N261 Exam 1 Actual Exam V3 | N261 Nursing (N261 Exam 1) |
University of California, Los Angeles
1. A nurse is assessing a patient with a potassium level of 6.2 mEq/L. Which EKG change
should the nurse expect to observe first?
A. Tall, peaked T waves
B. Prominent U waves
C. ST-segment depression
D. Prolonged QT interval
Answer: A
Rationale: Hyperkalemia primarily affects the repolarization phase of the cardiac cycle,
leading to the characteristic finding of tall, peaked T waves. As potassium levels continue to
rise, the PR interval may prolong and the QRS complex will eventually widen. This
assessment is critical because hyperkalemia can lead to lethal dysrhythmias and cardiac
arrest.
2. Which clinical manifestation would the nurse prioritize for a patient experiencing fluid
volume deficit?
A. Orthostatic hypotension
B. Distended neck veins
C. Bounding peripheral pulses
D. Decreased hematocrit
Answer: A
Rationale: Orthostatic hypotension occurs as a result of decreased circulating blood
volume, which reduces venous return to the heart. This finding indicates a significant loss
of intravascular fluid and places the patient at a high risk for falls. Monitoring blood
pressure and heart rate during position changes is a vital nursing assessment for these
patients.
3. A patient with COPD is found to have an arterial blood gas (ABG) result of pH 7.31, PaCO2
55, and HCO3 28. How should the nurse interpret these findings?
A. Partially compensated respiratory acidosis
B. Uncompensated metabolic acidosis
C. Compensated respiratory alkalosis
D. Uncompensated respiratory acidosis
,Answer: A
Rationale: The pH is below 7.35, indicating acidosis, and the PaCO2 is elevated, indicating
a respiratory origin. The HCO3 is elevated above normal (26), suggesting that the kidneys
are attempting to compensate by retaining bicarbonate. Because the pH has not yet
returned to the normal range, the condition is considered partially compensated.
4. When administering a hypertonic IV solution such as 3% Sodium Chloride, which
assessment is most important for the nurse to perform regularly?
A. Lung sounds and respiratory effort
B. Bowel sounds and abdominal girth
C. Daily weights at the same time
D. Skin turgor and moisture
Answer: A
Rationale: Hypertonic solutions pull fluid from the intracellular space into the
intravascular space, which carries a high risk of causing pulmonary edema. The nurse must
frequently auscultate lung sounds to detect crackles, which are an early sign of fluid
overload. Early detection allows for immediate intervention to prevent severe respiratory
distress.
5. The nurse is caring for a patient with a serum calcium level of 7.2 mg/dL. Which physical
assessment finding is consistent with this result?
A. Constipation and lethargy
B. Trousseau’s sign
C. Muscle flaccidity
D. Negative Chvostek’s sign
Answer: B
Rationale: Hypocalcemia increases neuromuscular excitability, which can be assessed
using Trousseau’s sign (carpal spasm induced by inflating a blood pressure cuff). A serum
calcium of 7.2 mg/dL is below the normal range of 8.5 to 10.5 mg/dL. Safety is a major
concern as severe hypocalcemia can lead to seizures or laryngeal spasms.
6. A patient is admitted with a sodium level of 115 mEq/L. Which nursing intervention is the
highest priority?
A. Encouraging increased oral fluid intake
B. Monitoring for peripheral edema
C. Administering hypotonic IV fluids
, D. Implementing seizure precautions
Answer: D
Rationale: Severe hyponatremia causes water to shift into brain cells, leading to cerebral
edema and significantly increasing the risk of seizures. Seizure precautions, including
padded side rails and suction equipment at the bedside, are essential safety measures. The
nurse must also monitor neurological status closely for changes in consciousness.
7. A nurse is reviewing the lab results of a patient receiving Furosemide. Which electrolyte
imbalance should the nurse be most concerned about?
A. Hyperkalemia
B. Hypomagnesemia
C. Hypokalemia
D. Hypernatremia
Answer: C
Rationale: Furosemide is a loop diuretic that promotes the excretion of water, sodium, and
potassium in the urine. Low potassium levels can cause cardiac instability and muscle
weakness, requiring close monitoring. The nurse should encourage the intake of
potassium-rich foods or coordinate with the provider for supplementation.
8. Which patient should the nurse assess first after receiving the morning shift report?
A. A patient with a pain level of 6/10 after a knee replacement
B. A patient with diabetes who has a fasting blood glucose of 140 mg/dL
C. A patient with pneumonia who has an oxygen saturation of 89% on room air
D. A patient scheduled for an endoscopy in three hours
Answer: C
Rationale: Using the ABC (Airway, Breathing, Circulation) framework, the patient with an
oxygen saturation of 89% is the highest priority due to compromised gas exchange. Oxygen
saturations below 90% typically require immediate nursing intervention and assessment.
The other patients are stable or have needs that can be addressed after ensuring
respiratory stability for the patient with pneumonia.
9. A nurse is caring for a patient who is post-operative day 1 after abdominal surgery. The
patient refuses to use the incentive spirometer because it hurts. What is the most
appropriate nursing action?
A. Administer prescribed analgesic and return in 30 minutes
B. Document the refusal and move to the next patient
University of California, Los Angeles
1. A nurse is assessing a patient with a potassium level of 6.2 mEq/L. Which EKG change
should the nurse expect to observe first?
A. Tall, peaked T waves
B. Prominent U waves
C. ST-segment depression
D. Prolonged QT interval
Answer: A
Rationale: Hyperkalemia primarily affects the repolarization phase of the cardiac cycle,
leading to the characteristic finding of tall, peaked T waves. As potassium levels continue to
rise, the PR interval may prolong and the QRS complex will eventually widen. This
assessment is critical because hyperkalemia can lead to lethal dysrhythmias and cardiac
arrest.
2. Which clinical manifestation would the nurse prioritize for a patient experiencing fluid
volume deficit?
A. Orthostatic hypotension
B. Distended neck veins
C. Bounding peripheral pulses
D. Decreased hematocrit
Answer: A
Rationale: Orthostatic hypotension occurs as a result of decreased circulating blood
volume, which reduces venous return to the heart. This finding indicates a significant loss
of intravascular fluid and places the patient at a high risk for falls. Monitoring blood
pressure and heart rate during position changes is a vital nursing assessment for these
patients.
3. A patient with COPD is found to have an arterial blood gas (ABG) result of pH 7.31, PaCO2
55, and HCO3 28. How should the nurse interpret these findings?
A. Partially compensated respiratory acidosis
B. Uncompensated metabolic acidosis
C. Compensated respiratory alkalosis
D. Uncompensated respiratory acidosis
,Answer: A
Rationale: The pH is below 7.35, indicating acidosis, and the PaCO2 is elevated, indicating
a respiratory origin. The HCO3 is elevated above normal (26), suggesting that the kidneys
are attempting to compensate by retaining bicarbonate. Because the pH has not yet
returned to the normal range, the condition is considered partially compensated.
4. When administering a hypertonic IV solution such as 3% Sodium Chloride, which
assessment is most important for the nurse to perform regularly?
A. Lung sounds and respiratory effort
B. Bowel sounds and abdominal girth
C. Daily weights at the same time
D. Skin turgor and moisture
Answer: A
Rationale: Hypertonic solutions pull fluid from the intracellular space into the
intravascular space, which carries a high risk of causing pulmonary edema. The nurse must
frequently auscultate lung sounds to detect crackles, which are an early sign of fluid
overload. Early detection allows for immediate intervention to prevent severe respiratory
distress.
5. The nurse is caring for a patient with a serum calcium level of 7.2 mg/dL. Which physical
assessment finding is consistent with this result?
A. Constipation and lethargy
B. Trousseau’s sign
C. Muscle flaccidity
D. Negative Chvostek’s sign
Answer: B
Rationale: Hypocalcemia increases neuromuscular excitability, which can be assessed
using Trousseau’s sign (carpal spasm induced by inflating a blood pressure cuff). A serum
calcium of 7.2 mg/dL is below the normal range of 8.5 to 10.5 mg/dL. Safety is a major
concern as severe hypocalcemia can lead to seizures or laryngeal spasms.
6. A patient is admitted with a sodium level of 115 mEq/L. Which nursing intervention is the
highest priority?
A. Encouraging increased oral fluid intake
B. Monitoring for peripheral edema
C. Administering hypotonic IV fluids
, D. Implementing seizure precautions
Answer: D
Rationale: Severe hyponatremia causes water to shift into brain cells, leading to cerebral
edema and significantly increasing the risk of seizures. Seizure precautions, including
padded side rails and suction equipment at the bedside, are essential safety measures. The
nurse must also monitor neurological status closely for changes in consciousness.
7. A nurse is reviewing the lab results of a patient receiving Furosemide. Which electrolyte
imbalance should the nurse be most concerned about?
A. Hyperkalemia
B. Hypomagnesemia
C. Hypokalemia
D. Hypernatremia
Answer: C
Rationale: Furosemide is a loop diuretic that promotes the excretion of water, sodium, and
potassium in the urine. Low potassium levels can cause cardiac instability and muscle
weakness, requiring close monitoring. The nurse should encourage the intake of
potassium-rich foods or coordinate with the provider for supplementation.
8. Which patient should the nurse assess first after receiving the morning shift report?
A. A patient with a pain level of 6/10 after a knee replacement
B. A patient with diabetes who has a fasting blood glucose of 140 mg/dL
C. A patient with pneumonia who has an oxygen saturation of 89% on room air
D. A patient scheduled for an endoscopy in three hours
Answer: C
Rationale: Using the ABC (Airway, Breathing, Circulation) framework, the patient with an
oxygen saturation of 89% is the highest priority due to compromised gas exchange. Oxygen
saturations below 90% typically require immediate nursing intervention and assessment.
The other patients are stable or have needs that can be addressed after ensuring
respiratory stability for the patient with pneumonia.
9. A nurse is caring for a patient who is post-operative day 1 after abdominal surgery. The
patient refuses to use the incentive spirometer because it hurts. What is the most
appropriate nursing action?
A. Administer prescribed analgesic and return in 30 minutes
B. Document the refusal and move to the next patient
