N2261 Final Questions With Complete Solutions
1. A client had a pneumonectomy for a recent diagnosis with
lung cancer. Throughout the hospital stay the client has been
engaged in care and has met all discharge criteria. While
performing discharge teaching the nurse notices that the client is
downcast and withdrawn. Which action by the nurse is the most
appropriate?
a. Continue with the discharge teaching and organize
transportation home
b. Reassure client that feelings of depression are normal and will
resolve on their own
c. Notify the physician and recommend a referral to mental
health services
d. Explore the clients mental health by asking the client to
describe their emotional state Correct Answer D
1. A client is being admitted for suspected ectopic pregnancy.
Which of the following signs and symptoms would be a priority
concern for the nurse?
a. Hypotension
b. Urinary retention
c. Abdominal pain
d. Nausea Correct Answer A
1. A client is being admitted to the unit with chills, severe
abdominal pain, and increased and purulent vaginal discharge.
The nurse identifies this as which of the following diagnoses?
a. Ectopic pregnancy
b. Benign prostatic hyperplasia
c. Chronic pelvic pain syndrome
,d. Pelvic inflammatory disease Correct Answer D
1. A client is diagnosed with a lung abscess. Which of the
following is a true statement regarding this diagnosis?
a. Antibiotics are only required until symptoms resolve
b. A lung abscess almost always becomes a chronic condition
c. A lung abscess is when the pleural space becomes filled with
purulent exudate
d. Clindamycin is a standard treatment for a lung abscess
Correct Answer D
1. A client is in the post-anesthesia care unit (PACU). Upon
arrival to the PACU the clients VS are 130/72, heart rate (HR)
76, O296% RA, RR 17. The nurse reassesses the VS 15min later
and they are now BP 97/72, HR 82, O296% RA, RR 17. The
nurse identifies the priority action as:
a. Administer morphine 5mg IV as ordered prn
b. Assess for autonomic dysreflexia
c. Administer atropine as ordered prn to increase the HR
d. Increase the intravenous flow rate as ordered prn Correct
Answer D
1. A client is POD5 for a lung transplant. They have been
transferred from ICU to the surgical unit. Which statement(s)
describe(s) the management of a client following lung
transplantation? Select all that apply.
a. High flow oxygen by a non-rebreather mask
b. Monitor for low-grade fever, fatigue, and oxygen desaturation
c. Lifelong administration of their immuno-suppressant
medication
,d. Corticosteroids may be administered if signs of rejection arise
Correct Answer BCD
1. A client is receiving a kidney transplant. Which of the
following statements indicate that the client understood the pre-
op education?
a. I will have oliguria post-operatively
b. I will need to live a more sedentary lifestyle to prevent
exposure to infection
c. I will take immunosuppressive medication for the rest of my
life
d. I will need to monitor for signs and symptoms of hypothermia
and hypotension Correct Answer C
1. A client is told they will need elective surgery in 1 month.
What surgical phase are they now in?
a. Pre-hospital
b. Pre-operative
c. Intra-operative
d. Post-operative Correct Answer A
1. A client with advanced cirrhosis asks the nurse why his
abdomen is so swollen. The nurse's response is based on the
knowledge of which of the following?
a. A lack of clotting factors promotes the collection of blood in
the abdominal cavity.
b. Portal hypertension and hypoalbuminemia cause a fluid shift
into the peritoneal space.
c. Decreased peristalsis in the gastro-intestinal tract contributes
to gas formation and distension of the bowel.
, d. Bile salts in the blood irritate the peritoneal membranes,
causing edema and pocketing of fluid. Correct Answer B
1. A client with known cirrhosis has an elevated blood level of
indirect (unconjugated) bilirubin. Which of the following might
cause this finding?
a. The gallbladder is unable to contract to release stored bile.
b. Bilirubin is not being conjugated and excreted into the bile by
the liver.
c. The Kupffer cells in the liver are unable to remove bilirubin
from the blood.
d. There is an obstruction in the biliary tract preventing flow of
bile into the small intestine. Correct Answer B
1. A client with known peripheral artery disease is being
admitted to the medical unit. The client voices several
complaints. Which symptom is of greatest concern for the
nurse?
a. Anxiety
b. Leg pain at rest
c. Elevation pallor
d. Hairless leg Correct Answer B
1. A client with PAD is receiving discharge teaching. Which
statement would indicate the client understood the discharge
instructions? Select all that apply.
a. "I will avoid crossing my legs"
b. "I will inspect my feet daily"
c. "I will use compression stockings"
d. "I will continue with my smoking cessation program Correct
Answer ABD
1. A client had a pneumonectomy for a recent diagnosis with
lung cancer. Throughout the hospital stay the client has been
engaged in care and has met all discharge criteria. While
performing discharge teaching the nurse notices that the client is
downcast and withdrawn. Which action by the nurse is the most
appropriate?
a. Continue with the discharge teaching and organize
transportation home
b. Reassure client that feelings of depression are normal and will
resolve on their own
c. Notify the physician and recommend a referral to mental
health services
d. Explore the clients mental health by asking the client to
describe their emotional state Correct Answer D
1. A client is being admitted for suspected ectopic pregnancy.
Which of the following signs and symptoms would be a priority
concern for the nurse?
a. Hypotension
b. Urinary retention
c. Abdominal pain
d. Nausea Correct Answer A
1. A client is being admitted to the unit with chills, severe
abdominal pain, and increased and purulent vaginal discharge.
The nurse identifies this as which of the following diagnoses?
a. Ectopic pregnancy
b. Benign prostatic hyperplasia
c. Chronic pelvic pain syndrome
,d. Pelvic inflammatory disease Correct Answer D
1. A client is diagnosed with a lung abscess. Which of the
following is a true statement regarding this diagnosis?
a. Antibiotics are only required until symptoms resolve
b. A lung abscess almost always becomes a chronic condition
c. A lung abscess is when the pleural space becomes filled with
purulent exudate
d. Clindamycin is a standard treatment for a lung abscess
Correct Answer D
1. A client is in the post-anesthesia care unit (PACU). Upon
arrival to the PACU the clients VS are 130/72, heart rate (HR)
76, O296% RA, RR 17. The nurse reassesses the VS 15min later
and they are now BP 97/72, HR 82, O296% RA, RR 17. The
nurse identifies the priority action as:
a. Administer morphine 5mg IV as ordered prn
b. Assess for autonomic dysreflexia
c. Administer atropine as ordered prn to increase the HR
d. Increase the intravenous flow rate as ordered prn Correct
Answer D
1. A client is POD5 for a lung transplant. They have been
transferred from ICU to the surgical unit. Which statement(s)
describe(s) the management of a client following lung
transplantation? Select all that apply.
a. High flow oxygen by a non-rebreather mask
b. Monitor for low-grade fever, fatigue, and oxygen desaturation
c. Lifelong administration of their immuno-suppressant
medication
,d. Corticosteroids may be administered if signs of rejection arise
Correct Answer BCD
1. A client is receiving a kidney transplant. Which of the
following statements indicate that the client understood the pre-
op education?
a. I will have oliguria post-operatively
b. I will need to live a more sedentary lifestyle to prevent
exposure to infection
c. I will take immunosuppressive medication for the rest of my
life
d. I will need to monitor for signs and symptoms of hypothermia
and hypotension Correct Answer C
1. A client is told they will need elective surgery in 1 month.
What surgical phase are they now in?
a. Pre-hospital
b. Pre-operative
c. Intra-operative
d. Post-operative Correct Answer A
1. A client with advanced cirrhosis asks the nurse why his
abdomen is so swollen. The nurse's response is based on the
knowledge of which of the following?
a. A lack of clotting factors promotes the collection of blood in
the abdominal cavity.
b. Portal hypertension and hypoalbuminemia cause a fluid shift
into the peritoneal space.
c. Decreased peristalsis in the gastro-intestinal tract contributes
to gas formation and distension of the bowel.
, d. Bile salts in the blood irritate the peritoneal membranes,
causing edema and pocketing of fluid. Correct Answer B
1. A client with known cirrhosis has an elevated blood level of
indirect (unconjugated) bilirubin. Which of the following might
cause this finding?
a. The gallbladder is unable to contract to release stored bile.
b. Bilirubin is not being conjugated and excreted into the bile by
the liver.
c. The Kupffer cells in the liver are unable to remove bilirubin
from the blood.
d. There is an obstruction in the biliary tract preventing flow of
bile into the small intestine. Correct Answer B
1. A client with known peripheral artery disease is being
admitted to the medical unit. The client voices several
complaints. Which symptom is of greatest concern for the
nurse?
a. Anxiety
b. Leg pain at rest
c. Elevation pallor
d. Hairless leg Correct Answer B
1. A client with PAD is receiving discharge teaching. Which
statement would indicate the client understood the discharge
instructions? Select all that apply.
a. "I will avoid crossing my legs"
b. "I will inspect my feet daily"
c. "I will use compression stockings"
d. "I will continue with my smoking cessation program Correct
Answer ABD
