NUR280 ACTUAL PAPER 2026 SOLUTIONS
GRADED A+
◉ 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.
◉ 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.
◉ 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.
◉ 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
◉ 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
◉ 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.
GRADED A+
◉ 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.
◉ 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.
◉ 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.
◉ 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
◉ 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
◉ 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.
