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NUR 280 ACTUAL EXAM 2024/2025 VERFIED
QUESTIONS AND ANSWERS WITH RATIONALE
GRADED A+(SOLVED)
The nurse is reviewing medical prescriptions for newly admitted clients. It would be a priority for the nurse to follow up with the physician if a client with
(a) a potassium level of 4.5mEq/L has Kayexalate (sodium polystyrene)
prescribed
(b) a Dilantin (phenytoin) level of 8 mcg/ml is placed on seizure precautions
(c) sensitivity to Aspirin (acetylsalicylic acid) is prescribed Tylenol (acetaminophen)
(d) sensitivity to Penicillin is prescribed Zithromax (azithromycin)
- A. The normal potassium level is 3.5 - 5.0 mEq/L. Giving Kayexalate in this situation may cause the client to lose potassium, causing hypokalemia, therefore the drug is not indicated; the therapeutic level for Dilantin is 10 - 20 mcg/ml, a level of 8 is sub therapeutic thereby increasing the risk of seizure activity. Acetaminophen can be safely prescribed to clients with ASA sensitivity. Azithromycin (Zithromax) can be safely prescribed for clients with sensitivity to Penicillin.
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
- 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.
- 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
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(+)
- 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.
It would be appropriate to assign which of these tasks to the CNA?
(a) Feeding a client who is experiencing dysphagia
(b) One-on-one client observation for safety
(c) Removal of an indwelling catheter
(d) Performing a simple dressing change
B. The Certified Nursing Assistant may be assigned to a client that requires one- to-one observation for safety; the other choices require skilled nursing intervention by a LPN (Licensed Practical Nurse) or RN (Registered Nurse).
The nurse should intervene if a staff member is observed:
(a) discussing a client's diagnosis with visiting family members
(b) collaborating with another nurse to review a prescription for blood transfusion
(c) interrupting other staff members discussing a client in the cafeteria
(d) reviewing a clients lab values with the nutritionist
- A. To maintain confidentiality the nurse should not discuss the client's diagnosis with family members; it is advisable that two nurses review the prescription for blood transfusion to identify the client, blood
type, Rh factor, expiration date and the blood numbers; interrupting staff members discussing a client in a public place should be done to maintain client confidentiality; collaborating with the nutritionist is an appropriate nursing intervention. Safe Effective Care Environment; Management of Care
The nurse is preparing a staff presentation on legal and ethical issues in nursing. The nurse would be correct to include which of the following examples?
(a) Putting a client in a geriatric chair with the lap tray in front of the client in the day room to watch television is false imprisonment
(b) Telling a client that you will put in a feeding tube if the client does not eat is an example of battery
(c) Telling a client with bipolar disorder who is suicidal that they have a right to refuse to take their medications is an example of malpractice
(d) Placing hands on a client who says "do not touch me" is an example of assault
A. Putting a client in a geriatric chair with the lap tray in front of them restricts movement which constitutes false imprisonment; choice B is an example of assault not battery; C is an example of negligence not malpractice and D is an example of battery not assault. Safe Effective Care Environment; Management of Care
The nurse from the pediatric unit has been temporarily assigned to the
Emergency Department. It would be most appropriate to assign that nurse
to the client who
(a) reports epigastric pain that "feels like indigestion"
(b) has back pain and a pulsating abdominal mass
(c) is HIV+ reporting vomiting and diarrhea
(d) presents with lower abdominal pain and is six weeks pregnant
- C. Vomiting and diarrhea can be managed on a non-emergent basis; clients reporting "indigestion" may be experiencing a cardiac event; clinical manifestations suggestive of abdominal aortic aneurysm include abdominal mass and abdominal throbbing; the client who is 6 weeks pregnant experiencing
picking of the clothes. This client should be seen first; dribbling, urinary frequency and burning on urination may be expected after an indwelling catheter is removed; flexion and extension of the neck is contraindicated with cervical traction, not foot traction; returning the confused client with Alzheimer's disease is not a priority. Safe Effective Care Environment; Management of Care
The nurse in a community health clinic is talking with the parent of a child with
Celiac Disease. Which of the following statements would require follow-up by the
nurse for additional teaching?
(a) "This weekend we are going to a seafood restaurant"
(b) "I can feed my child oatmeal and eggs for breakfast"
(c) "My child loves to eat rice and chicken for dinner"
(d) "Last night we ate fish with corn for dinner"
B. Oatmeal is contraindicated for children with Celiac disease. These clients should be on a gluten free diet. Foods to be avoided include barley, rye, oats and wheat; the other choices are permissible as a part of the dietary plan. Safe Effective Care Environment; Management of Care
The charge nurse is observing a Licensed Practical Nurse (LPN) performing
care for assigned clients. Follow up will be required if the LPN:
(a) assesses a client's apical pulse before administering Digoxin (lanoxin)
(b) elevates the client's stump on a pillow eight hours after amputation
(c) dons a clean glove on the dominant hand before tracheal suctioning
(d) positions a client on the operative side following a pneumonectomy
C. A sterile glove, not clean, should be used on the dominant hand during tracheal suctioning to prevent infection; the apical pulse should be assessed for one full minute prior to the administration of Digoxin (Lanoxin); elevation of the stump following amputation is performed for the first 24 hours only to prevent hip or knee flexion contracture; clients should be positioned on the operative side to promote lung expansion of the unaffected lung. Safe Effective Care Environment; Management of Care
The nurse at a health promotion fair has taught a group of parents about car seat
and seat belt safety. Which of the following statements, if made by the parent, would
indicate a correct understanding of the information given?
(a) "I will place my newborn infant in a rear facing car seat in the middle of the rear seat."
(b) "I will wear a lap seat belt high on my belly since I am 8 months pregnant."
(c) "I can use a front-facing car seat once my baby weighs 15 pounds."
(d) " I can allow my six-year-old to use a seat belt in the front passenger seat"
A. The newborn should be placed in a rear facing car seat with appropriate restraints until about one year of age and at least 20 pounds; the lap portion of the shoulder belt should be positioned snug around the hips, never the abdomen; all children under the age of 12 should be placed in the rear seat of the vehicle. Safe Effective Care Environment; Safety and Infection Control
The nurse is caring for a client being treated for Vancomycin Resistant
Enterococcus (VRE). The nurse should place the client on
(a) contact precautions
(b) droplet precautions
(c) protective precautions
(d) airborne precautions
A. Vancomycin resistant enterococcus (VRE) is spread by direct contact; disease that are transmitted by droplets (sneezing, coughing) include influenza, pneumonia, streptococcal pharyngitis; protective isolation precautions are used for persons with suppression of the immune system; airborne precautions are instituted for diseases transmitted via the air such as measles (rubeola), tuberculosis (TB), and varicella (chickenpox). Safe Effective Care Environment; Safety and Infection Control
statement, if made by one of the clients, would require further teaching?
(a) "I am glad that I can still clean my parakeet's cage"
(b) "I will not go to the parade this weekend"
(c) "I will increase protein in my diet"
(d) "I will miss not being able to work in my garden"
A. Client teaching of HIV infected individuals should include avoidance of bird droppings and soil to prevent the opportunistic infections toxoplasmosis and cryptococcosis; avoiding crowds and increasing protein in the diet are important for the maintenance of health; these clients do not need further teaching. Safe Effective Care Environment; Safety and Infection Control
The nurse in the emergency department is caring for clients admitted following a
rescue from a burning bus. The nurse should first see the client who
(a) has the tibia bone protruding through the skin and is in severe pain
(b) has third degree burns of the left foot and is crying
(c) is unconscious, pulseless, and has dilated pupils
(d) has soot on the face and the nares and is coughing
D. After a disaster clients are seen in order of priority. Those with life threatening injuries who are likely to survive are seen first (Class 1; Priority 1). Those that require immediate care, who can be evaluated within 2 hours, are seen next (Class II; Priority 2). Next are clients who could wait hours to days before treatment (Class III; Priority 3). The client in choice C is the most seriously injured and not likely to survive, they would be seen last (Class IV; Priority 4). That person should be separated from others but not abandoned. Safe Effective Care Environment; Safety and Infection Control
A nurse is observing a newly-hired nurse provide care for assigned clients. The
nurse should follow up if the newly-hired nurse is observed
(a) wearing gloves when taking the blood pressure of a client with disseminated varicella zoster
(b) cleansing the wound from the outer surface to the inner surface for a client whose wound is infected with a multi-drug resistant organism
(c) washing the hands with the fingertips pointed downward before providing care for a client on protective precautions
(d) removing the gloves before removing the gown when leaving a room of a client who is on contact precautions
B. Cleansing of the wound from the outer surface to the inner surface is incorrect technique. Wounds should be cleansed in an outward direction to avoid transferring organisms from the surrounding skin into the wound. Choices A, C, and D follow the principles of infection control, follow up is not required. Safe Effective Care Environment; Safety and Infection Control
The nurse is caring for a client who has been diagnosed with rheumatoid arthritis.
The nurse should anticipate that the client will initially be prescribed
(a) Disease-modifying rheumatic agents (DMARDs)
(b) Nonselective anti-inflammatory drugs (NSAIDs)
(c) Long-term corticosteroids
(d) Biologic Response Modifiers
B. The treatment of rheumatoid arthritis is aimed at relieving pain. NSAID's (Non steroidal anti- inflammatory drugs) are customarily the first type of agent used; the other agent's listed are used later in the management process. Physiological Integrity; Pharmacological and Parenteral Therapies
The nurse is assessing a 2-month-old-infant at a well baby clinic. The nurse should
anticipate the infant should
(a) roll from prone to back
(b) have no head lag
(c) smile socially
(d) have no tonic neck reflex
and bat is avoided to prevent injury; the stuffed toy may be offered to the toddler. Health Promotion and Maintenance
The nurse on a pediatric unit has been informed that the following clients are being
admitted. The nurse should first plan to assess the client who is
(a) 2 years old, has a temperature of 100.8 F and a blood pressure of 68/
(b) 4 years old with a history of asthma and has a peak expiratory flow rate (PERF) of 81%
(c) 5 years old, has a fracture of the tibia and is reporting pain rated 7 on a pain scale of 0 (no pain) to 10 (severe pain)
(d) 7 years old with ulcerative colitis and has had 15 bloody tinged stools today
A. The child experiencing fever and hypotension should be seen first, they are at the highest risk in this situation for decompensation; the average blood pressure for a toddler is 92/56; the child with asthma is not acutely ill at this time; pain is expected with a bone fracture, management of pain is important but does not take priority; ulcerative colitis is expected to produce 10 - 20 bloody stools per day, this is not the priority in this situation. Safe Effective Care environment; Management of Care
The nurse is providing discharge instructions to the parents of an infant who has a
cleft lip. The nurse should instruct the parents to
(a) place the infant in a prone position after each feeding
(b) encourage the parents to provide the infant rest periods during feedings
(c) regularly offer the infant a pacifier to enhance the sucking reflex
(d) elevate the child's head forty five degrees during feeding
B. The parent should be taught the ESSR (Enlarged nipple, Stimulate Suck by rubbing the nipple on the lower lip, Rest after each swallow to allow infant to complete swallowing) method of feeding to decrease the risk of aspiration; the infant should be fed in an upright position; prone position and pacifiers should not be used. Physiological Integrity; Physiological Adaptation
The nurse is assessing a 3-year-old during a well-child visit. During the visit the
boy says to his mother, "Mommy, I love you. I'm going to marry you". The nurse
should
(a) suggest to the mother not to encourage these types of statements
(b) explain to the child that he will not be able to marry his mother even though he loves her
(c) tell the mother that this statement is appropriate for his stage of development
(d) recommend that the mother provide more opportunities for her son to play with other 3-year-old boys
C. According to Sigmund Freud, the phallic stage occurs between 3 - 6 years of age. During this stage the child experiences unconscious sexual attraction to the parent of the opposite sex. This is called the Oedipal Complex. The statement is reflective of this stage of development. The other choices are not correct actions. Safe Effective Care environment; Management of Care
The nurse is assessing a child with coarctation of the aorta. Which of the following
would be an expected finding?
(a) diminished blood pressure in the upper extremities
(b) excessive weight gain
(c) high pitched murmur
(d) absence of femoral pulses
D. Coarctation of the aorta is characterized by narrowing of the aorta. As a result of this narrowing, absent femoral pulses, poor weight gain and increased blood pressure in the upper extremities are expected findings. A high pitched murmur is not present. Physiological Integrity; Physiological Adaptation
The nurse is caring for a child with an acyanotic heart defect. Which of the following
nurse recognizes that this could be an expected finding if the infant has
(a) intussusception
(b) Hirschsprung's disease
(c) umbilical hernia
(d) pyloric stenosis
D. Pyloric Stenosis is hypertrophy of the muscles of the pylorus causing narrowing of the pyloric canal between the stomach and duodenum. A characteristic olive shaped mass may be palpated in the epigastrium to the right of the umbilicus. Intussusception is characterized by currant jelly stools. Hirschprung's disease (congenital mega colon) results in ribbon-like foul smelling stools; a child with an umbilical hernia has swelling or protrusion around the umbilicus that is reducible. Physiological Integrity; Physiological Adaptation
The nurse is teaching a group of parents about the expected growth and
development of three-year-old children. The nurse should include that a three-year-
old should
(a) discriminate between fantasy and reality
(b) ride a tricycle independently
(c) have a vocabulary of 7,000 words
(d) play in a group of two or three with one being the leader
D. By the age of 3, a toddler should be able to ride a tricycle independently; the pre- school child is not able to discriminate between fantasy and reality. This is the developmental task of a school age child; at 3 years of age the vocabulary is at about 900 words; cooperative play with the incorporation of imaginary friends is common in this age group. Health Promotion and Maintenance
The nurse and the nursing assistant are caring for a group of clients. Which of the following client care activities should the nurse assign to the nursing assistant? Select all that apply.
(a)_____ reinforcing the dressing of a client who has a decubitus ulcer
(b) _____monitoring the vital signs of a client who had a myocardial infarction 12 hours
ago and is being transferred from the coronary care unit
(c)______administering a prescribed Fleet's enema to a client who will undergo a
colonoscopy in two hours
(d)______ placing a client who had an above the knee amputation 24 hours ago in a
prone position
(e)______ assisting a client who had a colon resection 36 hours ago to ambulate
(f) ______showing a client who had a vaginal hysterectomy 36 hours ago how to
perform perineal care
C, D, and E. All of these tasks are within the job description of a Certified Nursing Assistant and can be safely delegated; A, B, and F would require assessment, nursing intervention and patient education which is the role of the nurse. Safe Effective Care environment; Management of Care
The nurse is caring for a client with Acquired immunodeficiency syndrome (AIDS)
who was started on Zidovidine (AZT). It would be important for the nurse to assess
(a) blood ammonia serum
(b) serum potassium
(c) complete blood count (CBC)
(d) serum uric acid
C. Clients being treated with Zidovudine (AZT) should have routine monitoring of CBC (complete blood count), hepatic and renal function studies. Physiological Integrity; Physiological Adaptation
Time in minutes (8hours x 60 minutes)
Physiological Integrity; Pharmacological and Parenteral Therapies
The primary health care provider has prescribed an oral solution of Potassium Chloride (KCL) 20 mEq, PO, QD. The drug available is Potassium Chloride 10 mEq/15ml. How many ml should the nurse administer?
30 ml. Desired amount (20mEq) X Quantity (15ml)
Amount on hand (10 mEq)
Physiological Integrity; Pharmacological and Parenteral Therapies
The primary health care provider has prescribed Heparin 5000 units SC. The drug available is heparin sodium 7500units/ml. Choose all of the correct answers for nursing considerations for the administration of heparin sodium.
a)______ administer the heparin in the abdomen
b)______ administer 0.5ml of heparin sodium
c)______ aspirate after inserting the needle
d)______ use a 1 inch 21 gauge needle
e)______ refrain from massaging the site after administer heparin
(f)______ remember that protamine sulfate is the antidote for heparin
A, E, and F. Heparin is best absorbed from the abdomen; aspiration and massaging the site after injection is contraindicated, a 26 - 27 gauge 5/8 inch to ½ inch needle is used; the antidote for heparin is Protamine Sulfate. The correct dosage to be administered is
0.66ml. Desired amount 5,000 units X Quantity (1ml)
Amount on hand 7,500 units
Physiological Integrity; Pharmacological and Parenteral Therapies
The nurse has attended a staff development conference on cultural considerations for clients receiving hospice care. Which of the following statements if made by the nurse would require follow-up?
(a) The family of a client of the Buddhist faith may ask for a priest to be present at the time of death
(b) The family of a client of the Jewish faith may request to have mirrors covered after the death of the client
(c) The family of a client of the Muslim faith may request that the body of the client be turned to face the East at the time of the client's death
(d) The family of a client of the Hindu faith may request that the client body be bathe after the client's death*
D. It is customary in the Hindu faith that only family members touch the body after death.
the other statements are correct. Follow up is not necessary. Psychosocial Integrity
AD
The nurse is caring for a client with bipolar disorder who has lithium (Lithotabs) prescribed. The nurse should suggest that the client have which of the following snacks?
(a) A fresh fruit cup
(b) Coffee and oatmeal cookies
(c) Tuna fish salad on saltine crackers
(d) Raw vegetables
C. The client receiving Lithium (Eskalith) should be careful to include sodium in the diet
to prevent hyponatremia which predisposes the client to Lithium toxicity; Caffeine
should be avoided because of the diuretic effect which will further increase the
