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NUR280 Exam With Actual Questions And Verified Detailed Answers
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NUR280 Exam With Actual Questions And VerifiedDetailed Answers 2024-2025
Medications 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) allergic to Penicillin is ordered Zithromax (azithromycin) - Answer 1. A. The normal
potassium level is 3.5 - 5.0 mEq/L. Administering Kayexalate in this situation may result
in the client losing potassium, leading to hypokalemia, therefore the medication 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) manipulating a wet cast with the palmar surfaces of the hands
(d) using a wide base of support while transferring a client - Answer 2. A. Sedation is
informed by explanation and decision making before the administration of the
medication. Therapeutic interventions for detached retina include bedrest with the area
of detachment in a dependent position to allow healing to occur. The cast is handled
with the palms of the hands when it is wet to avoid denting. Transfers are accomplished
using a broad base of support 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, Myasthenia Gravis, recently started on Mestinon (pyridostigmine), and working
as a letter carrier
(d) 70, schizophrenic, lives alone and states she hears
non threatening voices. - Answer 3. B. An adolescent with uncontrolled Diabetes
Mellitus would require the most amount of disciplines; multidisciplinary to manage their
care i.e. Medicine, Nursing, Social Work, Nutritionist; the other choices do not need 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) two weeks post partum being maintained on a mechanical ventilator for respiratory
failure. 4. C. The care of the client post abdominal surgery is routine. The postpartum
nurse routinely cares for mothers post caesarean section so it is appropriate to assign
this client; The other choices are not appropriate to assign to this nurse.
The nurse working in a well baby clinic has seen many children today. It would be a
priority for the nurse to follow through on the infant 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 and able to ambulate with support - Answer 5. D. A child who is
normally developing should be ambulating independently by 12 months; the Babinski
reflex disappears after 2 years of age; an infant is able to hold his own bottle around 6
,months; stranger anxiety occurs around 7 months
The nurse is providing care to a mechanically ventilated client who was legally declared
brain
dead. An Advance Directive is not documented in 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 provided 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) COPD with a pulse oximetry reading of 90%
(b) Parkinson's Disease and is demanding to leave the hospital 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.
Which of the following tasks would be appropriate to delegate to the CNA?
(a) Feeding a client with dysphagia
(b) One-to-one observation of a client for safety
(c) Removal of an indwelling catheter
(d) Performing a simple dressing change - Answer 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) conferring with a colleague registered nurse about an order written for a blood
transfusion by a physician
(c) asking other staff members to refrain from discussing a client in the cafeteria
(d) discussing with the nutritionist a clients laboratory results - Answer 9. A.
In order to ensure this, the nurse should not disclose the diagnosis of the client to the
family. It is also recommended that two nurses review the prescription for blood
transfusion; the client identification, blood type, Rh factor, expiration date and the blood
numbers should be reviewed. Staff members discussing a client in a public place should
be interrupted in order to maintain confidentiality on their part. Lastly, it is also an
appropriate nursing intervention to coordinate with the nutritionist. Safety Effective
Care Environment; Management of Care The nurse is making a staff presentation
related to legal and ethical issues in nursing. The nurse would be correct to include
which of the following examples? (a) Placing 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) Battery would include telling a client that you will put in a feeding tube if the client
does not eat. (c) Malpractice would include telling a client with bipolar disorder who is
suicidal that they have a right to refuse to take their medications.
(d) Touching a client stating "do not touch me" describes battery - Choice A places a
client in a geriatric chair with the lap tray in front of the client and this 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
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