N261 Exam 1 Actual Exam V1 | N261 Nursing (N261 Exam 1) |
University of California, Los Angeles
1. A nurse is caring for a patient who is two days post-operative following abdominal surgery.
The patient reports sudden onset of shortness of breath and pleuritic chest pain. Which
action should the nurse take first?
A. Obtain an arterial blood gas (ABG) sample.
B. Administer the prescribed PRN analgesic.
C. Place the patient in a supine position.
D. Assess the patient’s oxygen saturation and lung sounds.
Answer: D
Rationale: Clinical judgment dictates that the nurse must first assess the patient’s
physiological status when a change in condition occurs. Shortness of breath and chest pain
in a post-operative patient are red flags for pulmonary embolism or atelectasis. Assessment
provides the necessary data to determine the severity of the situation before intervening or
notifying the provider.
2. Which task is most appropriate for a Registered Nurse (RN) to delegate to an Unlicensed
Assistive Personnel (UAP)?
A. Evaluating the effectiveness of a patient’s pain medication.
B. Providing discharge instructions to a patient going home.
C. Measuring and recording the intake and output of a stable patient.
D. Assessing a patient’s skin integrity after a fall.
Answer: C
Rationale: Measuring and recording intake and output is a routine, non-invasive task that
does not require clinical judgment, making it suitable for a UAP. Evaluation, assessment,
and patient education are core nursing responsibilities that cannot be delegated. The RN
remains accountable for the overall care plan even when tasks are delegated.
3. A nurse is utilizing the SBAR communication tool to report a patient’s condition to a
physician. Which information should the nurse include in the ‘Background’ section?
A. The patient’s current vital signs and mental status.
B. A suggestion for a specific laboratory test to be ordered.
C. A brief history of the patient’s admission diagnosis and medical history.
D. The reason the nurse is calling about the patient.
,Answer: C
Rationale: The Background component of SBAR provides the context for the current
situation, such as the patient’s history and clinical context. The Situation (S) identifies the
immediate reason for the call, while Assessment (A) covers current vitals and status.
Recommendation (R) involves the nurse’s suggestions for the next steps in care.
4. In the context of evidence-based practice (EBP), which of the following represents the
highest level of evidence?
A. A single randomized controlled trial (RCT).
B. Expert opinion from a specialty nursing organization.
C. A case-control study focusing on a rare disease.
D. A systematic review or meta-analysis of multiple RCTs.
Answer: D
Rationale: Systematic reviews and meta-analyses are considered the gold standard in the
hierarchy of evidence because they synthesize data from multiple high-quality studies. This
level of evidence reduces bias compared to single studies or expert opinions. Nurses should
look to these sources first when developing clinical protocols or interventions.
5. A nurse is assessing a patient with a diagnosis of chronic obstructive pulmonary disease
(COPD). Which clinical finding would the nurse expect as a compensatory mechanism for
chronic hypoxia?
A. Bradycardia.
B. Peripheral edema.
C. Increased capillary refill time.
D. Clubbing of the fingers.
Answer: D
Rationale: Clubbing of the fingers is a classic sign of chronic hypoxia, often seen in patients
with long-term respiratory or cardiovascular disease. It results from the proliferation of
soft tissue at the nail base due to low oxygen levels. Other signs like edema or bradycardia
are not specific compensatory mechanisms for chronic oxygen deprivation.
6. A patient becomes agitated and attempts to pull out their intravenous line. Which nursing
intervention should be attempted first before considering physical restraints?
A. Administering a PRN sedative medication.
B. Using therapeutic communication and reorientation.
C. Applying bilateral wrist restraints immediately.
, D. Asking the family to leave the room to reduce stimulation.
Answer: B
Rationale: Restraints should always be a last resort after less restrictive measures have
failed. Reorienting the patient and using therapeutic communication are initial steps to
manage agitation safely. Nurses must document all attempted alternatives before
implementing any form of physical restraint.
7. During a physical assessment, the nurse notes that the patient’s skin stays tented after
being pinched over the sternum. What does this finding indicate?
A. Fluid volume overload.
B. Normal skin elasticity.
C. Deficient fluid volume (dehydration).
D. Increased peripheral vascular resistance.
Answer: C
Rationale: Skin turgor is a reliable indicator of hydration status, and ‘tenting’ suggests that
the patient is dehydrated. As fluid volume decreases, the skin loses its elasticity and ability
to return to its original shape quickly. This finding necessitates further assessment of
mucous membranes, urine output, and electrolyte levels.
8. A nurse is preparing to administer a high-alert medication. Which action is the most critical
for patient safety?
A. Checking the patient’s name and room number.
B. Performing an independent double-check with another licensed nurse.
C. Administering the medication at the exact time ordered.
D. Asking the patient if they have ever taken the medication before.
Answer: B
Rationale: High-alert medications have a high risk of causing significant patient harm if
used in error. An independent double-check by two nurses helps catch errors in dosing or
patient identification. While the ‘five rights’ are always important, this specific redundancy
is a standard safety protocol for high-risk drugs like insulin or heparin.
9. A nurse is caring for a patient who is experiencing acute pain. Which of the following is the
most reliable indicator of the patient’s pain level?
A. The patient’s self-report of pain on a scale of 0 to 10.
B. The patient’s facial expressions and body language.
C. The patient’s heart rate and blood pressure.
University of California, Los Angeles
1. A nurse is caring for a patient who is two days post-operative following abdominal surgery.
The patient reports sudden onset of shortness of breath and pleuritic chest pain. Which
action should the nurse take first?
A. Obtain an arterial blood gas (ABG) sample.
B. Administer the prescribed PRN analgesic.
C. Place the patient in a supine position.
D. Assess the patient’s oxygen saturation and lung sounds.
Answer: D
Rationale: Clinical judgment dictates that the nurse must first assess the patient’s
physiological status when a change in condition occurs. Shortness of breath and chest pain
in a post-operative patient are red flags for pulmonary embolism or atelectasis. Assessment
provides the necessary data to determine the severity of the situation before intervening or
notifying the provider.
2. Which task is most appropriate for a Registered Nurse (RN) to delegate to an Unlicensed
Assistive Personnel (UAP)?
A. Evaluating the effectiveness of a patient’s pain medication.
B. Providing discharge instructions to a patient going home.
C. Measuring and recording the intake and output of a stable patient.
D. Assessing a patient’s skin integrity after a fall.
Answer: C
Rationale: Measuring and recording intake and output is a routine, non-invasive task that
does not require clinical judgment, making it suitable for a UAP. Evaluation, assessment,
and patient education are core nursing responsibilities that cannot be delegated. The RN
remains accountable for the overall care plan even when tasks are delegated.
3. A nurse is utilizing the SBAR communication tool to report a patient’s condition to a
physician. Which information should the nurse include in the ‘Background’ section?
A. The patient’s current vital signs and mental status.
B. A suggestion for a specific laboratory test to be ordered.
C. A brief history of the patient’s admission diagnosis and medical history.
D. The reason the nurse is calling about the patient.
,Answer: C
Rationale: The Background component of SBAR provides the context for the current
situation, such as the patient’s history and clinical context. The Situation (S) identifies the
immediate reason for the call, while Assessment (A) covers current vitals and status.
Recommendation (R) involves the nurse’s suggestions for the next steps in care.
4. In the context of evidence-based practice (EBP), which of the following represents the
highest level of evidence?
A. A single randomized controlled trial (RCT).
B. Expert opinion from a specialty nursing organization.
C. A case-control study focusing on a rare disease.
D. A systematic review or meta-analysis of multiple RCTs.
Answer: D
Rationale: Systematic reviews and meta-analyses are considered the gold standard in the
hierarchy of evidence because they synthesize data from multiple high-quality studies. This
level of evidence reduces bias compared to single studies or expert opinions. Nurses should
look to these sources first when developing clinical protocols or interventions.
5. A nurse is assessing a patient with a diagnosis of chronic obstructive pulmonary disease
(COPD). Which clinical finding would the nurse expect as a compensatory mechanism for
chronic hypoxia?
A. Bradycardia.
B. Peripheral edema.
C. Increased capillary refill time.
D. Clubbing of the fingers.
Answer: D
Rationale: Clubbing of the fingers is a classic sign of chronic hypoxia, often seen in patients
with long-term respiratory or cardiovascular disease. It results from the proliferation of
soft tissue at the nail base due to low oxygen levels. Other signs like edema or bradycardia
are not specific compensatory mechanisms for chronic oxygen deprivation.
6. A patient becomes agitated and attempts to pull out their intravenous line. Which nursing
intervention should be attempted first before considering physical restraints?
A. Administering a PRN sedative medication.
B. Using therapeutic communication and reorientation.
C. Applying bilateral wrist restraints immediately.
, D. Asking the family to leave the room to reduce stimulation.
Answer: B
Rationale: Restraints should always be a last resort after less restrictive measures have
failed. Reorienting the patient and using therapeutic communication are initial steps to
manage agitation safely. Nurses must document all attempted alternatives before
implementing any form of physical restraint.
7. During a physical assessment, the nurse notes that the patient’s skin stays tented after
being pinched over the sternum. What does this finding indicate?
A. Fluid volume overload.
B. Normal skin elasticity.
C. Deficient fluid volume (dehydration).
D. Increased peripheral vascular resistance.
Answer: C
Rationale: Skin turgor is a reliable indicator of hydration status, and ‘tenting’ suggests that
the patient is dehydrated. As fluid volume decreases, the skin loses its elasticity and ability
to return to its original shape quickly. This finding necessitates further assessment of
mucous membranes, urine output, and electrolyte levels.
8. A nurse is preparing to administer a high-alert medication. Which action is the most critical
for patient safety?
A. Checking the patient’s name and room number.
B. Performing an independent double-check with another licensed nurse.
C. Administering the medication at the exact time ordered.
D. Asking the patient if they have ever taken the medication before.
Answer: B
Rationale: High-alert medications have a high risk of causing significant patient harm if
used in error. An independent double-check by two nurses helps catch errors in dosing or
patient identification. While the ‘five rights’ are always important, this specific redundancy
is a standard safety protocol for high-risk drugs like insulin or heparin.
9. A nurse is caring for a patient who is experiencing acute pain. Which of the following is the
most reliable indicator of the patient’s pain level?
A. The patient’s self-report of pain on a scale of 0 to 10.
B. The patient’s facial expressions and body language.
C. The patient’s heart rate and blood pressure.
