an asthma
attack, the nurse must address the underlying airway inflammation. IV steroids (such as
methylprednisolone) are the standard next step to reduce inflammation and open the
airways.
Question 12
A patient arrives in the ED after a severe motor vehicle accident with HR 150, BP 90/50, and RR
18. What should the nurse perform first?
A) Obtain blood for a metabolic panel and electrolytes
B) Administer a STAT dose of IV potassium
) Administer IV opioids for pain
D) Document the vital signs in the chart
E) Call the patient's next of kin
Correct Answer: A) Take blood for electrolytes
Rationale: In severe trauma with tachycardia and hypotension (shock), electrolyte levels—
Brand New Version!
Question 1
Which of the following clinical findings would be the most significant reason to delay a patient’s
discharge from the hospital following a surgical procedure?
A) A reported pain level of 4/10 while walking
B) Inability to void independently since the surgery
C) A stable hemoglobin level of 8.0 g/dL
D) A resting heart rate of 100 beats per minute
E) A request for a final consultation with the dietitian
Correct Answer: B) Inability to void since surgery
Rationale: Postoperative urinary retention is a common but serious complication that must
be resolved before a patient is safe for discharge. It can lead to bladder distention and
potential renal reflux. While a hemoglobin of 8 or a heart rate of 100 requires monitoring,
they are often stable baselines for certain patients, whereas the inability to void is an acute
functional failure.
Question 2
A patient presents with a temperature of 101°F, HR 100, and RR 30. He is using accessory
muscles to breathe, and crackles are audible at the lung bases. What is the nurse's first priority?
A) Obtain a sputum sample and blood cultures
B) Administer oxygen to maintain O2 saturation >95%
C) Infuse a one-liter bolus of normal saline
D) Start the first dose of IV antibiotics
E) Perform a complete head-to-toe skin assessment
Correct Answer: B) Give him oxygen so his O2 sat is >95%
Rationale: According to the ABC (Airway, Breathing, Circulation) priority framework,
respiratory distress and hypoxia must be addressed immediately. Oxygen administration is
the most urgent intervention to stabilize the patient before moving on to diagnostic tests
(cultures) or curative treatments (antibiotics).
Question 3
While reviewing lab results, the nurse notes a patient has a serum potassium level of 6.0 mEq/L.
Which clinical finding should the nurse expect to assess?
A) Heart palpitations
B) Severe muscle spasms
C) Dark amber-colored urine
D) Extreme drowsiness
E) Hyperactive bowel sounds
Correct Answer: A) Heart palpitations
Rationale: Hyperkalemia (potassium > 5.0 mEq/L) significantly impacts cardiac electrical
, 2
conduction. It can lead to life-threatening dysrhythmias, such as peaked T-waves or
ventricular fibrillation. Patients often report these cardiac changes as palpitations or chest
discomfort.
Question 4
A patient is being discharged after receiving chemotherapy for Acute Myeloid Leukemia (AML).
Which finding must the patient be instructed to report to the provider immediately?
A) Mild nausea and one episode of vomiting
B) Muscle twitching and cramping
C) Generalized fatigue after light activity
D) Vertigo when changing from lying to sitting
E) A metallic taste in the mouth
Correct Answer: B) Muscle twitching and cramping
Rationale: Muscle twitching and cramping in a post-chemotherapy patient are hallmark
signs of electrolyte imbalances, specifically hyperkalemia or hypocalcemia, which are
associated with Tumor Lysis Syndrome. If left untreated, this can lead to acute renal failure
and cardiac arrest.
Question 5
What is typically the first clinical indicator of pneumonia in an 80-year-old male patient?
A) High fever and rigors (chills)
B) Altered mental status or confusion
C) Productive cough with green sputum
D) Sharp pleuritic chest pain
E) Increased respiratory rate of 20
Correct Answer: B) Altered mental status
Rationale: Older adults often present with "atypical" symptoms of infection. While younger
patients typically present with fever and cough, the elderly often exhibit sudden confusion,
lethargy, or altered mental status as the primary sign of pneumonia or a urinary tract
infection.
Question 6
A patient has a serum calcium level of 16 mg/dL. The nurse should monitor for which potential
complication?
A) Increased risk of falls
B) Acute kidney injury
C) Bacterial pneumonia
D) Severe heart palpitations
E) Increased bowel motility
Correct Answer: B) Acute kidney injury
Rationale: Severe hypercalcemia (calcium > 10.5 mg/dL) can lead to nephrocalcinosis and
, 3
renal vasoconstriction, which causes Acute Kidney Injury (AKI). It also causes an osmotic
diuresis, leading to dehydration, which further compromises renal function.
Question 7
Under which of the following circumstances would it be INCORRECT for a nurse to clamp a
chest tube?
A) While changing out the drainage system unit
B) While assessing the system for potential air leaks
C) While the patient is ambulating with physical therapy
D) While briefly lifting the system above the level of the chest during a turn
E) None of the above; it is always safe to clamp a chest tube
Correct Answer: C) When having the patient ambulate with PT
Rationale: A chest tube should never be clamped during ambulation or transport. Clamping
the tube prevents the escape of air or fluid from the pleural space, which can rapidly lead
to a tension pneumothorax, a life-threatening emergency.
Question 8
A patient develops Syndrome of Inappropriate Antidiuretic Hormone (SIADH) following
chemotherapy. What is the most critical risk for this patient?
A) Muscle cramps and twitching
B) Seizure-like activity
C) Cardiac palpitations
D) Anorexia and pallor
E) Severe hypertension
Correct Answer: B) Seizure like activity
Rationale: SIADH causes excessive water retention, which leads to dilutional hyponatremia.
When serum sodium levels drop significantly (typically < 120 mEq/L), brain cells swell
(cerebral edema), resulting in confusion, seizures, coma, and potentially death.
Question 9
A postoperative patient has an SpO2 of 95%, increased work of breathing, and fine crackles at
the lung bases. Which nursing intervention is most appropriate?
A) Apply a nasal cannula at 2L/min
B) Administer 125mL/hr of normal saline
C) Encourage the use of the incentive spirometer
D) Request an order for IV antibiotics
E) Place the patient in a prone position
Correct Answer: C) Have him use incentive spirometer
Rationale: Fine crackles and increased respiratory effort post-surgery are classic signs of
atelectasis (collapsed alveoli). The incentive spirometer (IS) promotes deep breathing and
, 4
alveolar expansion, which is the primary treatment for reversing atelectasis and preventing
pneumonia.
Question 10
Which of the following patients should the nurse evaluate first after the shift report?
A) A post-op patient reporting pain as 7/10
B) A patient with a DVT who is now complaining of shortness of breath
C) A patient with intermittent bubbling in the chest tube water seal
D) A patient with pneumonia and positive blood cultures
E) A patient scheduled for an elective cholecystectomy
Correct Answer: B) A patient with a DVT who is complaining of shortness of breath
Rationale: In a patient with a known Deep Vein Thrombosis (DVT), the sudden onset of
shortness of breath is highly suggestive of a Pulmonary Embolism (PE). This is a life-
threatening emergency that takes priority over stable pain or expected findings in other
patients.
Question 11
A patient with uncontrolled asthma is still short of breath after receiving an albuterol nebulizer.
What is the nurse's next expected action?
A) Perform STAT Pulmonary Function Tests (PFTs)
B) Administer IV Corticosteroids
C) Place the patient on continuous high-flow oxygen
D) Administer the first dose of IV antibiotics
E) Encourage the patient to lie flat and rest
Correct Answer: B) Give IV Steroids
Rationale: When a short-acting bronchodilator (Albuterol) fails to fully resolve an asthma
attack, the nurse must address the underlying airway inflammation. IV steroids (such as
methylprednisolone) are the standard next step to reduce inflammation and open the
airways.
Question 12
A patient arrives in the ED after a severe motor vehicle accident with HR 150, BP 90/50, and RR
18. What should the nurse perform first?
A) Obtain blood for a metabolic panel and electrolytes
B) Administer a STAT dose of IV potassium
) Administer IV opioids for pain
D) Document the vital signs in the chart
E) Call the patient's next of kin
Correct Answer: A) Take blood for electrolytes
Rationale: In severe trauma with tachycardia and hypotension (shock), electrolyte levels—
