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Verified Answers and Rationale for Nurs 620 Exam 1 at Maryville University

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1. A nurse is caring for a patient who has been prescribed digoxin
for heart failure. Which of the following is the most important
assessment before administering the medication?
a) Blood pressure
b) Heart rate
c) Respiratory rate
d) Oxygen saturation

Answer: b) Heart rate
Rationale: Digoxin is used to treat heart failure by increasing the force
of contraction and decreasing the heart rate. The nurse must assess the
patient's heart rate before administration, as it is important to hold the
dose if the heart rate is below 60 beats per minute.

2. A patient with chronic kidney disease (CKD) is scheduled for
hemodialysis. Which of the following laboratory results would
most concern the nurse?
a) Serum potassium of 5.2 mEq/L
b) Hemoglobin level of 10 g/dL
c) Serum creatinine of 3.0 mg/dL
d) Blood urea nitrogen (BUN) of 70 mg/dL

Answer: a) Serum potassium of 5.2 mEq/L
Rationale: Hyperkalemia is a common concern for patients with CKD,
as their kidneys are unable to excrete potassium effectively. A
potassium level above 5.0 mEq/L is considered high and could lead to
dangerous cardiac arrhythmias.

3. When teaching a patient about using an inhaler for asthma, the
nurse should instruct the patient to:
a) Exhale forcefully before using the inhaler

,b) Administer the medication on an empty stomach
c) Hold their breath for 5-10 seconds after inhaling
d) Take the medication only during an asthma attack

Answer: c) Hold their breath for 5-10 seconds after inhaling
Rationale: Holding the breath after inhalation allows the medication to
be absorbed more effectively by the lungs. It helps ensure the
medication reaches the bronchial tissue.

4. A nurse is caring for a postoperative patient who is
experiencing pain. The patient requests medication, stating their
pain is a "10" on a scale of 0-10. The nurse's first action should be
to:
a) Administer the prescribed pain medication
b) Ask the patient to describe the pain further
c) Assess the patient's vital signs
d) Notify the physician about the patient's pain

Answer: c) Assess the patient's vital signs
Rationale: Before administering pain medication, the nurse should first
assess vital signs to rule out any complications, such as hypotension or
tachycardia, which may be linked to pain or other postoperative
concerns.

5. A nurse is caring for a patient with a new diagnosis of type 2
diabetes mellitus. Which of the following should be included in
the patient’s teaching plan?
a) Type 2 diabetes is caused by a viral infection
b) Insulin therapy is required for all patients with type 2 diabetes
c) Regular physical activity helps to lower blood glucose levels
d) The condition will resolve with proper medication

, Answer: c) Regular physical activity helps to lower blood glucose
levels
Rationale: Regular exercise helps improve insulin sensitivity, reduce
blood glucose levels, and support overall health. Type 2 diabetes is a
chronic condition that requires ongoing management, including
lifestyle changes.

6. The nurse is caring for a patient receiving morphine sulfate for
postoperative pain. The nurse should monitor the patient for
which of the following side effects?
a) Tachycardia
b) Hypotension
c) Respiratory depression
d) Hyperreflexia

Answer: c) Respiratory depression
Rationale: Opioids like morphine can cause respiratory depression,
which is a serious side effect. The nurse should closely monitor the
patient's respiratory rate and depth, especially after administration of
morphine.

7. A patient with hypertension is prescribed lisinopril. Which of
the following should the nurse include in the patient’s teaching?
a) "Take the medication with a high-fat meal to improve absorption."
b) "Avoid using salt substitutes while taking this medication."
c) "You should take the medication only when your blood pressure is
elevated."
d) "Lisinopril is a long-term medication that will cure your
hypertension."

Answer: b) "Avoid using salt substitutes while taking this medication."
Rationale: Lisinopril is an ACE inhibitor, and it can raise potassium

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