NUR280 Exam Questions with 100% Correct Answers Latest Graded
A+
Question:
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)
Answer:
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.
Question:
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 (d) using a broad base of support while transferring a client
Answer:
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.
Question:
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.
Answer:
,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.
Question:
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
Answer:
4. C. The management of a client following abdominal surgery is standard. The 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.
Question:
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
Answer:
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
Question:
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
Answer:
6. C. Consent for organ donation is given by a client's next of kin in the absence of an Advance
Directive
Question:
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 (d)
Congestive Heart Failure (CHF) whose pitting edema has increased to 2(+)
Answer:
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.
Question:
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
Answer:
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).
Question:
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
Answer:
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
Question:
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 (b)
Telling a client that you will put in a feeding tube if the client does not eat is an example of battery
(c) Telling a client with bipolar disorder who is suicidal that they have a right to refuse to take their
medications is an example of malpractice (d) Placing hands on a client who says "do not touch me"
, is an example of assault
Answer:
A. Putting a client in a geriatric chair with the lap tray in front of them restricts movement which
constitutes false imprisonment; choice B is an example of assault not battery; C is an example of
negligence not malpractice and D is an example of battery not assault. Safe Effective Care
Environment; Management of Care
Question:
The nurse from the pediatric unit has been temporarily assigned to the Emergency Department. It
would be most appropriate to assign that nurse to the client who (a) reports epigastric pain that
"feels like indigestion" (b) has back pain and a pulsating abdominal mass (c) is HIV+ reporting
vomiting and diarrhea (d) presents with lower abdominal pain and is six weeks pregnant
Answer:
11. C. Vomiting and diarrhea can be managed on a non-emergent basis; clients reporting
"indigestion" may be experiencing a cardiac event; clinical manifestations suggestive of abdominal
aortic aneurysm include abdominal mass and abdominal throbbing; the client who is 6 weeks
pregnant experiencing abdominal pain must be evaluated to rule out ectopic pregnancy which could
be life threatening. Safe Effective Care environment; Management of Care
Four clients recently returned to the unit following invasive diagnostic testing.
Question:
The nurse should immediately intervene if one of the clients: (a) reports blood tinged sputum
following a bronchoscopy (b) has decreased abdominal girth following paracentesis (c) reports a
headache following a lumbar puncture (d) is observed flexing and extending the legs two hours
after cardiac catheterization
Answer:
D. Following cardiac catheterization of the femoral artery, the client remains on bedrest for 2 to 6
hours with the affected leg straight and the head of the bed elevated to 30 degrees; blood tinged
sputum is an expected finding after bronchoscopy; removal of fluid from the peritoneal cavity as in
paracentesis will result in decreased abdominal girth; post lumbar puncture headache ranging from
mild to severe may appear a few hours to days following the procedure. Safe Effective Care
Environment; Management of Care
Question:
The nurse is made aware of the following situations. The nurse should first check the client who (a)
had a transurethral prostatectomy (TURP) and is reporting urinary dribbling two hours after the
indwelling catheter is removed (b) has cervical traction and is moving the legs by flexing and
A+
Question:
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)
Answer:
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.
Question:
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 (d) using a broad base of support while transferring a client
Answer:
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.
Question:
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.
Answer:
,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.
Question:
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
Answer:
4. C. The management of a client following abdominal surgery is standard. The 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.
Question:
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
Answer:
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
Question:
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
Answer:
6. C. Consent for organ donation is given by a client's next of kin in the absence of an Advance
Directive
Question:
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 (d)
Congestive Heart Failure (CHF) whose pitting edema has increased to 2(+)
Answer:
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.
Question:
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
Answer:
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).
Question:
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
Answer:
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
Question:
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 (b)
Telling a client that you will put in a feeding tube if the client does not eat is an example of battery
(c) Telling a client with bipolar disorder who is suicidal that they have a right to refuse to take their
medications is an example of malpractice (d) Placing hands on a client who says "do not touch me"
, is an example of assault
Answer:
A. Putting a client in a geriatric chair with the lap tray in front of them restricts movement which
constitutes false imprisonment; choice B is an example of assault not battery; C is an example of
negligence not malpractice and D is an example of battery not assault. Safe Effective Care
Environment; Management of Care
Question:
The nurse from the pediatric unit has been temporarily assigned to the Emergency Department. It
would be most appropriate to assign that nurse to the client who (a) reports epigastric pain that
"feels like indigestion" (b) has back pain and a pulsating abdominal mass (c) is HIV+ reporting
vomiting and diarrhea (d) presents with lower abdominal pain and is six weeks pregnant
Answer:
11. C. Vomiting and diarrhea can be managed on a non-emergent basis; clients reporting
"indigestion" may be experiencing a cardiac event; clinical manifestations suggestive of abdominal
aortic aneurysm include abdominal mass and abdominal throbbing; the client who is 6 weeks
pregnant experiencing abdominal pain must be evaluated to rule out ectopic pregnancy which could
be life threatening. Safe Effective Care environment; Management of Care
Four clients recently returned to the unit following invasive diagnostic testing.
Question:
The nurse should immediately intervene if one of the clients: (a) reports blood tinged sputum
following a bronchoscopy (b) has decreased abdominal girth following paracentesis (c) reports a
headache following a lumbar puncture (d) is observed flexing and extending the legs two hours
after cardiac catheterization
Answer:
D. Following cardiac catheterization of the femoral artery, the client remains on bedrest for 2 to 6
hours with the affected leg straight and the head of the bed elevated to 30 degrees; blood tinged
sputum is an expected finding after bronchoscopy; removal of fluid from the peritoneal cavity as in
paracentesis will result in decreased abdominal girth; post lumbar puncture headache ranging from
mild to severe may appear a few hours to days following the procedure. Safe Effective Care
Environment; Management of Care
Question:
The nurse is made aware of the following situations. The nurse should first check the client who (a)
had a transurethral prostatectomy (TURP) and is reporting urinary dribbling two hours after the
indwelling catheter is removed (b) has cervical traction and is moving the legs by flexing and
