Nursing 110 test 5| 60 questions|
with complete solutions
Course
Nursing 110
1. A nurse is caring for a patient with hypovolemic shock. Which assessment finding requires
immediate intervention?
A. Urine output of 40 mL/hr
B. Blood pressure of 82/50 mmHg with altered mental status
C. Heart rate of 102 beats/min
D. Respiratory rate of 22 breaths/min
Answer: B. Blood pressure of 82/50 mmHg with altered mental status
Solution:
Hypovolemic shock causes inadequate tissue perfusion. Severe hypotension accompanied by
altered mental status indicates decreased cerebral perfusion and requires immediate fluid
resuscitation and rapid intervention.
2. Which electrolyte imbalance is most likely to cause peaked T waves on an ECG?
A. Hypokalemia
B. Hyperkalemia
C. Hyponatremia
D. Hypocalcemia
Answer: B. Hyperkalemia
Solution:
Hyperkalemia affects cardiac conduction and commonly produces tall peaked T waves, widened
QRS complexes, and may progress to life-threatening arrhythmias.
3. Which laboratory value indicates impaired kidney function?
A. Creatinine 3.0 mg/dL
B. Hemoglobin 14 g/dL
,C. Sodium 140 mEq/L
D. Potassium 4.2 mEq/L
Answer: A. Creatinine 3.0 mg/dL
Solution:
Normal serum creatinine is approximately 0.6–1.3 mg/dL. Elevated levels indicate decreased
renal filtration.
4. Which patient is at the greatest risk for developing pressure injuries?
A. Ambulatory patient with hypertension
B. Bedridden patient with poor nutrition
C. Patient with seasonal allergies
D. Patient receiving oral antibiotics
Answer: B. Bedridden patient with poor nutrition
Solution:
Immobility and poor nutritional status significantly increase pressure injury risk.
5. Which intervention helps prevent catheter-associated urinary tract infections (CAUTIs)?
A. Irrigate the catheter daily
B. Maintain a closed drainage system
C. Disconnect tubing frequently
D. Empty the drainage bag once weekly
Answer: B. Maintain a closed drainage system
Solution:
Maintaining a sterile, closed urinary drainage system reduces bacterial entry and infection risk.
6. Which assessment finding is expected in dehydration?
A. Bounding pulse
, B. Dry mucous membranes
C. Peripheral edema
D. Weight gain
Answer: B. Dry mucous membranes
Solution:
Dehydration commonly presents with dry mucous membranes, poor skin turgor, concentrated
urine, and hypotension.
7. Which patient should the nurse assess first?
A. Stable patient awaiting discharge
B. Patient reporting chest pain and shortness of breath
C. Patient requesting pain medication
D. Patient asking for a blanket
Answer: B. Patient reporting chest pain and shortness of breath
Solution:
Potential myocardial infarction or pulmonary embolism requires immediate assessment using
priority frameworks such as ABCs.
8. Which nursing action best prevents falls in hospitalized patients?
A. Raise all four side rails
B. Keep frequently used items within reach
C. Apply restraints routinely
D. Encourage patients to walk independently regardless of condition
Answer: B. Keep frequently used items within reach
Solution:
Reducing unnecessary reaching decreases fall risk while promoting patient independence.
9. Which oxygen delivery device provides the highest oxygen concentration?
with complete solutions
Course
Nursing 110
1. A nurse is caring for a patient with hypovolemic shock. Which assessment finding requires
immediate intervention?
A. Urine output of 40 mL/hr
B. Blood pressure of 82/50 mmHg with altered mental status
C. Heart rate of 102 beats/min
D. Respiratory rate of 22 breaths/min
Answer: B. Blood pressure of 82/50 mmHg with altered mental status
Solution:
Hypovolemic shock causes inadequate tissue perfusion. Severe hypotension accompanied by
altered mental status indicates decreased cerebral perfusion and requires immediate fluid
resuscitation and rapid intervention.
2. Which electrolyte imbalance is most likely to cause peaked T waves on an ECG?
A. Hypokalemia
B. Hyperkalemia
C. Hyponatremia
D. Hypocalcemia
Answer: B. Hyperkalemia
Solution:
Hyperkalemia affects cardiac conduction and commonly produces tall peaked T waves, widened
QRS complexes, and may progress to life-threatening arrhythmias.
3. Which laboratory value indicates impaired kidney function?
A. Creatinine 3.0 mg/dL
B. Hemoglobin 14 g/dL
,C. Sodium 140 mEq/L
D. Potassium 4.2 mEq/L
Answer: A. Creatinine 3.0 mg/dL
Solution:
Normal serum creatinine is approximately 0.6–1.3 mg/dL. Elevated levels indicate decreased
renal filtration.
4. Which patient is at the greatest risk for developing pressure injuries?
A. Ambulatory patient with hypertension
B. Bedridden patient with poor nutrition
C. Patient with seasonal allergies
D. Patient receiving oral antibiotics
Answer: B. Bedridden patient with poor nutrition
Solution:
Immobility and poor nutritional status significantly increase pressure injury risk.
5. Which intervention helps prevent catheter-associated urinary tract infections (CAUTIs)?
A. Irrigate the catheter daily
B. Maintain a closed drainage system
C. Disconnect tubing frequently
D. Empty the drainage bag once weekly
Answer: B. Maintain a closed drainage system
Solution:
Maintaining a sterile, closed urinary drainage system reduces bacterial entry and infection risk.
6. Which assessment finding is expected in dehydration?
A. Bounding pulse
, B. Dry mucous membranes
C. Peripheral edema
D. Weight gain
Answer: B. Dry mucous membranes
Solution:
Dehydration commonly presents with dry mucous membranes, poor skin turgor, concentrated
urine, and hypotension.
7. Which patient should the nurse assess first?
A. Stable patient awaiting discharge
B. Patient reporting chest pain and shortness of breath
C. Patient requesting pain medication
D. Patient asking for a blanket
Answer: B. Patient reporting chest pain and shortness of breath
Solution:
Potential myocardial infarction or pulmonary embolism requires immediate assessment using
priority frameworks such as ABCs.
8. Which nursing action best prevents falls in hospitalized patients?
A. Raise all four side rails
B. Keep frequently used items within reach
C. Apply restraints routinely
D. Encourage patients to walk independently regardless of condition
Answer: B. Keep frequently used items within reach
Solution:
Reducing unnecessary reaching decreases fall risk while promoting patient independence.
9. Which oxygen delivery device provides the highest oxygen concentration?
