NU 325 FINAL EXAM– QUESTIONS AND ANSWERS | VERIFIED
AND WELL DETAILED ANSWERS PLUS RATIONALES |
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1. A newly graduated registered nurse on a medical-surgical unit is assigned a client with
complex multisystem organ failure. The nurse feels overwhelmed and expresses concern
about patient safety to the charge nurse. What is the most appropriate action by the charge
nurse?
A. Reassign the client entirely to an experienced staff nurse without addressing the new
graduate's concerns.
B. Instruct the new graduate to independently manage the client to build clinical confidence
rapidly.
C. Pair the new graduate with an experienced preceptor to provide direct guidance and
collaborative care.
D. Report the new graduate's hesitation to the nursing supervisor as a failure of professional
competence.
ANSWER: C. Pair the new graduate with an experienced preceptor to provide direct
guidance and collaborative care.
Pairing a novice nurse with an experienced preceptor ensures patient safety while supporting
professional growth through mentorship and structured clinical guidance. Reassigning
without support avoids the learning opportunity, while independent management of complex
clients poses safety risks.
2. A nurse is reviewing the plan of care for an older adult client admitted with dehydration
and confusion. Which nursing intervention should be prioritized during the first 24 hours
of admission?
A. Restricting total oral and intravenous fluid intake to prevent rapid electrolyte shifts.
B. Implementing strict safety measures such as bed alarms and frequent reorientation while
initiating fluid resuscitation.
C. Applying soft wrist restraints continuously to prevent accidental removal of intravenous
lines.
D. Administering high-dose sedatives to control acute confusion and nighttime agitation.
,ANSWER: B. Implementing strict safety measures such as bed alarms and frequent
reorientation while initiating fluid resuscitation.
Dehydration frequently manifests as acute confusion in older adults, increasing fall risk.
Prioritizing non-restrictive safety interventions alongside rehydration addresses the root cause
of confusion while protecting the client from injury.
3. A nurse is preparing to administer a scheduled dose of digoxin to a client with heart
failure. Before administering the medication, which assessment finding requires the nurse
to withhold the dose and notify the primary healthcare provider?
A. Apical pulse rate of 54 beats per minute.
B. Blood pressure of 128/78 mmHg.
C. Serum potassium level of 4.2 mEq/L.
D. Respiratory rate of 16 breaths per minute.
ANSWER: A. Apical pulse rate of 54 beats per minute.
Digoxin has a negative chronotropic effect. An apical pulse below 60 beats per minute in an
adult client indicates potential toxicity and requires holding the medication and notifying the
provider. The remaining values are within normal limits.
4. A nurse is caring for a client who is prescribed warfarin therapy following a deep vein
thrombosis. Which dietary instruction is essential for the nurse to include in the discharge
teaching?
A. "Eliminate all green leafy vegetables entirely from your daily diet."
B. "Maintain a consistent, moderate intake of foods containing vitamin K without sudden drastic
changes."
C. "Increase your intake of garlic, ginger, and ginkgo biloba supplements to boost circulation."
D. "Double your dose of green vegetables whenever your international normalized ratio drops
below therapeutic range."
ANSWER: B. "Maintain a consistent, moderate intake of foods containing vitamin K
without sudden drastic changes."
Warfarin works by antagonizing vitamin K-dependent clotting factors. Sudden increases or
decreases in dietary vitamin K can destabilize therapeutic international normalized ratio
levels. Consistency is key rather than complete elimination.
,5. A nurse is assessing a client who has sustained a traumatic brain injury and exhibits
decerebrate posturing. How should the nurse recognize this physical finding?
A. Internal rotation and adduction of the arms with flexion of the elbows, wrists, and fingers.
B. Extension of the arms and legs, pronation of the arms, and plantar flexion of the feet.
C. Flaccid paralysis of all four extremities with absent deep tendon reflexes.
D. Unilateral jerking movements of the upper extremities progressing to generalized seizures.
ANSWER: B. Extension of the arms and legs, pronation of the arms, and plantar flexion of
the feet.
Decerebrate posturing is characterized by rigid extension of the upper and lower extremities,
internal rotation of the arms, pronation, and plantar flexion, indicating severe midbrain or
brainstem injury. Decorticate posturing involves flexion.
6. A nurse is caring for a client receiving intravenous heparin infusion for a pulmonary
embolism. The baseline activated partial thromboplastin time is 30 seconds. Which
laboratory value indicates that the heparin therapy is currently within the therapeutic
range?
A. 30 seconds
B. 45 seconds
C. 70 seconds
D. 110 seconds
ANSWER: C. 70 seconds
Therapeutic unfractionated heparin therapy typically targets an activated partial
thromboplastin time of 1.5 to 2.5 times the control value. With a control of 30 seconds, the
target range is 45 to 75 seconds, making 70 seconds appropriate.
7. A nurse is developing a care plan for a client with newly diagnosed type 1 diabetes
mellitus. Which pathophysiological concept should guide the nurse's baseline assessment?
A. Insulin resistance caused by downregulation of peripheral receptor sites.
B. Autoimmune destruction of pancreatic beta cells leading to absolute insulin deficiency.
C. Excessive hepatic glucose production triggered by dietary simple carbohydrate excess.
, D. Accelerated peripheral glucose uptake resulting from excessive physical exertion.
ANSWER: B. Autoimmune destruction of pancreatic beta cells leading to absolute insulin
deficiency.
Type 1 diabetes mellitus is characterized by an autoimmune-mediated destruction of the
insulin-producing beta cells in the islets of Langerhans, resulting in absolute insulin
deficiency requiring lifelong exogenous hormone replacement.
8. A nurse is caring for a client with chronic obstructive pulmonary disease experiencing
acute dyspnea. Which positioning technique should the nurse assist the client to assume?
A. Flat supine position with a single low pillow under the head.
B. High Fowler's position leaning slightly forward over a bedside table.
C. Trendelenburg position with the foot of the bed elevated 30 degrees.
D. Left lateral sims position with the upper knee flexed toward the chest.
ANSWER: B. High Fowler's position leaning slightly forward over a bedside table.
Leaning forward in a high Fowler's position (orthopneic position) fixes the shoulder girdle,
allowing accessory muscles of respiration to assist with chest expansion and relieve dyspnea in
clients with chronic respiratory disease.
9. A nurse is reviewing the medical record of a client scheduled for a diagnostic procedure
requiring intravenous iodinated contrast dye. Which home medication finding necessitates
immediate consultation with the physician?
A. Metformin
B. Lisinopril
C. Atorvastatin
D. Levothyroxine
ANSWER: A. Metformin
Metformin must be temporarily withheld before and for 48 hours after the administration of
iodinated contrast media to prevent lactic acidosis caused by potential contrast-induced acute
kidney injury.
10. A nurse is assessing an older adult client for early signs of delirium versus dementia.
Which clinical feature is most characteristic of delirium?
AND WELL DETAILED ANSWERS PLUS RATIONALES |
GUARANTEED PASS | LATEST EXAM UPDATE | EXAM PREP |
STUDY GUIDE | PRACTICE TEST| DOWNLOAD INSTANT PDF
1. A newly graduated registered nurse on a medical-surgical unit is assigned a client with
complex multisystem organ failure. The nurse feels overwhelmed and expresses concern
about patient safety to the charge nurse. What is the most appropriate action by the charge
nurse?
A. Reassign the client entirely to an experienced staff nurse without addressing the new
graduate's concerns.
B. Instruct the new graduate to independently manage the client to build clinical confidence
rapidly.
C. Pair the new graduate with an experienced preceptor to provide direct guidance and
collaborative care.
D. Report the new graduate's hesitation to the nursing supervisor as a failure of professional
competence.
ANSWER: C. Pair the new graduate with an experienced preceptor to provide direct
guidance and collaborative care.
Pairing a novice nurse with an experienced preceptor ensures patient safety while supporting
professional growth through mentorship and structured clinical guidance. Reassigning
without support avoids the learning opportunity, while independent management of complex
clients poses safety risks.
2. A nurse is reviewing the plan of care for an older adult client admitted with dehydration
and confusion. Which nursing intervention should be prioritized during the first 24 hours
of admission?
A. Restricting total oral and intravenous fluid intake to prevent rapid electrolyte shifts.
B. Implementing strict safety measures such as bed alarms and frequent reorientation while
initiating fluid resuscitation.
C. Applying soft wrist restraints continuously to prevent accidental removal of intravenous
lines.
D. Administering high-dose sedatives to control acute confusion and nighttime agitation.
,ANSWER: B. Implementing strict safety measures such as bed alarms and frequent
reorientation while initiating fluid resuscitation.
Dehydration frequently manifests as acute confusion in older adults, increasing fall risk.
Prioritizing non-restrictive safety interventions alongside rehydration addresses the root cause
of confusion while protecting the client from injury.
3. A nurse is preparing to administer a scheduled dose of digoxin to a client with heart
failure. Before administering the medication, which assessment finding requires the nurse
to withhold the dose and notify the primary healthcare provider?
A. Apical pulse rate of 54 beats per minute.
B. Blood pressure of 128/78 mmHg.
C. Serum potassium level of 4.2 mEq/L.
D. Respiratory rate of 16 breaths per minute.
ANSWER: A. Apical pulse rate of 54 beats per minute.
Digoxin has a negative chronotropic effect. An apical pulse below 60 beats per minute in an
adult client indicates potential toxicity and requires holding the medication and notifying the
provider. The remaining values are within normal limits.
4. A nurse is caring for a client who is prescribed warfarin therapy following a deep vein
thrombosis. Which dietary instruction is essential for the nurse to include in the discharge
teaching?
A. "Eliminate all green leafy vegetables entirely from your daily diet."
B. "Maintain a consistent, moderate intake of foods containing vitamin K without sudden drastic
changes."
C. "Increase your intake of garlic, ginger, and ginkgo biloba supplements to boost circulation."
D. "Double your dose of green vegetables whenever your international normalized ratio drops
below therapeutic range."
ANSWER: B. "Maintain a consistent, moderate intake of foods containing vitamin K
without sudden drastic changes."
Warfarin works by antagonizing vitamin K-dependent clotting factors. Sudden increases or
decreases in dietary vitamin K can destabilize therapeutic international normalized ratio
levels. Consistency is key rather than complete elimination.
,5. A nurse is assessing a client who has sustained a traumatic brain injury and exhibits
decerebrate posturing. How should the nurse recognize this physical finding?
A. Internal rotation and adduction of the arms with flexion of the elbows, wrists, and fingers.
B. Extension of the arms and legs, pronation of the arms, and plantar flexion of the feet.
C. Flaccid paralysis of all four extremities with absent deep tendon reflexes.
D. Unilateral jerking movements of the upper extremities progressing to generalized seizures.
ANSWER: B. Extension of the arms and legs, pronation of the arms, and plantar flexion of
the feet.
Decerebrate posturing is characterized by rigid extension of the upper and lower extremities,
internal rotation of the arms, pronation, and plantar flexion, indicating severe midbrain or
brainstem injury. Decorticate posturing involves flexion.
6. A nurse is caring for a client receiving intravenous heparin infusion for a pulmonary
embolism. The baseline activated partial thromboplastin time is 30 seconds. Which
laboratory value indicates that the heparin therapy is currently within the therapeutic
range?
A. 30 seconds
B. 45 seconds
C. 70 seconds
D. 110 seconds
ANSWER: C. 70 seconds
Therapeutic unfractionated heparin therapy typically targets an activated partial
thromboplastin time of 1.5 to 2.5 times the control value. With a control of 30 seconds, the
target range is 45 to 75 seconds, making 70 seconds appropriate.
7. A nurse is developing a care plan for a client with newly diagnosed type 1 diabetes
mellitus. Which pathophysiological concept should guide the nurse's baseline assessment?
A. Insulin resistance caused by downregulation of peripheral receptor sites.
B. Autoimmune destruction of pancreatic beta cells leading to absolute insulin deficiency.
C. Excessive hepatic glucose production triggered by dietary simple carbohydrate excess.
, D. Accelerated peripheral glucose uptake resulting from excessive physical exertion.
ANSWER: B. Autoimmune destruction of pancreatic beta cells leading to absolute insulin
deficiency.
Type 1 diabetes mellitus is characterized by an autoimmune-mediated destruction of the
insulin-producing beta cells in the islets of Langerhans, resulting in absolute insulin
deficiency requiring lifelong exogenous hormone replacement.
8. A nurse is caring for a client with chronic obstructive pulmonary disease experiencing
acute dyspnea. Which positioning technique should the nurse assist the client to assume?
A. Flat supine position with a single low pillow under the head.
B. High Fowler's position leaning slightly forward over a bedside table.
C. Trendelenburg position with the foot of the bed elevated 30 degrees.
D. Left lateral sims position with the upper knee flexed toward the chest.
ANSWER: B. High Fowler's position leaning slightly forward over a bedside table.
Leaning forward in a high Fowler's position (orthopneic position) fixes the shoulder girdle,
allowing accessory muscles of respiration to assist with chest expansion and relieve dyspnea in
clients with chronic respiratory disease.
9. A nurse is reviewing the medical record of a client scheduled for a diagnostic procedure
requiring intravenous iodinated contrast dye. Which home medication finding necessitates
immediate consultation with the physician?
A. Metformin
B. Lisinopril
C. Atorvastatin
D. Levothyroxine
ANSWER: A. Metformin
Metformin must be temporarily withheld before and for 48 hours after the administration of
iodinated contrast media to prevent lactic acidosis caused by potential contrast-induced acute
kidney injury.
10. A nurse is assessing an older adult client for early signs of delirium versus dementia.
Which clinical feature is most characteristic of delirium?
